The correct answer is: A. Exercise restriction for a minimum of 3 months and until normalization of inflammatory markers

A) The patient was initially diagnosed with pericarditis. She presented with two out of four diagnostic criteria (echocardiogram demonstrating effusion, characteristic pleuritic chest pain). Remaining diagnostic criteria that were not present in this case: ECG changes such as PR depressions and widespread ST elevations and pericardial friction rub on auscultation. However, her symptoms recurred after initial resolution and thereafter diagnosed with recurrent pericarditis. Despite multiple postulated mechanisms regarding the role of exercise on active inflammation of the myocardium or pericardium, the exact pathophysiology remains largely unknown.¹ The rationale behind the avoidance of physical activity when diagnosed with pericarditis is to reduce the risk of complications such as progression to myocarditis, worsening pericardial effusion and cardiac tamponade, constrictive pericarditis, or recurrent/refractory symptoms.¹ European Society of Cardiology (ESC) 2015 guidelines provide recommendations for non-competitive athletes and competitive athletes. In non-competitive athletes, exercise restriction should be considered until symptoms have resolved and inflammatory markers, ECG, and transthoracic echocardiogram (TTE) changes normalize. The recommendation for competitive athletes is to stop participation in exercise (for a minimum of 3 months) until resolution of symptoms or inflammatory markers, ECG, or TTE normalize. In our clinical practice, we recommend restricting maximum heart rate to 100 bpm and a step count less than 5,000 per day. Since the patient in this case is a competitive athlete, she is advised to stop exercise for a minimum of 3 months until her inflammatory markers normalize.

B) Surgical referral for pericardiectomy should be used as a last resort after multiple failed attempts with medical therapy and concurrent exercise reduction. In this case, the patient remained active as a basketball coach thus exercise restriction and repeat regimen with the addition of steroids are the best initial treatment for recurrence. Of note, immunomodulatory drugs could be considered after triple therapy (nonsteroidal anti-inflammatory drugs [NSAIDs], colchicine, low-moderate dose steroids) and exercise restriction fail to resolve symptoms, prior to pericardiectomy.

 C) Low to moderate doses (0.2-0.5 mg/kg/day) of oral corticosteroids are recommended in the absence of active infection in patients with incomplete response to prior NSAID plus colchicine as triple therapy or in the patient who cannot tolerate NSAID therapy. The patient started on NSAIDs and colchicine for recurrent pericarditis but was still experiencing symptoms. The patient weighs 63 kg and is therefore treated with 20 mg prednisone in addition to 800 mg ibuprofen TID and colchicine 0.6 mg daily. It is important to note, however, this is a chronic treatment strategy and should be followed by a slow taper as dictated by resolution of symptoms and normalization of inflammatory makers. A critical threshold for recurrences is a 10-15 mg/day dose of prednisone or equivalent with slow decrements as small as 1.0-2.5. mg at intervals of 2-6 weeks.² In the case of recurrence during steroid taper, every effort should be made not to increase the dose or reinstate corticosteroids.² Intrapericardial corticosteroid injection may bypass some of systemic side effects seen with an oral regimen, however, there needs to be further investigation with this strategy.

D) Recurrent pericarditis is defined as recurrence of symptoms after being symptom free for 4-6 weeks or longer after an initial diagnosis of pericarditis. Recurrence rate ranges from 15%-30% and may increase as high as 50% after first recurrence in patients not treated with colchicine. Colchicine is recommended in addition to standard anti-inflammatory therapy (NSAIDS and/or corticosteroids) without a loading dose and using weight-based dosing (0.5 mg daily if ideal body weight is <70 kg or 0.5 mg twice a day if ideal body weight is >70 kg). Colchicine has been shown to improve response rates to medical therapy, improve remission rates, and prevent reoccurrences. In cases of incomplete response to aspirin/NSAIDs and colchicine, corticosteroids may be added, not replace, these drugs, but to achieve better control of symptoms. Azathioprine is an immunomodulatory drug that can be considered in setting of persistent symptoms in the patient despite triple therapy. Azathioprine can also be considered as steroid-sparing strategy. In regards to biologics used to treat recurrent pericarditis, recent data from the RHAPSODY trial revealed patients treated with rilonacept (an interleukin 1-alpha and 1-beta cytokine trap) with recurrent pericarditis and systemic inflammation (defined by elevated C-reactive protein [CRP]) lead to rapid resolution of recurrent pericarditis episodes and lower risk of recurrence when compared to placebo.³ This group also trended towards faster weaning of other therapy, including corticosteroids. When using immunomodulation drugs, it is important to pursue a multidisciplinary approach and enlist the expertise of a rheumatologist and/or immunologist.

References

1. Shah, NP, Verma BR, Chandra AK, et al. Exercise is good for the heart but not for the inflamed pericardium? JACC Cardiovasc Imaging 2019;12:1880-81.
2. Adler Y, Charron P, Imazio M, et al. 2015 ESC guidelines for the diagnosis and management of pericardial diseases: the Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC). Eur Heart J 2015;36:2921–64.
3. Klein AL, Imazio M, Cremer P, et al. Phase 3 trial of interleukin-1 trap rilonacept in recurrent pericarditis. N Engl J Med 2021;384:31-41.