- Yehuda Adler, MD
Yehuda Adler, MD
- Professor of Cardiology
- Cardiac Rehabilitation Institute
- Tel Aviv University, Israel
- Massimo Imazio, MD, FESC
Massimo Imazio, MD, FESC
- Contract Professor of Physiology
- Maria Vittoria Hospital and Department of Public Health and Pediatrics, University of Torino, Torino, Italy
- Section Editors
- Bernard J Gersh, MB, ChB, DPhil, FRCP, MACC
Bernard J Gersh, MB, ChB, DPhil, FRCP, MACC
- Editor-in-Chief — Cardiovascular Medicine
- Section Editor — Coronary Heart Disease; Myopericardial Disease
- Professor of Medicine
- Mayo Clinic College of Medicine
- Jae K Oh, MD
Jae K Oh, MD
- Section Editor — Myopericardial Disease
- Professor of Medicine
- Mayo Clinic College of Medicine
Recurrent pericarditis is a common and often vexing problem for specialists in pericardial disease as well as general internists and family clinicians. The term refers to a syndrome in which acute pericarditis recurs after the agent inciting the original acute attack has disappeared or has ceased to be active.
Recurrent pericarditis, including its definition, proposed pathogenesis, clinical manifestations, diagnosis, and treatment, will be reviewed here. The clinical manifestations, diagnosis, and treatment of patients with an initial attack of acute pericarditis are discussed separately. (See "Clinical presentation and diagnostic evaluation of acute pericarditis" and "Treatment of acute pericarditis".)
The major clinical manifestations of acute pericarditis are chest pain, pericardial friction rub, widespread saddle-shaped or concave upward ST segment elevation on the electrocardiogram (ECG), and pericardial effusion . At least two of these features should usually be present to make the diagnosis. The clinical manifestations of acute pericarditis are discussed in greater detail elsewhere. (See 'Clinical presentation' below and "Clinical presentation and diagnostic evaluation of acute pericarditis", section on 'Clinical features'.)
Recurrent pericarditis is manifested by recurrence of the symptoms of acute pericarditis (table 1); however, the predominant feature of recurrent pericarditis is usually chest pain, and other clinical manifestations of acute pericarditis may not be present. The term recurrent pericarditis refers to a syndrome in which acute pericarditis recurs after the agent inciting the original acute attack has disappeared or has ceased to be active [2-5]. The recurrence of symptoms can be at any point following the prior cessation of acute pericarditis symptoms, but usually occurs weeks to months later. Generally there is an arbitrary defined period of six weeks from the initial or previous attack. Cases with incessant or persistent symptoms within six weeks are considered "incessant pericarditis" rather than "recurrent pericarditis."
The COlchicine for REcurrent pericarditis (CORE) trial, which enrolled 120 patients with recurrent pericarditis to evaluate colchicine therapy, required patients to have both of the following clinical criteria to meet their definition of recurrent pericarditis :
- Imazio M, Demichelis B, Parrini I, et al. Day-hospital treatment of acute pericarditis: a management program for outpatient therapy. J Am Coll Cardiol 2004; 43:1042.
- Robinson J, Brigden W. Recurrent pericarditis. Br Med J 1968; 2:272.
- Fowler NO. Recurrent pericarditis. Cardiol Clin 1990; 8:621.
- Fowler NO, Harbin AD 3rd. Recurrent acute pericarditis: follow-up study of 31 patients. J Am Coll Cardiol 1986; 7:300.
- Troughton RW, Asher CR, Klein AL. Pericarditis. Lancet 2004; 363:717.
- Imazio M, Bobbio M, Cecchi E, et al. Colchicine as first-choice therapy for recurrent pericarditis: results of the CORE (COlchicine for REcurrent pericarditis) trial. Arch Intern Med 2005; 165:1987.
- Maisch B, Ristić AD, Pankuweit S. Intrapericardial treatment of autoreactive pericardial effusion with triamcinolone; the way to avoid side effects of systemic corticosteroid therapy. Eur Heart J 2002; 23:1503.
- Imazio M, Bobbio M, Cecchi E, et al. Colchicine in addition to conventional therapy for acute pericarditis: results of the COlchicine for acute PEricarditis (COPE) trial. Circulation 2005; 112:2012.
- Spodick DH. Intrapericardial treatment of persistent autoreactive pericarditis/myopericarditis and pericardial effusion. Eur Heart J 2002; 23:1481.
- Brucato A, Brambilla G, Moreo A, et al. Long-term outcomes in difficult-to-treat patients with recurrent pericarditis. Am J Cardiol 2006; 98:267.
- Authors/Task Force Members, Adler Y, Charron P, et al. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases: The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC)Endorsed by: The European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2015; 36:2921.
- Maisch B. Recurrent pericarditis: mysterious or not so mysterious? Eur Heart J 2005; 26:631.
- Pankuweit S, Wädlich A, Meyer E, et al. Cytokine activation in pericardial fluids in different forms of pericarditis. Herz 2000; 25:748.
- DeLine JM, Cable DG. Clustering of recurrent pericarditis with effusion and constriction in a family. Mayo Clin Proc 2002; 77:39.
- Imazio M, Gaita F, LeWinter M. Evaluation and Treatment of Pericarditis: A Systematic Review. JAMA 2015; 314:1498.
- Soler-Soler J, Sagristà-Sauleda J, Permanyer-Miralda G. Relapsing pericarditis. Heart 2004; 90:1364.
- Raatikka M, Pelkonen PM, Karjalainen J, Jokinen EV. Recurrent pericarditis in children and adolescents: report of 15 cases. J Am Coll Cardiol 2003; 42:759.
- Imazio M, Brucato A, Adler Y, et al. Prognosis of idiopathic recurrent pericarditis as determined from previously published reports. Am J Cardiol 2007; 100:1026.
- Imazio M, Demichelis B, Parrini I, et al. Management, risk factors, and outcomes in recurrent pericarditis. Am J Cardiol 2005; 96:736.
- Lange RA, Hillis LD. Clinical practice. Acute pericarditis. N Engl J Med 2004; 351:2195.
- Klein AL, Abbara S, Agler DA, et al. American Society of Echocardiography clinical recommendations for multimodality cardiovascular imaging of patients with pericardial disease: endorsed by the Society for Cardiovascular Magnetic Resonance and Society of Cardiovascular Computed Tomography. J Am Soc Echocardiogr 2013; 26:965.
- Alraies MC, AlJaroudi W, Yarmohammadi H, et al. Usefulness of cardiac magnetic resonance-guided management in patients with recurrent pericarditis. Am J Cardiol 2015; 115:542.
- Artom G, Koren-Morag N, Spodick DH, et al. Pretreatment with corticosteroids attenuates the efficacy of colchicine in preventing recurrent pericarditis: a multi-centre all-case analysis. Eur Heart J 2005; 26:723.
- Imazio M, Demichelis B, Parrini I, et al. Recurrent pain without objective evidence of disease in patients with previous idiopathic or viral acute pericarditis. Am J Cardiol 2004; 94:973.
- Godeau P, Derrida JP, Bletry O, Herreman G. [Recurrent acute pericarditis and corticoid dependence. Apropos of 10 cases]. Sem Hop 1975; 51:2393.
- Imazio M, Spodick DH, Brucato A, et al. Controversial issues in the management of pericardial diseases. Circulation 2010; 121:916.
- Imazio M, Brucato A, Mayosi BM, et al. Medical therapy of pericardial diseases: part I: idiopathic and infectious pericarditis. J Cardiovasc Med (Hagerstown) 2010; 11:712.
- Markel G, Imazio M, Brucato A, Adler Y. Prevention of recurrent pericarditis with colchicine in 2012. Clin Cardiol 2013; 36:125.
- Imazio M, Brucato A, Cemin R, et al. Colchicine for recurrent pericarditis (CORP): a randomized trial. Ann Intern Med 2011; 155:409.
- Imazio M, Belli R, Brucato A, et al. Efficacy and safety of colchicine for treatment of multiple recurrences of pericarditis (CORP-2): a multicentre, double-blind, placebo-controlled, randomised trial. Lancet 2014; 383:2232.
- Imazio M, Trinchero R, Brucato A, et al. COlchicine for the Prevention of the Post-pericardiotomy Syndrome (COPPS): a multicentre, randomized, double-blind, placebo-controlled trial. Eur Heart J 2010; 31:2749.
- Imazio M, Brucato A, Forno D, et al. Efficacy and safety of colchicine for pericarditis prevention. Systematic review and meta-analysis. Heart 2012; 98:1078.
- Alabed S, Cabello JB, Irving GJ, et al. Colchicine for pericarditis. Cochrane Database Syst Rev 2014; 8:CD010652.
- Marcolongo R, Russo R, Laveder F, et al. Immunosuppressive therapy prevents recurrent pericarditis. J Am Coll Cardiol 1995; 26:1276.
- Scardapane A, Brucato A, Chiarelli F, Breda L. Efficacy of an interleukin-1β receptor antagonist (anakinra) in idiopathic recurrent pericarditis. Pediatr Cardiol 2013; 34:1989.
- Vassilopoulos D, Lazaros G, Tsioufis C, et al. Successful treatment of adult patients with idiopathic recurrent pericarditis with an interleukin-1 receptor antagonist (anakinra). Int J Cardiol 2012; 160:66.
- Picco P, Brisca G, Traverso F, et al. Successful treatment of idiopathic recurrent pericarditis in children with interleukin-1beta receptor antagonist (anakinra): an unrecognized autoinflammatory disease? Arthritis Rheum 2009; 60:264.
- Jain S, Thongprayoon C, Espinosa RE, et al. Effectiveness and Safety of Anakinra for Management of Refractory Pericarditis. Am J Cardiol 2015; 116:1277.
- Imazio M, Brucato A, Belli R, et al. Colchicine for the prevention of pericarditis: what we know and what we do not know in 2014 - systematic review and meta-analysis. J Cardiovasc Med (Hagerstown) 2014; 15:840.
- Lazaros G, Imazio M, Brucato A, et al. Anakinra: an emerging option for refractory idiopathic recurrent pericarditis: a systematic review of published evidence. J Cardiovasc Med (Hagerstown) 2015.
- Khandaker MH, Schaff HV, Greason KL, et al. Pericardiectomy vs medical management in patients with relapsing pericarditis. Mayo Clin Proc 2012; 87:1062.
- Brucato A, Brambilla G, Adler Y, et al. Therapy for recurrent acute pericarditis: a rheumatological solution? Clin Exp Rheumatol 2006; 24:45.
- CLINICAL PRESENTATION
- Intensity of symptoms
- Time course and frequency of recurrences
- Predictors of recurrence
- Laboratory and diagnostic testing findings
- - Electrocardiogram
- - Chest x-ray and echocardiogram
- - Signs of inflammation
- - Pericardial inflammation by imaging (CT and CMR)
- Communication with the patient
- Activity restriction
- Nonsteroidal antiinflammatory drugs
- - Our approach to glucocorticoid use
- - Intrapericardial steroids
- Other immune therapy
- Recurrent pain without objective evidence of disease
- Role of pericardiectomy
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS