Recurrent Pericarditis

After an episode of acute pericarditis, about 15 to 30 out of 100 people have a recurrence. In people who have already had a recurrence without colchicine, the risk of another one can reach about half. It is called recurrent when pain and signs of inflammation return after a symptom-free gap of at least 4 to 6 weeks. If the inflammation never fully settles, the condition is called incessant or chronic pericarditis, covered on the Chronic Pericarditis page.

Symptoms during a flare-up are usually similar to the first episode: sharp chest pain that gets worse when breathing or lying down, sometimes with fever. Recurrences often happen when medicines are being reduced or within a few weeks after they are stopped.

Why Pericarditis Comes Back

In many people, a recurrence is not caused by a new infection but by the immune system continuing to trigger inflammation. The risk of recurrence increases if the first episode was not treated with colchicine, anti-inflammatory medicines were stopped too soon, or corticosteroids were used, especially at high doses. Research shows a role for the inflammatory substance interleukin-1 in many cases, and it is now a target of treatment. A small number of cases are caused by autoimmune disease, TB, or a syndrome after heart injury, so these causes still need to be looked for.

Principles of Treatment

Treatment focuses on relieving flare-ups and preventing the next ones. Anti-inflammatory medicines are given together with colchicine, which is usually continued for at least six months. Medicines are tapered very slowly, one at a time, while symptoms and CRP are monitored. Low-dose corticosteroids are used when first-line medicines are not enough or cannot be used. For recurrences that keep coming back despite colchicine and that depend on corticosteroids, the ESC guidelines include a role for interleukin-1 blocking medicines. Surgery to remove the pericardium is considered only when all treatments have failed.

Prognosis

Although exhausting, recurrent pericarditis without a specific cause rarely progresses to tamponade or constriction, and the heart's pumping strength usually stays good. Recurrences usually become less frequent over time with planned treatment. Family support and open communication with your doctor help you get through the long treatment period.

A recurrence is confirmed with the same criteria as the first episode: typical chest pain, a rubbing sound from the heart lining, ECG changes, or new fluid in the sac around the heart. A rise in CRP is very helpful, because during a recurrence the ECG changes and fluid are often less pronounced.

If symptoms are not typical or CRP is normal, cardiac MRI can show whether the lining is still inflamed. This helps your doctor decide whether medicines need to be extended or added. Echocardiography assesses fluid and signs of constriction. With frequent recurrences, your doctor looks for a specific cause, such as autoimmune disease with an ANA test, TB, or autoinflammatory disease, because these causes need their own treatment.

Contact your doctor if the typical chest pain of pericarditis comes back, especially while your medicines are being tapered or after they have been stopped. Do not increase or start medicines on your own without guidance, because your doctor needs to confirm the recurrence with a CRP test and, if needed, echocardiography. Also contact your doctor if you have medicine side effects, such as severe diarrhea, stomach pain, or high blood sugar while taking corticosteroids.

Go to the emergency room right away if you have:

• Severe shortness of breath or breathlessness that worsens over a few hours
• Fainting or nearly fainting
• Severe, pressing chest pain that is different from your usual flare-ups
• Pale, cold, sweaty skin with a very fast heartbeat