Beyond pericardial effusion: the role of B-lines in echocardiographic assessment of pericardial inflammation

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Abstract Background Acute pericarditis is an inflammatory disorder of the pericardium. Though self-limiting, recurrent disease is difficult to manage, and diagnosis may be challenging as inflammatory signs fade over time. According to 2015 ESC Guidelines, diagnosis requires at least two among pleuritic chest pain, pericardial rubs, electrocardiographic (ECG) changes, or pericardial effusion. Indeed, up to half of all cases show no effusion, weakening the role of standard transthoracic echocardiography (TTE).Because lung B-lines are recognized markers of inflammation in pulmonary disease, we hypothesized that analogous "pericardial B-lines" could serve as a novel sign of active pericardial inflammation. Purpose We aimed to investigate whether pericardial B-lines could indicate pericardial inflammation and to determine whether pericardial echogenicity provides added diagnostic value. Methods We prospectively enrolled consecutive adults referred to a specialized pericarditis clinic for suspected pericarditis.All underwent clinical evaluation, ECG, and TTE by an EACVI-certified cardiologist, with diagnoses made according to ESC criteria. Pericardial B-lines were evaluated in parasternal views and categorized by length (>10 cm, 5–10 cm or <5 cm). Ultrasound gain was standardized before assessing pericardial echogenicity (scored mild, moderate, or intense). Our primary endpoint was the association of these TTE findings with actively inflamed pericardium, according to ESC criteria. Results A total of 618 participants (mean age 47±17 years, 62% female) were enrolled. Pericarditis was confirmed in 320 (52%), 72% idiopathic, 42% with pericardial effusion and 36% with elevated C-reactive protein (CRP). Pericardial B-lines measuring >10 cm were strongly associated with pericarditis (HR 2.41, 95% CI 1.85–3.16; p<0.001), while B-lines >5 cm showed a moderate association (HR 1.14, 95% CI 1.04–1.25; p=0.003). The presence of at least one B-line longer than 10 cm was highly predictive (HR 11.68, 95% CI 6.12–22.27; p<0.001), with 73% sensitivity and 81% specificity. Patients with B-lines >10 cm were more likely to have pericardial effusion (61% vs. 41%; p=0.006),CRP elevation (35% vs. 17%; p=0.006),higher INFLA-score (3±7 vs.-1±7, p = 0.003) and moderate/intense echogenicity (HR 2.8, 95% CI 1.40–5.44; p=0.003). Conclusions Our study suggests that pericardial B-lines and enhanced echogenicity may serve as novel markers of active pericardial inflammation. Since nearly 50% of pericarditis cases present without a detectable effusion, introducing these additional signs into routine TTE evaluation could improve diagnostic accuracy, especially in recurrent or atypical presentations. Further investigations should clarify whether systematic assessment of pericardial B-lines refines risk stratification, guides therapy and ultimately improves patient outcomes.Results, picture 1 PLAX and PSAX B-lines

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