AccScience Publishing / BH / Online First / DOI: 10.36922/bh.8292
REVIEW ARTICLE

Evaluation and management of recurrent pericarditis in special populations: A contemporary review

Harsha Sanaka1 Elio Haroun1 Karl Abou Zeid1 Aro Daniela Arockiam1 Allan L. Klein1 Tom Kai Ming Wang1*
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1 Department of Cardiovascular Medicine, Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Robert and Suzanne Tomsich, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, United States of America
Submitted: 30 December 2024 | Revised: 20 February 2025 | Accepted: 27 February 2025 | Published: 14 March 2025
© 2025 by the Author(s). This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution 4.0 International License ( https://creativecommons.org/licenses/by/4.0/ )
Abstract

About 15 – 30% of patients develop recurrent episodes of pericarditis following an acute pericarditis attack. In developed countries, most cases of pericarditis are of idiopathic etiology. First-line therapy typically includes non-steroidal anti-inflammatory drugs (NSAIDs) and colchicine, with corticosteroids being the traditional second-line agents. Anti-interleukin-1 (IL-1) agents are a novel treatment option increasingly utilized due to their high efficacy as an alternative second-line therapy or for resistant cases, while pericardiectomy remains the last resort. Special populations with recurrent pericarditis (RP), including patients at the extremes of age or during pregnancy, have been understudied. In some cases, pericarditis may develop secondary to infections (including viral infections, such as coronavirus disease 2019, bacterial infections, such as tuberculosis, and fungal infections), autoimmune diseases (such as systemic lupus erythematosus, rheumatoid arthritis, vasculitis, and inflammatory bowel disease), post-cardiac injury syndromes, cancer, and other rare conditions. Non-idiopathic etiologies are associated with a higher risk of RP, chronic constrictive pericarditis, and cardiac tamponade. The general treatment algorithm may not be applicable to these special populations due to patient-related or etiological factors. For example, NSAIDs or corticosteroids are often contraindicated in older patients due to comorbidities. Bacterial or fungal purulent pericarditis requires aggressive treatment of infection followed by pericardial fluid drainage, with corticosteroids and anti-IL-1 agents contraindicated in these cases. Therefore, management often requires a multidisciplinary approach and must take place at a specialized pericardial center to optimize patient outcomes. In this review, we present current evidence on the evaluation and management of RP in the aforementioned special populations.

Keywords
Pericarditis
Recurrent pericarditis
Echocardiography
Cardiac magnetic resonance
Special populations
Anti-inflammatories
Anti-interleukin-1 agents
Funding
None.
Conflict of interest
Allan L. Klein has received research grants from Kiniksa Pharmaceuticals and Cardiol Therapeutics and serves on the Advisory Board of Kiniksa Pharmaceuticals, Cardiol Therapeutics, and Pfizer.
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