Recurrence is a serious complication of acute pericarditis. Recurrent pericarditis is a term used when a pericarditis patient relapses after discontinuation of treatment. It can also be described as a pericardial pain occurring after recovery from an initial attack.
In some patients, the condition recurs only once, while for others, it recurs at intervals or many years.
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Types of recurrent pericarditis
When anti-inflammatory drugs are withdrawn, about 20%–50% of pericarditis patients relapse. If the relapse occurs within 6 weeks, it is termed incessant pericarditis. Comparatively, if a patient enjoys symptom-free intervals for longer than 6 weeks, the condition is referred to as intermittent pericarditis.
Some patients on steroid treatment may relapse below a threshold drug level threshold which varies from case to case. Cardiac tamponade, unless present in the index attack, is rare in recurrent pericarditis. Recurrent pericarditis is also not known to evolve into constrictive pericarditis.
In all cases, however, the first occurrence is often the most severe, with subsequent occurrences often being milder.
Etiology
Although the etiology of recurrent pericarditis can be diverse, in patients without a recent myocardial infarction or cardiac surgery, recurrent pericarditis is believed to be of viral or immunologic origin. The recurrence is thought to occur for any of the following reasons:
- Persistent viral infection
- An immunopathologic (autoimmune) mechanism that somehow got triggered
- A therapeutic regimen that was inadequate, such as coronary artery bypass grafting.
Corticosteroid administration in the initial treatment is also believed to be a possible cause of recurrent pericarditis, as it may influence viral replication when the dose is lowered.
Diagnosis of recurrent pericarditis
Although the yield from “diagnostic” pericardial tap and biopsy have improved cardiac tamponade, purulent infection, and neoplastic disease, these techniques are not useful in diagnosing the cause of pericarditis. Immediate hospitalization and investigation of the root cause of the infection are mandatory for a patient suspected of having viral pericarditis, with or without tamponade, or one whose response to anti-inflammatory drugs has failed.
PerDucer is an instrument that has been developed to invade the pericardium membrane in the absence of fluid effusion. Pericardioscopy and the PerDUCER are not usually available in most medical centers.
Management
A sophisticated method to prevent this disease from recurring has not been fully established.
The most straightforward treatment for managing recurrent pericarditis, once other complications have been ruled out, is an anti-inflammatory drug. If a patient is intolerant to the first anti-inflammatory drug, other types of anti-inflammatory drugs may be used. Frequently, a combination of drugs is used.
In rare cases, some patients may show refractory symptoms, indicating a need for the possible use of a corticosteroid. Corticosteroids are good at controlling pain and reducing pericardial effusion. However, these drugs are also known to increase the risk of relapse when patients are weaned off the drug. For this reason, whenever a corticosteroid is used for treating recurrent pericarditis, the dose is reduced gradually and over a period of two months or more.
The use of corticosteroids at immunosuppressive dosages has been studied; however, its use has not been assessed thoroughly enough to be recommended as an alternative therapy.
An anti-gout medication has also been found to be useful in the treatment of recurrent pericarditis with a fairly high success rate. However, more confirmatory studies may be needed before it emerges as a primary option for the prevention of recurrent pericarditis.
Pericardiectomy has never been successful in ending recurrences. Restriction of physical activity or limiting exertion to what is essential has also been practical advice given to patients undergoing treatment for recurrent pericarditis.
Imminent
Although there is progress in the treatment of recurrent pericarditis, there is no reliable non-invasive method by which autoimmune cases can be differentiated from other cases caused either by infection or reinfection. Predicting the final result of a pericardiectomy and discovering the cause of recurring pain when there is no evidence of pericarditis are two important areas where further studies are needed.
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