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  • Review Article
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Recurrent pericarditis: new and emerging therapeutic options

Nature Reviews Cardiology volume 13, pages 99–105 (2016)Cite this article

Subjects

Key Points

  • Recurrent pericarditis is the most troublesome complication after an episode of acute pericarditis, and occurs in 20–50% of patients with pericarditis

  • Most cases of recurrent pericarditis are idiopathic, and the pathogenesis is presumed to be immune-mediated or autoinflammatory

  • The mainstay of treatment for recurrent pericarditis is high doses of anti-inflammatory therapy—usually aspirin or an NSAID (generally ibuprofen or indomethacin) plus colchicine

  • Second-line drugs are corticosteroids, to be used at low-to-moderate doses (such as prednisone 0.2–0.5 mg/kg per day or equivalent), plus colchicine

  • Triple combination therapy (aspirin or NSAID plus colchicine and corticosteroid) should be considered for patients with multiple recurrences

  • Additional options for patients with multiple (three or more) failures of conventional anti-inflammatory therapies include azathioprine, intravenous immunoglobulins, and anakinra, with pericardiectomy being a last resort

Abstract

Recurrent pericarditis is one of the most common and troublesome complications after an episode of pericarditis, and affects 20–50% of patients treated for pericarditis. In most of these patients, the pericarditis remains idiopathic, although an immune-mediated (either autoimmune or autoinflammatory) pathogenesis is often presumed. The mainstay of therapy for recurrences is aspirin or NSAIDs, with the adjunct of colchicine. Corticosteroids are a second-line option to be considered for specific indications, such as connective tissue disease or pregnancy; contraindications or intolerance to aspirin, NSAIDs, and/or colchicine; or insufficient response to these medications. Furthermore, corticosteroids can be added to NSAIDs and colchicine in patients with persistent symptoms. In patients who do not respond adequately to any of these conventional therapies, alternative treatment options include azathioprine, intravenous human immunoglobulins, and anakinra. An improved understanding of how recurrent pericarditis develops after an initiating event is critical to prevent this complication, and further research is needed into the pathogenesis of recurrences. We discuss the aetiology and diagnosis of recurrent pericarditis, and extensively review the treatment options for this condition.

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Figure 1: Mechanisms of action of emerging treatments for recurrent pericarditis.
Figure 2: Treatment levels for recurrent pericarditis.
Figure 3: Clinical trials of colchicine for the prevention of recurrent pericarditis.

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Author information

Authors and Affiliations

  1. Cardiology Department, and Department of Public Health and Pediatrics, Maria Vittoria Hospital, University of Torino, Via Luigi Cibrario 72, Torino, 10141, Italy

    Massimo Imazio

  2. Cardiology Department, University of Athens Medical School, Hippokration General Hospital, 114 Vassilissis Sophias Avenue, Athens, 115 27, Greece

    George Lazaros

  3. Internal Medicine, Azienda Ospedaliera, Papa Giovanni XXIII, Piazza OMS 1, Bergamo, 24127, Italy

    Antonio Brucato

  4. University Division of Cardiology, Department of Medical Science, AOU Città della Salute e della Scienza di Torino, Torino, 10126, Italy

    Fiorenzo Gaita

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M.I. researched data and wrote the article. All the authors contributed substantially to discussion of its content, reviewing, and editing the manuscript before submission.

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Correspondence to Massimo Imazio.

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Imazio, M., Lazaros, G., Brucato, A. et al. Recurrent pericarditis: new and emerging therapeutic options. Nat Rev Cardiol 13, 99–105 (2016). https://doi.org/10.1038/nrcardio.2015.115

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