Chest radiography is of limited use in the assessment of pericardial disease although pericardial effusions, calcification and secondary signs and complications of pericardial disease may be evident. Interval enlargement of the cardiac silhouette should raise the suspicion of pericardial effusion.

Transthoracic echocardiography (TTE) is usually the initial investigation of suspected pericardial disease. It is cheap and widely available and has high accuracy for detecting pericardial effusions and signs of tamponade. TTE is also helpful for guiding diagnostic or therapeutic pericardiocentesis. Restricted acoustic windows limit its evaluation of the entire pericardium; loculated collections, intrapericardial blood clot and pericardial thickening may be difficult to assess. It is not very accurate for depicting pericardial thickening, because echogenicity of the pericardium is similar to adjacent tissues. Transoesophageal echocardiography is limited by a narrow field of view. CT and MR have distinct advantages over echocardiography: larger field of view, higher contrast media resolution, excellent anatomical delineation and multiplanar reformats. MDCT with multiplanar reformats, particularly if ECG gated, provides excellent motion-free assessment of the pericardium; advantages include speed and wide availability and accessibility. CT can also detect pericardial calcifications which may be indicative of constrictive pericarditis. Disadvantages of CT include ionising radiation and the need for intravenous iodinated contrast agent. MRI can provide a comprehensive assessment of the pericardium. When T1- and T2-weighted sequences (some with ECG-gated breath-hold techniques) are combined with cine-based functional cardiac imaging, both pericardial disease and its impact on cardiac function can be assessed. MRI has some advantages over ultrasound and CT in detecting and characterising pericardial collections and masses. Limitations of MRI include its inability to reliably depict calcification and relatively long data acquisition times, especially with regard to breath-holding. Arrhythmias, which commonly occur in association with pericardial disease, may affect image acquisition and quality; nevertheless, CT or MR should be used when findings on echocardiography are difficult to interpret or non-diagnostic.

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