Elsevier

Progress in Cardiovascular Diseases

Volume 59, Issue 4, January–February 2017, Pages 360-368
Progress in Cardiovascular Diseases

Recurrent Pericarditis

https://doi.org/10.1016/j.pcad.2016.10.001Get rights and content

Abstract

Recurrent pericarditis is the most common and troublesome complication of pericarditis affecting 20% to 50% of patients. Its pathogenesis is often presumed to be immune-mediated, but additional investigations are needed to clarify the pathogenesis in order to develop etiology-oriented therapies. Imaging with computed tomography and especially cardiac magnetic resonance holds promise to help in the identification of more difficult cases and improve their management.

Refractory recurrent pericarditis with corticosteroid dependence and colchicine resistance remain still an unsolved issue in search of new therapies, although old drugs such as azathioprine, intravenous immunoglobulins, and biological agents seem promising, but new randomized clinical trials are needed to confirm their role. Despite compromising the quality of life, idiopathic recurrent pericarditis has an overall good long-term outcome without mortality and significant risk of constrictive pericarditis evolution. The risk of constriction, the most feared complication, is related to the etiology and not the number of recurrences.

Section snippets

Introduction and search strategy

MEDLINE and Cochrane Library were systematically screened with specific terms “(recurrent pericarditis) AND (“2011”[pdat]:“2016”[pdat]) NOT (review[pt] OR editorial[pt] OR letter[pt])”. Non-humans studies, non-English language and duplicate reporting were excluded. Twenty-eight of 50 articles were rejected as being judged non pertinent for the present review by agreement between two authors (MI and EG). Pertinent articles were appraised as full text. Furthermore, the most relevant studies

Definition

Recurrent pericarditis is one of the most troublesome complication of pericarditis and should be distinguished from incessant pericarditis.1., 2.Incessant pericarditis refers to patients without remission or who have early reappearance of symptoms within 4 to 6 weeks after a documented first episode of pericarditis and it is often due to inappropriate treatment of pericarditis (e.g. an early discontinuation of anti-inflammatory therapy, low doses of drugs, lack of specific recommendations on

Clinical manifestations

The main clinical manifestation of recurrent pericarditis is the “pericardial” pain, which is similar in characteristics to the pain of acute pericarditis. The other typical manifestations of pericarditis, such as electrocardiographic changes, pericardial friction rub and pericardial effusion are typically less frequent in relapses than in the index attack. Usually, the clinical manifestations of pericarditis become more and more attenuated from one episode to a subsequent episode of recurrence.

Etiology

The etiology of recurrent pericarditis is not completely understood, although an immune-mediated pathogenesis is often presumed as also suggested by the findings of non-organ specific and anti-heart antibody in patients with recurrences, as well as the response to corticosteroids and colchicine therapy.1., 9., 10.

However, inadequate therapy of pericarditis, albeit often underestimated, may represent a main cause of recurrences. To this regard, low doses of anti-inflammatory drugs, short therapy

Diagnosis

The diagnosis of recurrent pericarditis is based on the demonstration of a previous episode of acute pericarditis associated with the finding of “pericarditic pain” and another finding of pericarditis [e.g. pericardial friction rub, electrocardiographic changes, new or worsening pericardial effusion, elevation of inflammation markers, as C-reactive protein (CRP) or white blood cell count] (Table 3).

In patients with repeated relapses, the diagnosis is mainly based on the confirmation of the

Therapy

The cornerstone of therapy for recurrences is physical restriction until symptoms resolution and C-reactive protein normalization in addition to an anti-inflammatory therapy based on aspirin or NSAID plus colchicine as first choice; then if the patient is not responding or has recurrences it is possible to add corticosteroids (Table 4).3., 4., 5., 6., 7.

The assessment of C-reactive protein values could be used for the initial diagnosis and to monitor the activity of the disease in order to

Outcomes and prognosis

The prognosis of idiopathic recurrent pericarditis is generally good without mortality and significant risk of constriction even despite several recurrences. Indeed, the risk of constriction does not depend on the number of relapses, but it is related to the etiology of pericarditis.2

Conclusions and perspectives

Recurrent pericarditis is the most common and troublesome complication of pericarditis affecting 20 to 50% of patients. Its pathogenesis is often presumed to be immune-mediated, but additional investigations are needed to clarify the pathogenesis in order to develop etiology-oriented therapies. Imaging with CT and especially CMR holds promise to help in the identification of more difficult cases and improve their management. Refractory recurrent pericarditis with corticosteroid dependence and

Statement of conflict of interest

None of the authors have any conflicts of interests with regard to this publication.

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