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detailed assessment of pericardial inflammation, effusion, and constrictive physiology—while enhancing diagnostic precision for assessing disease activity and

monitoring progression and responses to therapy.1,3,12

Table 3 shows the standard imaging techniques and protocols of multimodality imaging.

4.1.5. Pericardial Diseases Center of Excellence

A pericardial diseases center (PDC) offers a structured

solution to managing the complexity of pericardial disorders, which can otherwise strain healthcare systems.13,14 These centers are particularly effective in

improving care and outcomes for patients with recurrent

or refractory pericarditis, as well as those requiring

frequent follow-ups, while reducing emergency visits

and hospitalizations. Indications for referral to a

specialized pericardial center include recurrent, incessant or chronic pericarditis, suspected or confirmed

constrictive pericarditis, large or complex pericardial

effusion requiring pericardial drainage or window, or

when advanced therapies, such as biologics and pericardiectomy, are being considered. PDCs also play a vital

role in screening patients for clinical trials and monitoring responses and adverse events of emerging treatments. Figure 4 summarizes the framework and key

components of a PDC.

The development of such a PDC begins with a needs

assessment, considering local disease prevalence,

healthcare gaps, and resource availability. A welldefined protocol is critical, outlining staff responsibilities, referral processes, clinical workflows, and

strategies for continuous quality improvement. These

centers should provide access to specialized resources,

including multimodality imaging (eg, echocardiography,

CMR, CCT), rheumatology, infectious diseases, genetics,

consultation with cardiothoracic surgery, and specialty

pharmacies. Advanced practice providers play a major

role in the workflow of a PDC.14 Clear communication

pathways ensure timely referrals and follow-ups,

particularly for high-priority cases. Key components of

TABLE 3 Standard Multimodality Cardiac Imaging Techniques and Protocols for Evaluating Pericardial Diseases

TTE CCT CMR

Technique a) 2-dimensional echocardiography

b) Doppler echocardiography

c) M-mode echocardiography

d) Speckle-tracking echocardiography

a) Axial imaging, multiplanar reconstruction volume-rendered

imaging þ contrast and delayed

phase

b) Cine imaging (retrospective ECG

gating)

a) Cine white-blood imaging (steadystate free precession)

b) Black-blood imaging (T1W or T2W

turbo spin echo, fat suppression may

be considered)

c) T2-STIR

d) LGE imaging (fat suppression

recommended)

e) Free-breathing cine imaging

(gradient echo)

f) Myocardial tagging

g) Other T1, T2, fat saturation

sequences

Evaluation a) Pericardial thickness

PEff: location, size, fluid characteristics,

pericardiocentesis approach

CTP: IVC plethora, cardiac chamber collapse, swinging

heart

CP: IVC plethora and respirophasic septal shift, wall

tethering, ventricle conical deformity, pericardial

thickening

Pericardial mass: location, size

Chamber quantification and regional wall motion

abnormalities

b) CTP: respirophasic variation E-wave mitral inflow

>30%/tricuspid inflow >60%

CP: Mitral E/A ratio >0.8, mitral medial e’ >8 cm/s,

annulus reversus, hepatic vein expiratory end-diastolic

reversal/forward velocity >0.8, respirophasic variation

E-wave mitral inflow >25%/tricuspid inflow >40%

a) Pericardial thickening, calcifications

PEff: location, size, fluid

characteristics, pericardiocentesis

approach

Pericardial mass characterization

b) Chamber quantification

Chamber tethering

Septal bounce

a) Chamber quantification, CP: septal

bounce, conical deformity, wall

tethering; PEff: location, size

b) Pericardial thickness, IVC plethora

Pericardial mass: location, size

c) Pericardial edema, myocardial

edema

d) Pericardial inflammation/fibrosis,

myocardial inflammation/fibrosis

e) Respirophasic septal shift in CP

f) Wall tethering in CP

g) PEff and pericardial mass

characterization

Adapted with permission from Klein et al.1

CCT ¼ cardiac computed tomography; CMR ¼ cardiac magnetic resonance; CP ¼ constrictive pericarditis; CTP ¼ cardiac tamponade; ECG ¼ electrocardiogram; IVC ¼ inferior vena

cava; LGE ¼ late gadolinium enhancement; PEff ¼ pericardial effusion; STIR ¼ short-tau inversion recovery; T1W ¼ T11-weighted, T2W ¼ T2-weighted, TTE ¼ transthoracic

echocardiography.

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a PDC include comprehensive evaluations, timely imaging and laboratory investigations, and personalized

treatment plans. Patients benefit from dedicated education on self-management strategies and access to

rapid interventions, which help mitigate disease flares.

Follow-up schedules are adjusted based on individual

patient needs, ranging from frequent visits during

active phases (such as every 3 months) to less frequent

visits when stable (such as every 6-12 months). Protocols for medication adjustments, escalation, or

tapering are also integral, ensuring effective disease

management in collaboration with multidisciplinary

teams. As patient volumes increase, PDCs can evolve

from being part of broader cardiovascular services to

standalone units, optimizing specialized care delivery.

By enhancing patient outcomes and streamlining

healthcare utilization, PDCs represent a valuable model

for managing these conditions within tertiary care

centers.

4.2. Pericarditis

4.2.1. Novel Clinical Diagnostic Criteria and Perspectives

Based on expert consensus, we propose the following

novel diagnostic criteria for pericarditis (Figure 5):

1. Pleuritic chest pain or equivalent with suggestive

clinical presentation (must be present)

2. Plus $1 additional finding (0 ¼ unlikely, 1 ¼ possible,

and 2þ ¼ definitive diagnosis).

a. Pericardial friction rub (<1/3)

b. Electrocardiogram changes consisting of diffuse

ST-segment elevation and/or PR-segment depression (up to 60%)

c. Inflammatory biomarkers elevation (such as C-reactive protein [CRP], sedimentation rate)

FIGURE 4 Framework and Components of a Pericardial Diseases Center

Referral (local and outside)

 • Patient/self

 • Physician: primary care,

 emergency physician, internal

 medicine, cardiologist,

 rheumatologist, cardiac surgeon

Triage

 • Prior clinical records, test

 results and images uploaded

 to medical record

 • Chart review by APP or physician

 • Order and schedule appropriate

 appointments and tests

Initial clinic visit

 • Thorough history and

 examination with pericardial

 specialist physician.

 • Labs, ECG, echocardiography,

 consider CMR ± CCT

Treatment Plan

 • Medications - combinations,

 courses, side effects

 • Addition of labs

 • Exercise restriction

Patient Education

 • Pericardial disease

 discussion - etiologies/risk

 factors, clinical features,

 tests, treatment options

 • Side effects of medications

 • Surveillance and

 managing flare-ups

 • Reassurance

Follow-up

 • 3-month follow-up with

 APP (in-person or

 virtual, labs repeated)

 • 6-month follow-up with

 pericardial specialist

 physician (in-person,

 labs, ECG, and imaging

 repeated, as needed)

Multidisciplinary Approach

 • Rheumatology

 • Infectious disease

 • Cardiothoracic surgery

 • Specialist radiology

 and pharmacy

Research

 • Screen patients for

 clinical trials

 • Monitoring treatment

 efficacy and side effects

 • Follow-up visits

 • Article publications and

 conference presentations

APP ¼ advanced practice provider; CCT ¼ cardiac computed tomography; CMR ¼ cardiac magnetic resonance; ECG ¼ electrocardiogram.

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9

d. Cardiac imaging (especially echocardiography evidence) of new or worsening pericardial effusion (up

to 60%)

e. Cardiac imaging evidence of pericardial inflammation (especially CMR pericardial late gadolinium

enhancement/edema, computed tomography as

alternative)

These criteria, in comparison with the prior 2015 European Society of Cardiology guidelines criteria,7 place

more emphasis on the clinical presence of classic chest

pain or equivalent (typically sharp, pleuritic, relieved by

sitting up or leaning forward) being necessary for diagnosis, incorporating equally elevated inflammatory biomarkers and multimodality cardiac imaging findings of

pericardial effusion and inflammation into the criteria,

and dividing into categories of definite, possible, and

unlikely pericarditis diagnoses. The diagnostic criteria

likely perform best in patients with acute pericarditis,

though can be applicable to patients with recurrences/

flares.

About 15% of patients will have concomitant myocarditis such as peri-myocarditis (myocarditis dominant) or

myo-pericarditis (pericarditis dominant), manifested by

elevated markers of myocardial injury (troponin) and left

ventricular global or regional systolic dysfunction.7,15

Pericarditis encompasses several conditions including a

noninflammatory phenotype (low or near normal CRP,

often associated with autoimmune conditions) seen in

10% to 20% of cases, and an inflammatory phenotype seen

in 80% to 90% of patients. These patients with an inflammatory phenotype and elevated CRP can present with

high fever, neutrophilic leukocytosis, and pericardial and/

or pleural effusions.16,17 If treated with appropriate antiinflammatory therapies, most acute pericarditis cases

will have a benign course and resolve without recurrence.

Risk factors for a poor prognosis and/or need for hospitalization include high fevers, subacute course, presence

of large pericardial effusion with echocardiography features of tamponade physiology, failure to respond to

nonsteroidal anti-inflammatory drugs (NSAIDs), as well as

concomitant myocarditis.1

Acute pericarditis refers to the diagnosis with full resolution of symptoms within 4 weeks. Recurrent pericarditis is diagnosed when there is a relapse of symptoms

following a symptom-free interval of $4 to 6 weeks after

the initial flare, with completion of medical therapy.

Recurrence rates after an initial episode vary from 15% to

30% and further increase to 50% after a first recurrence.7,15 Risk factors for recurrence include a lack of

FIGURE 5 Novel Diagnostic Criteria and Classification by Duration for Pericarditis

Diagnosis of Pericarditis

Duration of Pericarditis Classification

1. Acute: Event lasting <4-6 weeks

2. Incessant: Event lasting >4 to 6 weeks without remission

3. Recurrent: New episode with signs and symptoms of pericardial inflammation after

 a symptom-free interval of 4 to 6 weeks

4. Chronic: Event lasting >3 months

1. Pleuritic chest pain or equivalent suggestive clinical presentation (must be present)

2. Plus at least 1 more finding (0 = unlikely, 1 = possible, 2+ = definite diagnosis)

 a) Pericardial friction rub

 b) ECG changes: diffuse ST-elevation and/or PR-segment depression

 c) Inflammatory biomarkers elevation (C-reactive protein, sedimentation rate)

 d) Cardiac imaging evidence of new or worsening pericardial effusion

 (especially echocardiography, other imaging modalities as alternative)

 e) Cardiac imaging evidence of pericardial inflammation (cardiac magnetic

 resonance pericardial late gadolinium enhancement and/or edema,

 computed tomography with contrast as alternative)

Duration of pericarditis classification is adapted with permission from Chiabrando et al.8 ECG ¼ electrocardiogram.

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