Recurrent pericarditis:
why it comes back and what to do

Article written and reviewed by Dr Luca Moretti

Pericarditis can return even after an apparently resolved episode. It is called recurrent pericarditis when, after a documented first episode and a period of remission, a new episode occurs that is compatible with renewed inflammation of the pericardium. Recurrence is one of the most frequent complications: after a first episode it affects about 15-30% of patients, and the risk increases after a first recurrence, especially if treatment has not been adequate.
However, return of pain should not automatically be labeled as a recurrence. It is necessary to verify whether there are truly signs of disease activity and to distinguish pericarditis from other causes of chest pain.

If pain returns after pericarditis, it is useful to:

• not increase or restart medication independently;
• check whether the pain has features similar to the previous episode;
• assess CRP, ECG and echocardiogram when indicated;
• use cardiac magnetic resonance imaging in uncertain or complex cases;
• review the duration and tapering schedule of the previous treatment;
• limit physical activity again during the inflammatory phase;
• consider specialist management if recurrences are frequent or resistant.

The monograph on recurrent pericarditis examines pathophysiology and classification in greater depth. This guide instead answers the practical question: what it means when pericarditis returns, how a recurrence is confirmed and what current treatment options are available.

How to tell whether it is truly a recurrence

A typical recurrence often reproduces the pain experienced during the previous episode: sharp or pleuritic chest pain, worsening when lying down and possible improvement when leaning the torso forward. Low-grade fever, fatigue and elevated inflammatory markers may recur. However, the clinical picture may be less complete than during the first episode.
For this reason, diagnosis is not based on pain alone. ECG, C-reactive protein, echocardiogram and, when the clinical picture is uncertain, cardiac magnetic resonance imaging are used. CMR can document pericardial edema and contrast enhancement and can be particularly useful in patients who have symptoms but few evident findings on traditional tests.

It is important to distinguish a true recurrence from persistent non-inflammatory pain. After several episodes, some people continue to feel chest discomfort even when CRP and imaging show no significant disease activity. In these cases, repeatedly increasing anti-inflammatory drugs or corticosteroids can expose the patient to adverse effects without treating the actual cause of the symptom.
At the opposite extreme, a recurrence with pain very similar to previous episodes should not automatically be considered harmless: if significant shortness of breath, syncope, hypotension or rapid deterioration develops, complications and other emergencies must be excluded.

Why pericarditis can return

In most recurrent idiopathic forms, a new infection is not identified every time. The mechanism is more often a reactivation of the inflammatory or autoinflammatory response, with an important role for interleukin-1 and the inflammasome. This understanding has profoundly changed treatment of the most difficult forms and explains why drugs directed against IL-1 can be very effective in selected patients.
The risk of recurrence increases when the first episode has not been treated adequately, colchicine was not used when indicated, or medications were tapered too quickly. Early or prolonged corticosteroid use, especially at high doses and with rapid tapering, is also associated with greater treatment dependence and more recurrences.

This does not mean that every recurrence is caused by a treatment error. Some patients have a marked autoinflammatory predisposition in which the disease tends to flare despite correct management. In other cases, an apparent recurrence may be a sign of an underlying cause that has not yet been recognized, such as an autoimmune disease, cancer or a specific infection.
Etiologic reassessment is particularly important when the clinical picture is atypical, resistant, associated with high fever, large effusions or other systemic signs.

How recurrent pericarditis is treated

Treatment of a recurrence generally uses aspirin or an NSAID together with colchicine. Colchicine is continued for longer than after a first episode, generally for at least 6 months, with duration individualized according to the number of recurrences, response and tolerability. The anti-inflammatory drug should be tapered gradually once remission has been achieved.
Corticosteroids are avoided as a first option whenever possible. They may be necessary if NSAIDs and colchicine are contraindicated or ineffective, or when there is a specific autoimmune disease, but the strategy should use the lowest effective dose and a slow taper.

Repeated recurrences may require months of treatment. Therapy should not be tapered on several fronts at the same time: generally one medication is reduced at a time when the patient is in remission and disease-activity markers are favorable. This makes it easier to recognize a possible flare and reduces the likelihood of tapering too quickly.
General treatment is discussed in more detail in the guide how pericarditis is treated.

When anakinra, rilonacept or other advanced therapies are needed

In patients with recurrent pericarditis and a clear inflammatory phenotype, especially when the disease is colchicine-resistant or corticosteroid-dependent, anti-IL-1 drugs have changed treatment options. Anakinra blocks the interleukin-1 receptor; rilonacept binds IL-1 alpha and IL-1 beta and prevents their action.
The AIRTRIP trial showed a reduction in recurrences with anakinra in patients with colchicine-resistant, corticosteroid-dependent disease. The RHAPSODY trial showed a marked reduction in recurrences with rilonacept compared with placebo in patients with recurrent pericarditis and systemic inflammation.

These results do not mean that biologic drugs should be used after a single uncomplicated recurrence. They are specialist therapies that require patient selection, exclusion of infections, assessment of vaccination status and monitoring for adverse effects. The 2025 ESC guidelines recommend them in patients with recurrent pericarditis that does not respond to first-line therapies and corticosteroids and has inflammatory activity.
Other immunomodulatory strategies, such as azathioprine or intravenous immunoglobulin, may have a role in selected situations, but the advent of anti-IL-1 drugs has made treatment of autoinflammatory forms more targeted.

What to do to reduce the risk of another recurrence

Prevention of further recurrences is based mainly on achieving stable remission before tapering treatment. It is important to take colchicine for the planned duration, not stop corticosteroids or anti-inflammatory drugs abruptly, and not return to intense physical activity too early.
During a flare, exercise should again be limited. The 2025 ESC guidelines recommend restricting physical activity until remission, for at least 1 month, and then tailoring return to activity to the individual case.

In patients with multiple recurrences, structured follow-up is useful and should take into account not only pain but also CRP and imaging when necessary. The goal is not simply to achieve a few symptom-free days, but stable remission that allows treatments to be tapered gradually without reactivating the disease.
If the condition becomes difficult to control, involvement of a center experienced in pericardial diseases can help define the inflammatory phenotype, optimize imaging and choose the appropriate time for possible advanced therapies.

Frequently asked questions about recurrent pericarditis

When is pericarditis considered recurrent?
When, after a documented first episode and an interval of remission, a new episode compatible with pericardial inflammation occurs.
Why can it come back?
Often because of reactivation of the inflammatory or autoinflammatory response; inadequate treatment or overly rapid tapering can increase the risk.
Is it dangerous?
It can be very disabling, but in idiopathic forms the cardiac prognosis is generally favorable. Each recurrence should nevertheless be confirmed and properly assessed.

How is it treated?
Generally with aspirin or an NSAID plus colchicine; corticosteroids and advanced therapies are reserved for selected situations.
Are anakinra and rilonacept needed for everyone?
No. They are indicated mainly in inflammatory recurrent forms that are resistant to conventional therapies or corticosteroid-dependent.