Pericardial Manifestations in Systemic Lupus Erythematosus: Clinical Spectrum and Potential Modifying Factors

Background: Pericardial involvement is the most common cardiac manifestation of systemic lupus erythematosus (SLE), ranging from mild effusion to recurrent pericarditis and cardiac tamponade. The influence of antiphospholipid syndrome (APS) on lupus-related pericardial disease remains unclear. Methods: A systematic review was conducted in accordance with PRISMA 2020 guidelines and registered in PROSPERO. PubMed, Web of Science, Scopus, and the Cochrane Library were searched from inception to January 2026 for observational studies evaluating pericardial manifestations in adult SLE patients. APS/aPL status was considered a potential modifying factor when reported. Results: Seven observational studies were included. Pericardial involvement ranged from acute and recurrent pericarditis to large effusions and cardiac tamponade. Across studies, it was consistently associated with higher disease activity and markers of immune activation. Recurrent pericarditis emerged as a clinically relevant phenotype linked to more severe disease and worse outcomes. Cardiac tamponade, although rare, was associated with significant morbidity and mortality. APS/aPL-related data were heterogeneous and inconsistently reported across studies. No consistent APS-specific association with pericardial disease could be established, although APS or aPL-related findings were occasionally reported in selected severe or clinically complex presentations. Conclusions: Pericardial involvement in SLE reflects systemic inflammatory burden and spans a broad clinical spectrum. Current evidence regarding APS remains limited and heterogeneous, although APS may contribute to disease complexity in selected severe presentations. Importantly, isolated aPL positivity should not be interpreted as equivalent to formally classified APS. Prospective studies with standardized definitions and systematic assessment of APS are needed.