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

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.