Journal of the American College of Cardiology (JACC)The Paradigm Shift in the Management of Recurrent Pericarditis

This comprehensive review presents evidence-based advances in recurrent pericarditis management since 2015 ESC guidelines, emphasizing cardiac MRI-guided therapy and interleukin-1 inhibitor integration. The analysis synthesizes randomized trial data supporting earlier biologic intervention and individualized treatment protocols for this challenging condition affecting 15-30% of acute pericarditis patients.

⚕️ Key Clinical Considerations ⚕️

• Advanced Imaging Integration: CMR T2 and LGE sequences provide 73% sensitivity/99% specificity for diagnosis, enabling precise pericardial inflammation characterization and treatment monitoring beyond traditional biomarkers
• Biologic Therapy Efficacy: RHAPSODY trial demonstrated rilonacept reduced recurrence risk (HR: 0.04, 95% CI: 0.01-0.18, p<0.001) in patients with ≥2 recurrences and inflammatory phenotype
• Treatment Duration Reduction: CMR-guided therapeutic approach significantly decreased recurrence rates, glucocorticoid exposure, and pericardiocentesis requirements in 507-patient retrospective analysis
• Inflammatory Phenotype Targeting: IL-1 inhibitors specifically benefit patients with CRP >1 mg/dL and persistent pericardial LGE, representing paradigm shift from symptom-based to biomarker-guided therapy
• First-Line Therapy Optimization: Colchicine plus NSAIDs remains standard care with proven NNT of 3-5 across multiple trials, while corticosteroids increase recurrence risk despite symptom relief

🎯 Clinical Practice Impact 🎯

• Patient Communication: Inform patients about treatment duration potentially decreasing from 4.7-6.2 years to shorter courses with advanced therapies. Discuss CMR monitoring benefits for treatment optimization and the availability of FDA-approved biologic options for refractory cases.
• Practice Integration: Implement CMR-guided treatment protocols for patients with multiple recurrences. Consider earlier IL-1 inhibitor consultation for inflammatory phenotype patients rather than prolonged conventional therapy escalation.
• Risk Management: Monitor for biologic therapy side effects including injection site reactions and infections. Avoid corticosteroid dependence given increased recurrence risk and prolonged disease course documented in clinical trials.
• Action Items: Establish CMR protocols for treatment monitoring, develop inflammatory phenotype identification criteria (≥2 recurrences, CRP >1 mg/dL, persistent LGE), and create biologic therapy referral pathways for appropriate candidates.

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