2012 Winter Image of the Issue: Seeing Pericardial Inflammation with Multi-modality Imaging
Heart & Vascular Institute Physician eNewsletter - Winter 2012
Before treatment (left) and after treatment (right):
The Cardiac MRI shows a thickened and inflamed
pericardium (arrows) that resolves with treatment.
For the first time, we can actually visualize the severity
of the pericarditis and manage the patients appropriately
to prevent recurrence and any complications, Dr. Klein notes.
Click on the image for a larger view (image will open in a new window).
A multi-modality imaging strategy can properly diagnose pericarditis so the disease can be effectively managed.
A patient presenting with pericarditis—inflammation of the lining around the heart—can be mistakenly diagnosed and poorly treated when there is lack of understanding about the disease and its complications. Pericarditis can be confused with nonspecific chest pain, or even heart attack. Even when properly identified, pericarditis that is not aggressively treated with antiinflammatory medication can recur and become disabling for patients.
Such was the case for a patient who several years ago came to the office of Dr. Allan Klein, Director of Cardiovascular Imaging Research, Director of the Center for the Diagnosis and Treatment of Pericardial Diseases and a staff cardiologist in the Section of Cardiovascular Imaging at Cleveland Clinic.
The patient was in tears and devastated by his symptoms. He was experiencing severe chest pain that radiated to his shoulder every time he took a breath. Lying down flat was so uncomfortable that he forced himself to stay in an upright position all the time. He had trouble doing his job as an accountant and his family life was suffering as well.The patient was seen at the Pericardial Center where Dr. Klein performed a clinical exam and evaluated blood tests including inflammatory markers such as CRP and WSR, then conducted imaging including a MRI of the heart to assess inflammation in the pericardium. “We pieced together the information: The patient had a very ‘rip-roaring’ case of recurrent pericarditis, and once we saw that, we put him on triple therapy,” says Dr. Klein, referencing a three-pronged medical strategy including a non-steroidal anti-inflammatory such as ibuprofen, colchicine and prednisone.
“We prescribed all three agents because it was critical to hit this inflammation hard and to nip it in the bud to prevent complications such as constrictive pericarditis where the heart becomes constricted by the thickened pericardium,” says Dr. Klein.
It is essential to treat active recurrent pericarditis long enough with medications and to gradually taper drug therapy over a 6 month period so the pain does not reappear. “Pericarditis can come back in 20 to 30 percent of the time and last up to 10 years,” says Dr. Klein. Eventually, in most cases, it will burn itself out.
First pericarditis must be properly identified, and because the disease can result in nonspecific symptoms and it can cause a diagnostic and imaging dilemma for clinicians.
Most patients will have normally have and EKG and C-Xray but these tests may not be specific and other imaging modalities are used. The three types of imaging most commonly used to diagnose pericarditis are echocardiography, cardiac computed tomography (CT) and cardiac MRI. While echocardiography is the first order of business, so to speak, the findings may not point conclusively to the extent of inflammation or thickening around the heart.
CT and MRI can complement initial echocardiography. Additional imaging can clearly visualize pericardial thickening in constrictive pericarditis and demonstrate inflammatory involvement of the pericardium. Also, MRI can be used to monitor inflammation in patients with recurrent pericarditis and identify patients with persistent inflammation despite medication.
At the pericardial center, patients gain access to an experienced cardiologist and cardiac nurse specializing in pericardial disease. They get proper blood tests, echocardiograms, chest x-rays and advanced imaging, including CT or cardiac MRI. They also get a hemodynamic assessment in the cardiac catheterization (cath) lab. Consultation is provided, along with referrals to infectious disease and rheumatology and cardiothoracic surgery specialists if necessary.
In this patient’s case, the ability to properly diagnose and aggressively treat his recurrent pericarditis with medications resulted in full recovery and a return to an active lifestyle. A year after his initial appointment, he was given a clean bill of health and stopped taking all medications.
The patient went on to run a half-marathon—a physical feat that would have been impossible in his previous condition.
“The takeaway from this case is that it’s extremely important to properly diagnose the inflammation in pericarditis so it can be properly be treated to prevent the disease from recurring,” Dr. Klein says.
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