Quantitative Pericardial DHE: A Helpful Clinical Tool in Recurrent Pericarditis?

Among patients with multiple pericarditis recurrences, higher quantitative delayed hyperenhancement (DHE) on cardiac magnetic resonance imaging (CMR) indicates a longer clinical course. So concludes a recent Cleveland Clinic study in JACC: Cardiovascular Imaging, the first to show the incremental prognostic value of adding quantitative DHE to other clinical variables in patients with recurrent pericarditis.

“Pericardial DHE on CMR may last beyond the acute phase of pericarditis, suggesting ongoing pericardial inflammation despite treatment,” says the study’s senior author, Allan Klein, MD, Director of Cleveland Clinic’s Pericardial Disease Center. “We undertook this study to determine the value of quantitative assessment of DHE (samplin predicting the clinical course of recurrent pericarditis in patients with multiple recurrences by the time of presentation.”

Study recap

Dr. Klein and colleagues retrospectively identified 159 patients with recurrent pericarditis who underwent DHE imaging (sample images below) at Cleveland Clinic from 2007 through early 2015 and were followed for at least six months. They quantified inflammation on short-axis DHE sequences by contouring the pericardium, using normal septal myocardium as a reference region and then quantifying the pericardial signal that was more than 6 standard deviations above the reference.

Clinical remission was the primary end point; time to recurrence and recurrence rate were secondary outcomes.

Post-gadolinium DHE images, produced using a quantitative approach, from a patient with severe inflammation.

Over a median follow-up of 23 months (interquartile range, 15 to 34 months), 20 percent of patients achieved clinical remission. Multivariate analysis showed that lower quantitative pericardial DHE was independently associated with clinical remission (P = .008).

Notably, adding quantitative DHE to background clinical and laboratory variables yielded incremental prognostic value, providing significantly better discrimination for clinical remission (P = .004).

Additionally, higher pericardial DHE values were associated with shorter times to recurrence (P = .012) and higher six-month recurrence rates (P = .026).

Implications for practice and research

“This study demonstrates that quantitative pericardial DHE may offer insight into pericarditis duration and expected response to treatment,” remarks Dr. Klein. “Qualitative assessment is done in clinical practice but was not as robust as the quantitative approach in our study.”

He adds that the prognostic value of inflammatory markers tends to be lower among patients with recurrent pericarditis, who are often on intense anti-inflammatory regimens when evaluated. “In such presentations,” he notes, “a baseline assessment of pericardial DHE may be of value, especially since traditional prognostic markers for acute pericarditis — such as fever and pericardial effusion — were not associated with clinical outcomes in our cohort.”

Dr. Klein points out that this study was hypothesis-generating and future investigations are needed to definitively guide use of quantitative pericardial DHE. “Clinical trials examining the interval change in pericardial DHE in patients with recurrent pericarditis, with correlation to symptoms and inflammatory markers, could help elucidate the precise changes in medication dosing that would be indicated,” he says.

In an accompanying editorial in JACC: Cardiovascular Imaging, cardiologist Massimo Lombardi, MD, who practices in Italy, concurs.

“The data presented [in this study], if confirmed, may push clinicians to modify their diagnostic workflow,” writes Dr. Lombardi. “After TTE, the next imaging test would be CMR as a means to stratify patients and modulate the medical therapy that is quite articulate and offers several options depending on the severity of the picture.” He adds that a prospective randomized trial is needed “to transform this initial thought-provoking suggestion into a consolidated clinical procedure for adoption.”