Quantitative assessment of pericardial delayed hyperenhancement helps identify patients with ongoing recurrences of pericarditis

Abstract

Objectives: Recurrences of pericarditis (RP) are often difficult to diagnose due to lack of clinical signs and symptoms during subsequent episodes. We aimed to investigate the value of quantitative assessment of pericardial delayed hyperenhancement (DHE) in diagnosing ongoing recurrences of pericarditis.

Methods: Quantitative DHE was measured in 200 patients with established diagnosis of RP using cardiac MRI. Conventional clinical criteria for diagnosis of pericarditis were ≥2 of the following: chest pain, pericardial rub, ECG changes and new or worsening pericardial effusion.

Results: A total of 67 (34%) patients were identified as having ongoing episode of recurrence at the time of DHE measurements. In multivariable analysis, chest pain (OR: 10.9, p<0.001) and higher DHE (OR: 1.32, p<0.001) were associated with ongoing recurrence of RP. Addition of DHE to conventional clinical criteria significantly increased the ability to diagnose ongoing recurrence (net reclassification improvement (NRI): 0.80, p<0.001; integrated discrimination improvement (IDI): 0.12, p<0.001). Among 150 patients with history of RP who presented with chest pain, higher DHE was still independently associated with ongoing recurrence (OR: 1.28, p<0.001), showed incremental value over clinical criteria (NRI: 0.76, p<0.001; IDI: 0.13, p<0.001) and demonstrated a sensitivity of 70% and specificity of 74%.

Conclusion: Among patients with RP, quantitative DHE provided incremental information to diagnose ongoing recurrences over conventional clinical criteria of pericarditis. Quantitative DHE demonstrated acceptable test characteristics to diagnose ongoing recurrence even in RP patients presenting with chest pain.

Keywords: cardiac imaging techniques; magnetic resonance imaging; pericardial delayed hyperenhancement; pericarditis; recurrence.

Conflict of interest statement

Competing interests: None declared.

Figures

Figure 1

Flow diagram demonstrating derivation of study cohort. CMRI, cardiac MRI; DHE, delayed hyperenhancement; RP, recurrent pericarditis.

Figure 2

ROC curves showing additive value of DHE in diagnosing ongoing episode of recurrence among all patients with established history of recurrent pericarditis. Red: conventional clinical criteria of pericarditis (AUC 0.69); blue: conventional clinical criteria of pericarditis+DHE (AUC 0.80). AUC, area under the curve; DHE, delayed hyperenhancement; ROC, receiver operating characteristic.

Figure 3

ROC curves showing additive value of DHE in diagnosing ongoing episode of recurrence of recurrent pericarditis in patients who presented with chest pain (n=150). Red: conventional clinical criteria of pericarditis (AUC 0.65); blue: conventional clinical findings+DHE (AUC 0.76). AUC, area under the curve; DHE, delayed hyperenhancement; ROC, receiver operating characteristic.

Figure 4

Changes of DHE over time in patients with follow-up CMRI. Markers represent the average of the observed data obtained index CMRI date (time zero) over the intervals of 0–150 days, 151–300 days and >300 days. Error bars represent 95%CIs. The regression line is obtained by the mixed model approach. The P values for change over time are shown. CMRI, cardiovascular MRI; DHE, delayed hyperenhancement.

Figure 5

Delayed hyperenhancement (DHE) images from patients with RP. Panels A and B are DHE images from a 47-year-old female patient with RP who had minimal pericardial DHE at presentation. Panels C and D show severe pericardial DHE in a 61-year-old female patient with RP diagnosed as having an ongoing recurrence at presentation, while panels E and F are images from the same patient showing improved DHE post-treatment. Panels A, C and E show images before contouring, and the pericardium is bright from intense DHE in panel C. Postcontouring (B, D and F), quantitative signal >6 SD above normal myocardium is shown as yellow. On these short-axis images, the pericardium has been outlined between the green and red tracings, and normal septal myocardium has been outlined as a reference region (blue tracing). While DHE images show very low quantitative DHE (quantitative DHE=2 cm3) in panel B, panel D shows high-quantitative DHE (quantitative DHE=142 cm3). In comparison with panel D, panel F shows improved DHE (quantitative DHE=34 cm3) after 200 days of anti-inflammatory therapy. RP, recurrent pericarditis.