Acute recurrent pericarditis: from pathophysiology towards new treatment strategy

Abstract

Acute idiopathic or so-called viral pericarditis is a frequent and usually benign disease, although recurrences are frequent. Data strongly suggest the presence of underlying autoinflammatory and/or autoimmune disorders. It has been reported that there is an inflammatory response of the innate immune system typical of ‘autoinflammatory diseases’, predominantly mediated by interleukin-1 (IL-1). This may result from the activation of the inflammasome by a cardiotropic virus or a non-specific agent. The inflammatory response of the adaptive immune system, typical of ‘autoimmune diseases’—mainly mediated by autoantibodies or autoreactive T lymphocytes—seems also involved as anti-heart or anti-intercalated disk autoantibodies were associated with a higher number of recurrences and hospitalisations. Current guidelines recommend that aspirin/non-steroidal anti-inflammatory drugs for a few weeks should be associated to colchicine for 6 months in recurrent pericarditis. In refractory cases, low-dose corticosteroids or immunosuppressive drugs have been proposed with limited efficacy. Growing evidences suggest a place of IL-1 receptor antagonists in the treatment of recurrent pericarditis. Many retrospective studies, one recent randomised placebo-controlled study and data of a real-life large international registry showed the good efficacy of anakinra with a good safety profile. Other IL-1 receptor antagonists showed promising results (canakinumab, rilonacept). However, IL-1 receptor antagonists’ position in the treatment algorithm of recurrent pericarditis needs further evaluation in larger prospective clinical trials to replicate initial findings as well as to assess safety, cost-effectiveness and long-term efficacy.

Is Acetylsalicylic Acid a Safe and Potentially Useful Choice for Adult Patients with COVID-19 ?

“…At intermediate-to-high doses (650 mg to 4 g/day), ASA is able to irreversibly inhibit both COX-1 and COX-2, and at these doses ASA has been used for treating severe inflammatory disorders (e.g., rheumatic fever, Kawasaki disease, adult-onset Still's disease, and recurrent pericarditis) [69][70][71][72][73][74]. Significant improvement of some inflammation-related symptoms (e.g., fever, joint symptoms) and reductions of plasma levels of inflammation markers (e.g., white blood cell count, erythrocyte sedimentation rate, and C-reactive protein) have been obtained with the use of intermediate-to-high doses of ASA in all the aforementioned conditions [69][70][71][72][73][74]. In addition, a single high dose of ASA has improved symptoms related to both the common cold and flu, including fever, myalgias, headache, and sore throat [75,76].…”

“…Concern over the use of ASA are mostly related to side effects occurring in four main situations: (1) long-term course of therapy with intermediate-to-high doses in rheumatic-immune disorders; (2) long-term use of low doses for the prevention of ischemic cardiovascular diseases; (3) use of low doses for the prevention of thrombotic complications during pregnancy; (4) short-term use of high doses in children with a viral infection. Irrespective of its effectiveness, intermediate-to-high doses of ASA have been used for the treatment of different rheumatic-immune disorders, including rheumatic fever, Kawasaki disease, adult-onset Still's disease, and recurrent pericarditis [69][70][71][72][73]. In some of these conditions, side effects of ASA, mainly gastrointestinal (e.g., nausea, epigastric pain or discomfort, and bleeding), were rare and generally related to the long-term use of high ASA doses [129,130].…”

Idiopathic recurrent pericarditis – a new orphan autoinflammatory disease? A retrospective analysis of cases of idiopathic recurrent pericarditis and a design of а double-blind, randomized, placebo-controlled study to evaluate the efficacy and safety of RPH-104 treatment in patients with idiopathic recurrent pericarditis

“…Рассмотрение ИРП в спектре АВЗ позволяет не трактовать данную патологию, как осложнение острого перикардита, как считалось ранее некоторыми авторами [19]. Рецидивное течение -закономерная особенность хронического по своей патофизиологии аутовоспалительного процесса, что сближает ИРП с другими АВЗ, тесно связанными с активацией инфламмасомы [22].…”

Pericardial Angiosarcoma: A Diagnostic Challenge

“…Acute pericarditis is a common clinical entity diagnosed when two of the four findings are present: chest pain, pericardial friction rub, diffuse concave upward ST segment elevation on electrocardiogram (EKG), and pericardial effusion on echocardiogram [ 1 ]. Recurrence after an acute episode occurs in at least 20-50% of the patients [ 2 ]. With the advances in medicine, immunization, and treatment of infections such as tuberculosis, the etiologies of acute pericarditis have changed.…”