Treatment of Recurrent Pericarditis Tratamiento de la pericarditis recurrente

Recurrent pericarditis is probably the most common and troublesome complication of pericarditis, affecting about 20% to 30% of patients after a first attack of acute pericarditis. Recurrent pericarditis is defined as the recurrence of symptoms and signs of pericarditis after an arbitrary symptom-free interval of 6 weeks. A minimal symptom-free interval of 4 to 6 weeks after the index attack is important to avoid labeling incessant cases without resolution of the first attack of pericarditis as recurrences. Such incessant cases are also named as ‘‘incessant pericarditis’’ and do not represent a real recurrence. Proposed diagnostic criteria for recurrent pericarditis include recurrent chest pain and 1 or more of the following signs: fever, pericardial friction rubs, electrocardiographic changes, echocardiographic evidence of new or worsening pericardial effusion, or elevated markers of inflammation (ie, elevated leukocyte count, erythrocyte sedimentation rate, or C-reactive protein level). Many patients with a previous attack of pericarditis may experience recurrent pain but without a true recurrence documented by objective evidence of disease activity (ie, elevated C-reactive protein). This finding is important to avoid misunderstandings and unnecessary antiinflammatory therapies. The etiopathogenesis of recurrences is poorly understood and most cases remain idiopathic. However most cases are considered to be immune-mediated, although this has been only partially confirmed by the presence of either nonspecific or specific autoantibodies (ie, antinuclear antibodies, antiheart antibodies). Other cases may be related to an autoinflammatory disease (ie, familial Mediterranean fever) or an infective cause (usually viral either as chronic infection, reinfection or new infection, as demonstrated in up to one-third of recurrent pericardial effusions requiring pericardiocentesis). Some cases are the expression of a previously unknown neoplastic pericardial disease (especially lung cancer, but cases have been reported with breast cancer, lymphomas, and more rarely with primary cancer of the pericardium, especially pericardial mesothelioma). In clinical practice, several cases of recurrences may be especially related to inappropriate or incomplete treatment of the first attack or to a subsequent recurrence due either to dosage or treatment length. The aim of the present editorial is to briefly review current management strategies for recurrent pericarditis