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Patients with recurrent pericarditis were treated with the interleukin-1 trap rilonacept. Those who had a response were randomly assigned to receive continued rilonacept or placebo. Rilonacept led to a significantly lower risk of pericarditis recurrence than placebo.

In a randomized trial, patients with acute pericarditis were assigned to either colchicine or placebo in addition to conventional antiinflammatory therapy. Colchicine significantly reduced the incidence of incessant or recurrent pericarditis. Colchicine has been used for centuries to treat and prevent gouty attacks 1 and more recently has been recommended to treat and prevent serositis in patients with familial Mediterranean fever and recurrent pericarditis. 2 , 3 Preliminary data from nonrandomized trials have also supported the use of colchicine for the treatment and prevention of acute pericarditis. 4 In a single-center, open-label, randomized trial, called the Colchicine for Acute Pericarditis (COPE) study, the addition of colchicine to conventional therapy with either aspirin or glucocorticoids halved the recurrence rate after an initial attack of acute pericarditis. 5 Our study, called the Investigation on Colchicine for Acute Pericarditis . . .

The initial mechanism for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection is the binding of the virus to the membrane-bound form of ACE2, which is mainly expressed in the lung. Since the heart and the vessels also express ACE2, they both could become targets of the virus. However, at present the extent and importance of this potential involvement are unknown. Cardiac troponin levels are significantly higher in patients with more severe infections, patients admitted to intensive care units or in those who have died. In the setting of COVID-19, myocardial injury, defined by an increased troponin level, occurs especially due to non-ischaemic myocardial processes, including severe respiratory infection with hypoxia, sepsis, systemic inflammation, pulmonary thrombosis and embolism, cardiac adrenergic hyperstimulation during cytokine storm syndrome, and myocarditis. At present, there are limited reports on definite diagnosis of myocarditis caused by SARS-CoV-2 in humans and limited demonstration of the virus in the myocardium. In conclusion, although the heart and the vessels are potential targets in COVID-19, there is currently limited evidence on the direct infection of the myocardium by SARS-CoV-2. Additional pathological studies and autopsy series will be very helpful to clarify the potentiality of COVID-19 to directly infect the myocardium and cause myocarditis.

Colchicine is an ancient drug, traditionally used for the treatment and prevention of gouty attacks; it has become standard of treatment for pericarditis with a potential role in the treatment of coronary artery disease. Atherosclerotic plaque formation, progression, destabilisation and rupture are influenced by active proinflammatory cytokines interleukin (IL)-1β and IL-18 that are generated in the active forms by inflammasomes, which are cytosolic multiprotein oligomers of the innate immune system responsible for the activation of inflammatory responses. Colchicine has a unique anti-inflammatory mechanism: it is not only able to concentrate in leucocytes, especially neutrophils, and block tubulin polymerisation, affecting the microtubules assembly, but also inhibits (NOD)-like receptor protein 3 (NLRP3) inflammasome. On this basis, colchicine interferes with several functions of leucocytes and the assembly and activation of the inflammasome as well, reducing the production of interleukin 1β and interleukin 18. Long-term use of colchicine has been associated with a reduced rate of cardiovascular events both in chronic and acute coronary syndromes, with an overall good safety profile. This review will focus on the influence of colchicine on the pathophysiology of coronary artery disease, reviewing essential pharmacology and discussing the most important and recent clinical studies. On the basis of current literature, colchicine is emerging as a possible new valuable, safe and cheap agent for the treatment of acute and chronic coronary syndromes.

Key Points Recurrent pericarditis is the most troublesome complication after an episode of acute pericarditis, and occurs in 20–50% of patients with pericarditis Most cases of recurrent pericarditis are idiopathic, and the pathogenesis is presumed to be immune-mediated or autoinflammatory The mainstay of treatment for recurrent pericarditis is high doses of anti-inflammatory therapy—usually aspirin or an NSAID (generally ibuprofen or indomethacin) plus colchicine Second-line drugs are corticosteroids, to be used at low-to-moderate doses (such as prednisone 0.2–0.5 mg/kg per day or equivalent), plus colchicine Triple combination therapy (aspirin or NSAID plus colchicine and corticosteroid) should be considered for patients with multiple recurrences Additional options for patients with multiple (three or more) failures of conventional anti-inflammatory therapies include azathioprine, intravenous immunoglobulins, and anakinra, with pericardiectomy being a last resort Many patients with pericarditis experience recurrent episodes. In this Review, Imazio et al . emphasize the importance of identifying the aetiology of the disease, and summarize the available evidence for the various treatment options. First-line anti-inflammatory therapy involves aspirin, NSAIDs, and colchicine; additional and alternative options include corticosteroids, anakinra, azathioprine, and intravenous immunoglobulins. Recurrent pericarditis is one of the most common and troublesome complications after an episode of pericarditis, and affects 20–50% of patients treated for pericarditis. In most of these patients, the pericarditis remains idiopathic, although an immune-mediated (either autoimmune or autoinflammatory) pathogenesis is often presumed. The mainstay of therapy for recurrences is aspirin or NSAIDs, with the adjunct of colchicine. Corticosteroids are a second-line option to be considered for specific indications, such as connective tissue disease or pregnancy; contraindications or intolerance to aspirin, NSAIDs, and/or colchicine; or insufficient response to these medications. Furthermore, corticosteroids can be added to NSAIDs and colchicine in patients with persistent symptoms. In patients who do not respond adequately to any of these conventional therapies, alternative treatment options include azathioprine, intravenous human immunoglobulins, and anakinra. An improved understanding of how recurrent pericarditis develops after an initiating event is critical to prevent this complication, and further research is needed into the pathogenesis of recurrences. We discuss the aetiology and diagnosis of recurrent pericarditis, and extensively review the treatment options for this condition.

Colchicine is effective for the treatment of acute pericarditis and first recurrences. However, conclusive data are lacking for the efficacy and safety of colchicine for treatment of multiple recurrences of pericarditis. We did this multicentre, double-blind trial at four general hospitals in northern Italy. Adult patients with multiple recurrences of pericarditis (≥two) were randomly assigned (1:1) to placebo or colchicine (0·5 mg twice daily for 6 months for patients weighing more than 70 kg or 0·5 mg once daily for patients weighing 70 kg or less) in addition to conventional anti-inflammatory treatment with aspirin, ibuprofen, or indometacin. Permuted block randomisation (size four) was done with a central computer-based automated sequence. Patients and all investigators were masked to treatment allocation. The primary outcome was recurrent pericarditis in the intention-to-treat population. This trial is registered with ClinicalTrials.gov, number NCT00235079. 240 patients were enrolled and 120 were assigned to each group. The proportion of patients who had recurrent pericarditis was 26 (21·6%) of 120 in the colchicine group and 51 (42·5%) of 120 in the placebo group (relative risk 0·49; 95% CI 0·24–0·65; p=0·0009; number needed to treat 5). Adverse effects and discontinuation of study drug occurred in much the same proportions in each group. The most common adverse events were gastrointestinal intolerance (nine patients in the colchicine group vs nine in the placebo group) and hepatotoxicity (three vs one). No serious adverse events were reported. Colchicine added to conventional anti-inflammatory treatment significantly reduced the rate of subsequent recurrences of pericarditis in patients with multiple recurrences. Taken together with results from other randomised controlled trials, these findings suggest that colchicine should be probably regarded as a first-line treatment for either acute or recurrent pericarditis in the absence of contraindications or specific indications. Azienda Sanitaria 3 of Torino (now ASLTO2).

BackgroundThere are limited data on acute pericarditis according to different age groups. The aim of this study is to investigate the role of age-related features in clinical characteristics, management, and outcomes of acute pericarditis, with a focus on the geriatric population.MethodsPatients with a first episode of acute pericarditis were consecutively enrolled between January 2014 and June 2022, and divided into four groups according to age (G1: 18–35 years; G2: 35–55 years; G3: 55–75 years; G4: >75 years). Clinical characteristics and medical therapy were recorded at baseline, and during follow-up.ResultsA total of 471 patients (median age 56.3 (IQR 33–73) years, 32.3% women) were included. Younger age (G1-G2-G3) was associated with a higher frequency of chest pain, pericardial rubs (p<0001), ECG changes (p=0.002) and were more commonly treated with colchicine (p<0.001), and non-steroidal anti-inflammatory drugs (p=0.006). Older patients (G4) depicted more commonly dyspnoea, pericardial/pleural effusion (p=0.007) and were more often treated with corticosteroids (p=0.037). A secondary cause of pericarditis was detected in 128/471 (27.2%) patients. Older patients were more commonly hospitalised and had a complicated course with new-onset atrial fibrillation (p<0.001) and cardiac tamponade (p=0.005), compared with younger patients, who presented more recurrences (respectively G1: 43.0%, G2: 34.7%, G3: 28.2% and G4: 16.2%; p<0.001). After multivariable analysis, younger age remained the strongest independent predictor for recurrences (HR 3.23, 95% CI 1.81 to 5.58, p<0.001).ConclusionOlder age is associated with less recurrences of pericarditis, but more severe complications with need for hospitalisation.

Pericardiocentesis is useful in the diagnosis and treatment of pericardial effusive disease. To date, a number of methods have been developed to reduce complications and increase the success rate of the procedure. The aim of the present study was to evaluate the efficacy and the safety of echocardiography-guided pericardiocentesis under continuous echocardiographic monitoring in the management of pericardial effusion. We prospectively performed 161 pericardiocentesis procedures in 141 patients admitted from 1993 to 2015 in 3 centers. This procedure was performed for tamponade or large pericardial effusion in 157 cases and for diagnosis in 4 cases. A percutaneous puncture was performed where the largest amount of fluid was detected. To perform a real-time echo-guided procedure, a multi-angle bracket was mounted on the echocardiographic probe to support the needle and enable its continuous visualization during the puncture. The procedure was successful in 160 of 161 cases (99%). Two major complications occurred (1.2%): 1 mediastinal hematoma that required surgical drainage in a patient on anticoagulant therapy and 1 pleuropericardial shunt requiring thoracentesis. Seven minor complications occurred (4.3%): 1 pleuropericardial shunt, 1 case of transient AV type III block, 3 vasovagal reactions (1 with syncope), and 2 cases of acute pulmonary edema managed with medical therapy. No punctures of any cardiac chamber occurred, and emergency surgical drainage was not required in any case. In conclusion, echocardiography-guided pericardiocentesis under continuous visualization is effective, safe, and easy to perform, even in hospitals with low volumes of procedures with or without cardiac surgery.