Patients with pericarditis often present with positional chest pain. The work-up should differentiate pericarditis from other potential causes. There are multiple non-invasive imaging modalities that may improve diagnostic accuracy and can be used to monitor disease progression and response to therapy.
In this side-by-side comparison, we compare the latest clinical practice guidelines from the American College of Cardiology (ACC) and the European Society of Cardiology (ESC) on pericarditis. This article reviews imaging modalities for the evaluation of pericarditis. The recommendations made are meant to guide clinical practice, taking into consideration the unique needs of patients.
Pericarditis Guidelines for Comparison
| Item | 2025 Concise Clinical Guidance: An ACC Expert Consensus Statement on the Diagnosis and Management of Pericarditis: A Report of the American College of Cardiology Solution Set Oversight Committee | 2025 ESC Guidelines for the management of myocarditis and pericarditis: Developed by the task force for the management of myocarditis and pericarditis of the European Society of Cardiology (ESC) |
|---|---|---|
| Authoring Society | American College of Cardiology | European Society of Cardiology |
| Publication Date | August 2025 | August 2025 |
| Graded Recommendations | No | Yes |
| Links | Summary / Full Text | Summary / Full Text |
Key Takeaways
The ESC guideline introduces the term “inflammatory myopericardial syndrome" (IMPS) to better illustrate the potential overlap of myocarditis and pericarditis. IMPS includes isolated pericarditis and myocarditis, as well as mixed forms of inflammatory myocardial and pericardial disease. The guideline includes recommendations for the evaluation and management of myocarditis and pericarditis with advice for specific sub-types of pericarditis, as well as recommendations that address age, pregnancy/lactation, and fertility.
The ACC guideline is more focused offering clinical practice recommendations for the evaluation, diagnosis, and management of pericardial diseases including acute and chronic pericarditis, pericardial effusion, constrictive pericarditis, and pericardial masses with malignant infiltration.
Now we will review the similarities and differences in non-invasive imaging modalities that can be used to diagnose and/or monitor pericarditis.
Transthoracic echocardiography (TTE)
According to both societies TTE is the first imaging modality that should be used to evaluate pericarditis.
TTE can detect the presence of pericardial effusion, pericardial thickening, constrictive pericarditis, and myocardial involvement.
However, TTE is unable to characterize tissue to identify the grade of inflammation.
Cardiac Magnetic Resonance (CMR)
The advantage of CMR is the ability to assess the degree of pericardial inflammation.
The ESC recommends CMR to aid in the diagnosis of pericarditis and assess pericardial thickening, oedema, and/or late gadolinium enhancement (LGE). Follow-up imaging may also be used to monitor disease progression and/or treatment response for certain patients.
The ACC agrees with using CMR for the initial evaluation of pericarditis and to evaluate recurrent/incessant pericarditis with follow-up CMRs to assess disease progression and response in recurrent/incessant pericarditis. The ACC does not recommend follow-up CMR for patients with acute pericarditis.
Cardiac Computed Tomography (CCT)
CCT is good at picking up pericardial calcification in constrictive pericarditis.
The ESC recommends CCT to evaluate pericardial thickness, calcifications, masses, and loculated pericardial effusions. It also can be used to evaluate concomitant pleuropulmonary diseases and chest wall abnormalities and to exclude coronary artery disease. CCT may be helpful in patients with large pericardial effusions with tamponade.
The ACC does not recommend CCT for the routine assessment of pericarditis, but may consider CCT to evaluate chest pain of other causes.
Nuclear Medicine Scans
Nuclear medicine scans may be helpful to patients unable to undergo CMR due to an irregular heartbeat or artifact from an implanted device and fluorodeoxyglucose positron emission tomography (FDG-PET) combined with CT plays an important role in detecting cardiac sarcoidosis.
The ESC suggests FDG-PET or FDG-PET/CT be considered for patients with suspected pericarditis whose TTE and CMR were inconclusive.
The ACC did not make a recommendation regarding nuclear medicine scans, but did say that currently nuclear imaging is limited to the research setting or in patients who cannot have a CMR.
Comparison of Recommendations (Non-Invasive Imaging)
| Type | ACC | ESC |
|---|---|---|
| TTE | Recommended: TTE for evaluating and surveillance of pericardial effusion, signs of tamponade, constriction, and myocardial involvement of pericarditis. | Complete clinical evaluation, including history, physical examination, chest x-ray, biomarkers, ECG, and echocardiography is recommended in all patients with suspicion of myocarditis and/or pericarditis for the initial diagnostic assessment. |
| CMR | Recommended for recurrent/incessant pericarditis and reasonable for acute pericarditis: CMR for initial evaluation of pericarditis in terms of pericardial LGE, oedema, thickening, effusion, signs of constriction, and myocardial involvement for diagnosis and risk stratification, especially for complicated/indeterminant cases. Reasonable for recurrent/incessant pericarditis, not recommended for acute pericarditis: CMR for assessing treatment response and surveillance of pericarditis. | CMR is recommended in patients with the clinical suspicion of myocarditis (using updated LL criteria) and/or pericarditis for the non-invasive diagnosis of inflammatory reaction. CMR is recommended in patients with suspected pericarditis when a diagnosis cannot be made using clinical criteria to assess evidence of pericardial thickening, oedema, LGE, and to assess the persistence of disease during follow-up in selected cases. |
| CCT | Reasonable: CCT for evaluation of other chest pain causes other than acute pericarditis. Not recommended: CCT for routine assessment of pericarditis. | CT is recommended to evaluate pericardial thickness, calcifications, masses, and loculated pericardial effusions, as well as concomitant pleuropulmonary diseases and chest abnormalities. Invasive coronary angiography or coronary CT, depending on clinical likelihood, is recommended in patients with IMPS if an acute coronary syndrome is suspected to rule out obstructive coronary artery disease. |
| Nuclear Medicine | Not addressed. | Carb-free F-FDG-PET or F-FDG-PET/CT should be considered for the diagnostic work-up in patients with suspected myocarditis and/or pericarditis in whom echocardiography and CMR are inconclusive for the clinical diagnosis. |
This concludes our guidelines side-by-side comparison on imaging modalities for the evaluation of pericarditis. Don’t forget to sign up for alerts to stay informed on the latest published guidelines and articles.
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