Multimodality imaging in pericardial diseases: recent advances in diagnosis and management

Background: Systemic lupus erythematosus (SLE) is a chronic autoimmune disease characterized by immune dysregulation and systemic inflammation, with the cardiovascular (CV) system representing a major yet frequently under-recognized target. Cardiac involvement spans from subclinical myocardial inflammation to overt pericardial disease, myocarditis, valvular abnormalities, coronary microvascular dysfunction, and accelerated atherosclerosis. Given that CV disease remains a leading cause of morbidity and mortality in SLE, early detection of silent cardiac injury is crucial. Aim: This review aims to provide a comprehensive and clinically oriented overview of CV involvement in SLE, focusing on the role of multimodal cardiac imaging in the detection, characterization, and risk stratification of cardiac abnormalities, as well as its potential implications for clinical management and preventive strategies. Methods: This narrative review is based on a structured, non-systematic search of PubMed (2013-2026), combining the term "systemic lupus erythematosus" with imaging-related keywords including "transthoracic echocardiography," "cardiac magnetic resonance," and "cardiac computed tomography." English-language studies in adult populations were screened and selected according to clinical relevance, methodological robustness, and contribution to understanding SLE-related cardiac involvement. Discussion: Multimodal cardiac imaging plays a central role in the evaluation of SLE-related cardiac disease. Transthoracic echocardiography (TTE) represents the first-line modality for the assessment of ventricular function, pericardial disease, and valvular abnormalities, while deformation imaging enables the detection of subtle myocardial dysfunction. Cardiac magnetic resonance (CMR) provides comprehensive tissue characterization, allowing differentiation between active inflammation and chronic fibrosis. Cardiac computed tomography (cCT) identifies subclinical coronary atherosclerosis and high-risk plaque features, whereas nuclear imaging techniques offer insight into inflammatory activity and microvascular dysfunction. Conclusions: An integrated, imaging-based approach enables early diagnosis, refined CV risk stratification, longitudinal monitoring, and personalized therapeutic strategies. Multimodal imaging thus represents a key pillar of precision medicine in lupus-associated CV disease.

Systemic lupus erythematosus (SLE) is a challenging autoimmune and multi-system condition. With advances in cardiovascular screening and therapies for SLE patients, we evaluated the cardiovascular characteristics, multi-modality imaging, and outcomes of SLE at our tertiary referral center over an 8year period. Consecutive patients from our SLE registry from April 2012 to March 2020 were retrospectively analyzed. Data pertaining to cardiovascular manifestations, investigations, management, and outcomes were assessed. We studied 258 SLE patients (mean age 42.2 ± 14.7 years); 233 (90.3%) were female. The main cardiac manifestations at index SLE clinic were pericardial disease in 33.3%, valve disease in 18%, cardiomyopathy in 9.6%, and stroke in 7.4%. During a mean follow-up of 3.0 ± 2.2years after index SLE clinic, there were 5 (1.9%) deaths, 24 (9.3%) cardiovascular events, and 44 (17.1%) SLE-related hospitalizations. A history of stroke and hypertension were independently associated with cardiovascular events, hazard ratio (HR) (95% confidence intervals (CI)) of 5.38 (1.41-20.6) and 3.31 (1.02-10.7), respectively, while younger age and lower albumin predicted SLE-related hospitalizations. Cardiovascular manifestations are prevalent in SLE, especially for pericardial, valvular, and atherosclerotic diseases. With contemporary SLE and cardiovascular management, subsequent adverse cardiovascular events were infrequent in this study.

With a rapidly growing spectrum, non-specific symptoms and overlapping etiologies, pericardial diseases can represent a real diagnostic challenge. Consequently, multimodality imaging has taken a front seat in the diagnosis and management of these conditions. Cardiac CT offers an excellent anatomical characterization of pericardial thickening, fat stranding and/or presence of calcifications. and is also the preferred modality to assess extra-cardiac structures. Active pericardial inflammation, edema and fibrosis comprise pericardial characterization using CMR and allows for a precise diagnosis, disease staging and patient specific tailoring of therapies. PET scan still occupies a very modest role in the evaluation of pericardial diseases but might help discriminating malignant pericardial effusion and extrapulmonary tuberculous. More than ever, clinicians need to master how these modalities complement each other while avoiding unnecessary cost and to translate this knowledge into a more customized patient's care approach. The aim of this review was to recognize the role of multimodality imaging in the investigation of various pericardial diseases, assess how these modalities can impact the clinical course and treatment of these affections and finally elucidate their role in the patient's prognostication.

Pericardial diseases have changed their epidemiology in the past few years. With the aging population and decreasing incidence of communicable diseases, the causes of pericardial diseases have significantly changed from infectious and malignant to postradiation and cardiac surgery causes. Despite that, pericardial diseases remain difficult to diagnose. The accurate and timely diagnosis of these diseases is essential to avoid the late sequela of pericardial constriction and pericardial cirrhosis. Echocardiography remains the first test of choice for the assessment of patients with suspected pericardial diseases. Most patients with acute pericarditis have a self-limiting course and do not need further imaging. However, in the era of multimodality imaging, other modalities, namely, computed tomography (CT) and magnetic resonance imaging (CMR), are often utilized in complex cases. These two modalities provide a wide-open view of the pericardium and adjacent structures. They have high resolution to assess pericardial calcification, a hallmark of many diseases especially tuberculous constrictive pericarditis. CMR is also unique in its ability to assess pericardial late gadolinium enhancement (LGE) and edema. These have been recently suggested to be very important in the progression from acute pericarditis to constrictive pericarditis. In addition, they provide prognostic value to assess which patients are at high risk of developing heart failure and resource utilization. Thus, in the current era, patients with suspected complex pericardial diseases will need a multimodality approach rather than a single modality approach.

Although pericardial diseases are common in the daily clinical practice and can result in a significant morbidity and mortality, imaging of patients with suspected or known pericardial disorders remain challenging. Multimodality imaging is part of the management of pericardial diseases. Echocardiography, cardiac computed tomography, and cardiovascular magnetic resonance are often used as complementary imaging modalities. The choice of one or multiple imaging modalities is driven by the clinical context or conditions of the patient. The scope of the present document is to highlight the respective role of each technique according to the clinical context in the diagnosis and management of pericardial diseases.

ericardial pathology is commonly encountered in clinical practice and may present either as an isolated process or in association with other systemic disorders.Recognizing pericardial pathology can be relatively straightforward, particularly if the clinical manifestation is typical (eg, the patient with acute pericarditis and an audible friction rub reporting retrosternal pain, exacerbated by inspiration or in the supine position) or when an associated disease process gives a direct clue to the diagnosis (eg, the finding of a complex pericardial effusion in a patient with a known malignancy).In these situations, the diagnostic pathway can be limited to a relatively small sequence of tests to basically confirm the initial clinical suspicion. 1owever, pericardial disease can also result in nonspecific symptoms and equivocal physical findings.When the initial tests of choice turn out to be nondiagnostic or the course of the disease is prolonged, pericardial disease may cause considerable diagnostic dilemmas.Furthermore, established diagnostic techniques may not visualize the full extent of the pericardial disease process.In such difficult clinical situations, an integrated multimodality imaging approach may provide incremental value.Unfortunately, current guidelines do not address the role of a multimodality approach in the difficult to manage pericardial patient. 1 This review will therefore discuss the potential role of different imaging modalities in the diagnosis and management of pericardial disorders, with a specific focus on what constitutes a rational multimodality imaging approach.

Multimodality Imaging of Pericardial Diseases

Sympathetic ophthalmia is a bilateral granulomatous uveitis that occurs following unilateral trauma or surgery and is sight-threatening in the contralateral eye. Despite significant potential morbidity, disease remains poorly understood. Variable presentations and clinical courses, as well as a lack of definitive diagnostic laboratory tests can complicate the diagnosis and result in delayed treatment, which can beget permanent vision loss. This review focuses on recent advances in areas of pathophysiology, classification, diagnosis and treatment. Sympathetic ophthalmia is thought to involve a cell-mediated immune response to retinal and uveal antigens exposed through trauma or surgery. Multiple mechanisms have been implicated, including activation of the interleukin-23/IL-17 pathway. Ongoing emphasis is placed on early disease recognition and prompt treatment with multimodal imaging. Multiple authors advocate for the routine use of optical coherence tomography (OCT) for screening and disease monitoring. Systemic steroids and steroids sparing-immunosuppressive agents remain the mainstay of treatment. Understanding pathophysiology may provide useful targets for drug development, as well as allow for identification of patients at risk. OCT is a useful tool in early diagnosis and management of sympathetic ophthalmia, as OCT changes may precede clinical symptoms and signs, allowing for early disease detection and better visual outcomes.

Pericardial disease is frequently encountered in routine clinical practice, resulting in an important cause of morbidity and mortality. Many different entities can involve and damage the pericardium, such as inflammatory diseases (from acute pericarditis to chronic constrictive pericarditis), cardiac tamponade, pericardial cysts, tumors, hematomas, diverticula and congenital absence of the pericardium. They may present isolated or associated with other systemic disorders. Transthoracic echocardiography is nowadays the initial imaging method of choice in the evaluation of the pericardium and is the preferred modality in acute pericarditis and cardiac tamponade. Computed tomography and cardiac magnetic resonance offer many advantages, providing excellent visualization of the pericardium and surrounding structures, tissue or fluid characterization and functional evaluation with real-time images. These facts are relevant in pathologies such as constrictive pericarditis and pericardial masses. Pericardial disease can present with non-specific signs and symptoms. In these patients, an integrated approach coordinating transthoracic echocardiography, cardiac computed tomography and cardiac magnetic resonance allows establishing an accurate diagnosis and prognosis, and becomes essential for the clinician. Good knowledge of the strengths and the limitations of each imaging modality is essential for a rational use of these techniques. Le malattie del pericardio sono di frequente riscontro nella pratica clinica e rappresentano una causa importante di morbilità e mortalità. Le entità cliniche che possono coinvolgere e danneggiare il pericardio sono molteplici, tra queste si includono le malattie infiammatorie (dalla pericardite acuta alla pericardite cronica costrittiva), il tamponamento cardiaco, le cisti pericardiche, tumori, ematomi, diverticoli e l’assenza congenita del pericardio. Ciascuna di queste condizioni si può presentare da sola, o associata a disordini sistemici. Oggigiorno l’ecocardiografia transtoracica rappresenta l’indagine strumentale iniziale nello studio del pericardio, essendo inoltre la metodica preferita nella pericardite acuta e nel tamponamento cardiaco. A loro volta la tomografia computerizzata e la risonanza magnetica offrono molti vantaggi, tra i quali un’ottima visualizzazione del pericardio e delle strutture attigue, la caratterizzazione di tessuti e fluidi e una valutazione funzionale con immagini in tempo reale. Questi aspetti sono particolarmente rilevanti in patologie come la pericardite costrittiva e le masse pericardiche. Le malattie del pericardio possono presentarsi con segni e sintomi aspecifici. Nei pazienti affetti da tali condizioni, un approccio integrato che preveda l’utilizzo di ecocardiografia transtoracica, tomografia computerizzata e risonanza magnetica consente di stabilire accuratamente tanto la diagnosi come la prognosi, e risulta essenziale per il medico. Una buona conoscenza dei vantaggi e delle limitazioni di ciascuna tecnica è fondamentale per un loro utilizzo razionale.

Pericardial disease

Introduction Constrictive pericarditis (CP) can result from uncontrolled inflammation of the pericardium. This can be due to various etiologies. CP can lead to both left- and right-sided heart failure with associated poor quality of life, so early recognition is key. The evolving role of multimodality cardiac imaging allows for earlier diagnosis and facilitates management to help mitigate this adverse outcome. Areas covered This review discusses the pathophysiology of constrictive pericarditis, chronic inflammation and autoimmune etiologies, clinical presentation of CP, and advances in multimodality cardiac imaging for diagnosis and management. Echocardiography and cardiac magnetic resonance (CMR) imaging remain cornerstone modalities to evaluate this condition, whereas additional imaging modalities such as computed tomography and FDG-positron emission tomography can provide complementary information. Expert opinion Advances in multimodality imaging allow for a more precision diagnosis of constrictive pericarditis. There has been a paradigm shift in pericardial disease management with advances in multimodality imaging, especially CMR, to detect subacute and chronic inflammation. This has enabled imaging-guided therapy (IGT) to both help prevent and potentially reverse established constrictive pericarditis.

Imaging-Guided Therapies for Pericardial Diseases

48 - Echocardiography in the Context of Other Cardiac Imaging Modalities

PURULENT PERICARDITIS AND PURULENT PERICARDIAL EFFUSION DUE TO METHICILLIN-SENSITIVE STAPHYLOCOCCUS AUREUS (MSSA) IN A PATIENT TAKING SARILUMAB AND STEROIDS

Disorders of the pericardium represent a diverse range of conditions that traditionally may not have received the same level of attention by cardiologists and physicians, owing partly to a lack of research into advanced diagnostic modalities, and limited, evidencebased treatment options. In recent years, there has been a timely resurgence of interest in pericardial diseases, in particular pericarditis. This is attributable to advances in multimodality cardiovascular imaging, in particular cardiac magnetic resonance (CMR), which may help guide treatment decisions for patients with pericardial syndromes. Additionally, increased research and understanding of the pathophysiological basis of pericarditis have shed light on the role of inflammation in pericarditis. This knowledge may help identify potential specific treatment targets. This article aims to provide a practical review of the role of multimodality cardiovascular imaging (echocardiography, multidetector cardiac computed tomography (MDCT), CMR) in pericardial conditions, focusing on the strengths and potential limitations of each imaging modality.