Recurrent pericarditis and constrictive pericarditis

This page covers pericarditis that will not settle or keeps coming back, and the constrictive syndromes that can follow.^[1] It follows the 2025 ESC myocarditis and pericarditis guideline, with the 2015 ESC pericardial guideline given only as dated history.^[1][2] The first episode is covered in Acute pericarditis: diagnosis and colchicine, and effusion and tamponade in Pericardial effusion and tamponade physiology. Myocardial involvement is covered in Myocarditis: presentation, biopsy criteria, management, and amyloid restrictive cardiomyopathy in Cardiac amyloidosis: AL vs ATTR, imaging, tafamidis.

Definitions and stages

ESC 2025 Table 3: Terminology and stages (pericarditis rows)

^[1]

• Table 3 footnote c defines incessant pericarditis as persistent symptoms without a symptom-free interval of >4 weeks despite full-dose guideline-directed medical therapy (including corticosteroids), or early relapse during tapering.^[1]
• In Section 11.6, ESC 2025 defines recurrent pericarditis as a relapse after a documented first episode of acute pericarditis, a symptom-free interval, complete discontinuation of anti-inflammatory therapy, and evidence of subsequent recurrence.^[1]
• The same section uses "incessant" for persistent symptoms without clear remission, including persistence or recurrence during drug tapering, because these cases can progress directly to constrictive pericarditis within a few months.^[1]
• Section 4.4.2 describes subacute pericarditis as persistent symptoms for >1 month and <3 months, a stage that may progress directly to constrictive pericarditis within a few months and needs timely optimal therapy and close follow-up.^[1]

Chronic pericarditis refers to cases lasting >3 months.^[1]

Inflammatory and non-inflammatory phenotypes

The inflammatory phenotype shows pericardial inflammation with evidence of systemic inflammation, often with fever and/or raised C-reactive protein, effusion and/or pleural effusion.^[1] ESC 2025 says these forms typically respond well to targeted anti-inflammatory therapies, including colchicine and anti-IL-1 agents.^[1] The non-inflammatory phenotype is pericarditis without C-reactive protein elevation, or with only low elevation of systemic markers such as high-sensitivity C-reactive protein.^[1] It occurs in 10%–20% of patients, its pathogenesis is unknown, and these cases are often difficult to treat.^[1] In autoimmune diseases with the type I interferon gene signature, C-reactive protein appears to be an unreliable marker of inflammation.^[1]

How often pericarditis recurs, and why

^[1]

ESC 2025 gives examples of inadequate treatment of the first episode: too-fast tapering, no colchicine, or treatment with corticosteroids.^[1] In its prognosis section, recurrence affects 20%–30% of patients not treated with colchicine.^[1] Omission of colchicine and high-dose corticosteroids with fast tapering are risk factors for recurrences or a chronic course.^[1] The probability of recurrence is higher in females (HR 1.67), probably because specific causes such as autoimmune diseases are more frequent.^[1]

In developed countries the aetiology of recurrences is poorly known, and most cases are labelled idiopathic.^[1]

• ESC 2025 says most cases were historically probably autoinflammatory or autoimmune, based on phenotype, latency of several weeks after the index episode, autoantibodies and response to anti-inflammatory or immunosuppressive treatment.^[1]

A course with multiple recurrences is possible but not usual in simple presumed viral pericarditis, and should prompt a search for an underlying cause.^[1]

The autoinflammatory link

• Compared with the previous guidelines, ESC 2025 notes that some inflammatory forms of recurrent pericarditis resemble genetic autoinflammatory diseases with periodic fevers, such as FMF and TRAPS.^[1]

In FMF serositis episodes last only 1–3 days, while in TRAPS fever and symptoms last for weeks.^[1]

• Mutations linked to these disorders have been reported in up to 10% of patients with multiple recurrences, especially with a positive family history and a poor response to colchicine.^[1]
• ESC 2025 adds that rare deleterious MEFV variants were observed more frequently in idiopathic recurrent pericarditis than in ancestry-matched controls (allele frequency 9/200 vs 2932/129 200, P = 0.040).^[1]

These conditions are characterized by exaggerated production of IL-1 by the inflammasome.^[1]

• Familial occurrence of pericarditis has been reported among the relatives of idiopathic recurrent pericarditis patients, ranging from 4% to 10%, and counselling may be warranted in these cases.^[1]

Assessing a patient with recurrent pericarditis

In chronic forms, symptoms are similar to previous attacks but often milder.^[1] In unclear or difficult-to-treat cases, CMR may be performed to assess the degree of inflammation and individualize therapy, especially before tapering or stopping drugs.^[1] CMR detects thickening, oedema and LGE of the pericardium, and pericardial LGE may imply ongoing inflammation and neovascularization rather than simple scarring.^[1]

• ESC 2025 recommends monitoring serum C-reactive protein and CMR to assess clinical remission, guide treatment length and evaluate response in more complicated and difficult-to-treat cases (text; no class or level given).^[1]

Recommendation Tables 3 and 15 (ESC 2025; selected rows)

^[1]

• At least three scores have been proposed to identify patients at increased risk of complicated pericarditis and chronicity, but ESC 2025 says they have not been validated or replicated and remain investigational.^[1]

Treating incessant and recurrent pericarditis

Recommendation Table 10 (ESC 2025): medical therapy in pericarditis

^[1]

• The specific indications in footnote d include, for example, systemic inflammatory disease on maintenance corticosteroids, post-pericardiotomy syndromes, post-vaccine pericarditis, severe renal failure, and concomitant therapies interacting with NSAIDs such as oral anticoagulants.^[1]

How to combine and taper the drugs

In incessant or recurrent pericarditis the mainstay of therapy is always colchicine with aspirin/NSAID or with low to moderate doses of corticosteroids.^[1] For more difficult cases, chest pain can be controlled with aspirin or an NSAID plus low to moderate corticosteroids and colchicine (triple therapy).^[1] The intravenous route should be considered to secure a clinical response or control symptoms in more difficult or resistant cases.^[1] A patient who recurs during corticosteroid tapering should continue colchicine and receive an NSAID on top, instead of a higher corticosteroid dose.^[1] Which drug is tapered first, corticosteroid or NSAID, depends on age, kidney function, haemorrhagic risk and oral anticoagulant use.^[1] Treatment with aspirin/NSAIDs and steroids should be extended in an individualized way, with slower tapering than for a first episode.^[1]

• Colchicine duration: the Figure 16 footnote says colchicine is recommended to prevent recurrence; it advises considering at least 3 months for a first episode and at least 6 months for incessant or recurrent cases, and colchicine is withdrawn as the last drug only after stable remission.^[1]
• Steroid dose: low to moderate means, for example, prednisone 0.2–0.5 mg/kg/day or an equivalent dose of another corticosteroid (Figure 16 footnote c).^[1]
• When steroids fail: ESC 2025 says that with an incomplete response to aspirin/NSAIDs and colchicine, corticosteroids may be added at low to moderate doses as triple therapy, and that in recurrences every effort should be made not to increase or reinstate them.^[1]
• Bone protection: calcium 1200–1500 mg/day and vitamin D 800–1000 IU/day should be offered to all patients on glucocorticoids, with bisphosphonates recommended for men ≥50 years and postmenopausal women starting long-term prednisone ≥5.0–7.5 mg/day or equivalent.^[1]

ESC 2025 Table 13: Specific initial dosing and duration of therapy for acute and recurrent pericarditis

^[1]

• Table 13 footnote a says the attack dose is kept until symptoms resolve and inflammatory markers and other investigations normalize, and tapering is then recommended.^[1]

Its monitoring list is blood count, creatinine, creatine kinase, transaminases, C-reactive protein and echocardiography.^[1] Indomethacin is usually considered for incessant or recurrent cases, and colchicine is then maintained for at least 6 months.^[1] Full-dose aspirin/NSAID is recommended with normal or mildly reduced renal function; with moderate to severe renal impairment, dose adjustment or corticosteroids are recommended.^[1]

• Anakinra should be tapered after clinical remission; one scheme cited is full dose every other day for at least 3 months, then half-dose every other day for at least 3 months.^[1]

ESC 2025 Table 14: Tapering of corticosteroids

^[1]

Table 14 gives a prednisone starting dose of 0.20–0.50 mg/kg/day.^[1] Every decrease in prednisone should be made only if the patient is asymptomatic and C-reactive protein is normal, particularly for doses <25 mg/day.^[1] Higher doses are to be avoided except in special cases, and then only for a few days with rapid tapering to 25 mg/day.^[1]

^[1]

Anti-IL-1 therapy

• ESC 2025 says that for corticosteroid dependence, colchicine resistance and elevated C-reactive protein (at baseline or in a later episode), clinical trials and an international registry supported anakinra or rilonacept.^[1]

An advantage of these agents is the rapid onset of action and the possibility of rapid corticosteroid withdrawal.^[1] There is evidence of efficacy with anti-IL-1 monotherapy.^[1] ESC 2025 says concomitant colchicine could be helpful to reduce recurrences and prolong recurrence-free survival.^[1] Colchicine should be maintained and withdrawn as the last drug only after stable remission.^[1]

• Switching from low-dose steroid: in stable remission on chronic low-dose corticosteroid (for example prednisone ≤5 mg or equivalent) plus colchicine, a switch to IL-1 blockade should be tailored to the patient, weighing tolerability, age and sex issues and patient preference.^[1]
• Infection risk: anti-IL-1 agents may be associated with a moderate increase in the overall risk of mild to moderate infections, and the Table 13 footnote says anakinra, due to its short half-life, may be the preferable choice in patients at increased risk of infections.^[1]
• Malignancy: safety data are reassuring for new malignancy risk, but safe use in patients with known active malignancy has not been well investigated.^[1]
• Availability: rilonacept is registered in the USA but is not currently available in Europe (ESC 2025 Table 13 footnote).^[1]

^{[8] [9]}

• In the RHAPSODY long-term extension (74 patients, 24 additional months of open-label rilonacept), the annualized incidence of recurrence on rilonacept up to the 18-month decision milestone was 0.04 events per patient-year, against 4.4 events per patient-year prestudy while on oral therapies.^[10]
• Of 8 patients who suspended rilonacept at the 18-month decision point, 6 (75%) recurred; continuing treatment carried a 98% lower risk of recurrence than suspension (hazard ratio 0.02).^[10]

A post hoc RHAPSODY analysis found that, in 86 enrolled patients, mean time to rilonacept monotherapy was 7.9 weeks with no recurrences.^[11]

• In a 2-centre open-label phase II/III randomized-withdrawal study of goflikicept in idiopathic recurrent pericarditis, 9 of 10 placebo patients recurred and no goflikicept patient recurred within 24 weeks of randomization (20 of 22 enrolled patients randomized).^[12]

Colchicine trials in recurrence

^{[6] [7]}

When standard therapy is not enough

• Azathioprine: used empirically after aspirin/NSAID, colchicine and corticosteroids fail; ESC 2025 says it seems more appropriate as a steroid-sparing agent and has limited efficacy for acute pain.^[1]

• Intravenous immunoglobulins: tested in refractory recurrent pericarditis after failure of first and second options and anti-IL-1 agents; ESC 2025 says they may work in infectious or non-infectious causes.^[1]

• Non-inflammatory phenotype: both corticosteroids and immunoglobulins have been proposed.^[1]

• Hydroxychloroquine: has shown a steroid-sparing effect and increased flare-free survival in recurrent pericarditis with colchicine resistance and corticosteroid dependence.^[1]

• The hydroxychloroquine evidence is a post hoc analysis of prospectively collected data: 15 patients with refractory idiopathic recurrent pericarditis on hydroxychloroquine 400 mg/day, matched 1:1 to 15 standard-care controls.^[13]

• It did not reduce recurrence risk (14 of 15 in the hydroxychloroquine group relapsed) but was associated with an increased median flare-free survival and a reduced hazard ratio for flare (HR 0.36), and with a ≥50% glucocorticoid dose reduction in 33.3% versus 0% of controls.^[13]

• ESC 2025 also says refractory recurrent pericarditis and/or pericardial fluid formation despite optimal medical and interventional therapy is considered a possible indication for surgical pericardiectomy.^[1]

• In a 20-year single-institution cohort of 513 isolated pericardiectomies, 158 were for effusive/chronic relapsing pericarditis; overall mortality was 3 of 158 (1.9%) in that group versus 9 of 355 (2.5%) for constriction (P = .65).^[21]

Overall survival was higher in the effusive/chronic relapsing group than in the constriction cohort.^[21]

Constrictive pericarditis

• Pericardial constriction is a chronic condition with a thickened, fibrotic and often calcified pericardium that impairs diastolic filling, and it is named constrictive pericarditis when associated with pericarditis.^[1]

The main symptoms are dyspnoea, oedema, orthopnoea and fatigue.^[1]

• The classic picture is usually isolated right heart failure with normal or nearly normal natriuretic peptide levels, and venous congestion, hepatomegaly, pleural effusions and ascites may occur.^[1]

The ESC 2026 heart failure guideline lists constrictive pericarditis among causes of decreased natriuretic peptide levels.^[3]

• ESC 2025 Section 11.9 describes right heart failure with preserved biventricular function, without previous or concomitant myocardial disease; systolic dysfunction from myocardial fibrosis or atrophy can worsen the haemodynamics in advanced cases.^[1]

Who develops constriction

^[1]

• In a prospective cohort of 500 consecutive first episodes of acute pericarditis (2000 to 2008; median follow-up 72 months), constriction developed in 2 of 416 with idiopathic/viral pericarditis (0.48%) versus 7 of 84 with other causes (8.3%).^[14]

In that first-episode cohort, incidence rates ran from 0.76 per 1000 person-years for idiopathic/viral pericarditis to 31.65 for tuberculous and 52.74 for purulent pericarditis.^[14]

• Although chronic pericarditis impairs quality of life, ESC 2025 says its rate of progression to constriction is negligible (<1%), lower than after a single episode of acute pericarditis, unless a specific aetiology is found.^[1]

Incessant cases, by contrast, may directly progress to constriction within a few months, while this complication is extremely rare in idiopathic recurrent pericarditis.^[1]

• In developed countries ESC 2025 reports viral or idiopathic causes in 42%–49%, cardiac surgery in 11%–37%, radiation (mostly for breast cancer or Hodgkin's disease) in 9%–31%, connective tissue disorders in 3%–7%, purulent pericarditis or TB in 3%–6%, and miscellaneous causes in <10%.^[1]

TB is a major cause of constrictive pericarditis in developing countries.^[1] Cases have been reported after pericardiectomy, especially after partial pericardiectomy.^[1]

^[1]

In Australia

• A retrospective cohort of all hospitalized patients with pericardial disease in New South Wales (2004 to 2021, statewide admitted-patient data) found constriction in 763 of 45,445 (1.7%): 530 (1.2%) at index presentation and 233 (0.5%) during follow-up.^[22]
• Constriction during follow-up was more common after hospitalization for heart failure (HR 5.3), non-constrictive recurrent pericardial disease needing hospitalization (HR 3.7) or pericardiocentesis (HR 3.6).^[22]

The authors call for long-term vigilance for constriction in at-risk populations.^[22]

Diagnosis

Diagnostic rows for constriction (ESC 2025 Recommendation Tables 4 and 24; ESC 2026 heart failure Recommendation Table 4)

^{[1] [3]}

The ESC 2026 row carries footnote e: right and left heart catheterization is needed for the differential diagnosis of constrictive pericarditis and restrictive cardiomyopathy.^[3] ESC 2025 likewise lists the distinction between restrictive cardiomyopathy and constriction, when imaging cannot make it, as a specific indication for catheterization.^[1] Transthoracic echocardiography can detect constrictive pathophysiology.^[1] CT before pericardiectomy shows the anatomy and extent of calcification, and a higher calcium burden has been associated with a better post-surgical outcome.^[1] The role of nuclear imaging in pericarditis is less well established, and FDG-PET/CT is generally complementary, most often used when CMR cannot be.^[1]

• The source study compared 130 patients with surgically confirmed constriction at Mayo Clinic (2008 to 2010) with 36 patients diagnosed with restrictive myocardial disease or severe tricuspid regurgitation after constriction had been considered but ruled out.^[15]

In its abstract the cut-offs are septal shift with medial e' ≥9 cm/s or a hepatic vein expiratory diastolic reversal ratio ≥0.79.^[15] In atrial fibrillation or flutter (n=29), all variables except mitral inflow velocity still differed between groups.^[15]

• Normal-thickness constriction: ESC 2025 says constriction may occur with normal pericardial thickness in up to 20% of cases, while advanced and classic cases show prominent thickening and calcification.^[1]
• In a retrospective Mayo Clinic review of 143 patients with proven constriction who underwent pericardiectomy (1993 to 1999), the pericardium was of normal thickness (≤2 mm) in 26 (18%), and pericardiectomy was equally effective in relieving symptoms regardless of the presence or absence of increased thickness.^[18]
• Catheterization criterion: in 100 consecutive patients catheterized for constriction versus restrictive myocardial disease (59 surgically documented constriction), the systolic area index had a sensitivity of 97% and a predictive accuracy of 100% for surgically proven constriction.^[16]
• That study says early rapid filling and equalization of end-diastolic pressures are also present in restrictive myocardial disease, whereas enhanced ventricular interaction is unique to constriction.^[16]
• Restrictive cardiomyopathy: the ESC 2023 cardiomyopathy guideline says overt restrictive cardiomyopathy presents with signs and symptoms typical of HFpEF, and that cardiac MRI distinguishes it from constrictive pericarditis.^[4]

^[1]

Transient and effusive–constrictive forms

ESC 2025 Table 18: Definitions and therapy of main constrictive pericardial syndromes

^[1]

Transient constriction is constriction with ongoing inflammation that can be reversed following anti-inflammatory treatment or that heals spontaneously.^[1] It develops in about 10% of cases of pericarditis with or without effusion and resolves with anti-inflammatory therapy in >50% of cases.^[1] Biomarkers such as elevated C-reactive protein and multimodality imaging, including CMR, are mandatory to detect pericardial inflammation.^[1]

• ESC 2025 says a trial of 3–6 months of anti-inflammatory therapy is recommended in newly diagnosed constrictive pericarditis before referral for pericardiectomy (text; the formal Recommendation Table 24 row recommends anti-inflammatory therapy in haemodynamically stable patients with a transient or new diagnosis of constriction and evidence of pericardial inflammation, Class I, Level C).^[1]

Its Figure 13 note says empirical anti-inflammatory therapy is warranted only with evidence of pericarditis by clinical criteria, biomarkers and/or imaging.^[1]

• In a Mayo Clinic echocardiogram database review (212 patients with constriction, 1988 to 1999), 36 resolved without pericardiectomy; prior cardiovascular surgery was the commonest cause (25%), and resolution in 22 followed serially came at an average of 8.3 weeks.^[17]
• ESC 2025 notes that it is important to distinguish constrictive physiology from actual heart failure symptoms, since there may be features of septal bounce, respiratory phase-dependent shift of the ventricular septum and Doppler features of constriction without heart failure symptoms.^[1]

Effusive–constrictive pericarditis combines effusion with thickening and constriction of the pericardium, and constriction is uncovered when an effusion with tamponade is drained.^[1]

• Its haemodynamic definition is right atrial pressure failing to fall by ≥50% or to <10 mmHg despite intrapericardial pressure lowered to near 0 mmHg at pericardiocentesis.^[1]

Current multimodality imaging allows the diagnosis without catheterization, and echo-Doppler signs of effusive constriction may be seen before pericardiocentesis.^[1] Tricuspid regurgitation or right heart failure may also keep right atrial pressure high after effective pericardiocentesis.^[1] Idiopathic cases are most commonly found in developed countries, while TB appears to be the most common cause in developing countries.^[1]

• Effusive constriction can often resolve spontaneously or with anti-inflammatory therapy when there is evidence of transient constriction; in resistant cases visceral pericardiectomy must be performed, because the epicardial layer constricts the heart.^[1]

• In a prospective series (1986 to 2001), 15 of 190 patients with tamponade who had combined pericardiocentesis and catheterization had effusive–constrictive pericarditis; constriction had been recognized clinically in only seven.^[19]

Seven needed pericardiectomy, all with visceral pericardial involvement, and three resolved spontaneously.^[19]

^[1]

Medical therapy and pericardiectomy

Recommendation Tables 24 and 13 (ESC 2025)

^[1]

• Medical therapy of specific causes such as TB is considered to prevent constriction, and antituberculosis drugs may cut the risk of constriction from >80% to <10%.^[1]

In advanced cases medical therapy is supportive for congestion, but surgery should never be delayed.^[1]

• ESC 2025 says constrictive pericarditis should be treated empirically with anti-inflammatory therapy, and that failures of medical therapy and constriction without pericarditis should be referred for pericardiectomy without delay.^[1]

• Extent: complete pericardiectomy is recommended for constrictive pericarditis because it gives superior long-term outcomes and fewer recurrences than partial anterior or anterophrenic resection, which may leave residual constrictive tissue (text; no class or level given).^[1]

• Where: pericardiectomy should be performed at high-volume centres with the required expertise.^[1]

• When: early pericardiectomy within 6 months of symptom onset is associated with the lowest operative mortality.^[1]

• Bypass: ESC 2025 says cardiopulmonary bypass can play an important role in enabling safe and complete pericardiectomy, particularly in selected complex or high-risk cases, whereas the 2015 guideline advised avoiding it except for difficult control of bleeding.^[1]

• Waffle procedure: in the absence of a surgical plane for proper decortication it can be considered, but it usually offers only temporary improvement, with a high rate of recurrent constriction (text; no class or level given).^[1]

• Tricuspid regurgitation: ESC 2025 text says repair is recommended when TR is more than mild, anatomy is suitable and the patient is already undergoing pericardiectomy, and that supporting evidence is limited (text; the Class I row above names severe regurgitation).^[1]

• Caution: for milder or more advanced disease, radiation-induced disease, reduced EF or advanced renal disease, caution is necessary; radical rather than anterior phrenic-to-phrenic pericardiectomy is warranted for the best outcomes.^[1]

• Contraindications may include severe hepatic dysfunction with cirrhosis and ascites, uncontrolled infection or sepsis, and other life-limiting diseases.^[1]

• Heart transplantation is very rarely indicated in constrictive pericarditis; however, it may be considered as a last-resort option in highly selected, exceptional cases.^[1]

^[1]

• In a single-centre series of 163 patients who underwent pericardiectomy for constrictive pericarditis over a 24-year period, perioperative mortality was 6%, and 7-year Kaplan-Meier survival was 88% for idiopathic, 66% for post-surgical and 27% for post-radiation constriction.^[20]
• Predictors of poor survival were prior radiation, worse renal function, higher pulmonary artery systolic pressure, abnormal left ventricular systolic function, lower serum sodium and older age, while pericardial calcification had no impact on survival.^[20]

^[1]

Special populations

Pregnancy and lactation

Recommendation Table 25 (ESC 2025; selected pericarditis rows)

^[1]

• ESC 2025 text says high-dose aspirin or NSAIDs such as ibuprofen and indomethacin can be used up to the 20th week of gestation, and that azathioprine and IVIG are compatible with pregnancy and breastfeeding.^[1]

Children and older adults

Colchicine halved recurrences in children, as in adults.^[1]

• Corticosteroids should be restricted even more than in adults, because side effects such as striae rubrae and growth impairment are particularly harmful in growing children.^[1]
• ESC 2025 says anti-IL-1 agents are a new therapeutic option for children with recurrent pericarditis, especially if corticosteroid-dependent, but they are often difficult to withdraw when clinical remission is achieved: in one study it cites, only 15% of children were able to stop them after a mean follow-up of 2.6 years.^[1]

Few children were enrolled in the anakinra and rilonacept trials.^[1]

In the studies cited by ESC 2025, older patients received glucocorticoids more often and had a lower risk of recurrence than younger patients.^[1] NSAIDs should be used cautiously in older adults, doses adapted (colchicine halved in some cases), and renal impairment and drug interactions checked.^[1]

Athletes

Exercise after pericarditis

^{[1] [5]}

• The AHA/ACC statement says athletes with acute pericarditis and a complicated presentation are at greater risk of recurrence and progression to pericardial constriction and should have longitudinal clinical surveillance.^[5]

It defines a complicated presentation as temperature >38 °C, subacute course, large effusion, tamponade, myopericarditis, or resistance to NSAIDs.^[5] It considers return reasonable when there is no chest pain, effusion or elevation of serum markers of inflammation.^[5]

Pitfalls

• Reaching for steroids first: corticosteroids are not recommended as the first option without a specific indication (ESC 2025, Class III, Level C), and high doses with fast tapering are risk factors for recurrence or a chronic course.^[1]
• Raising the steroid dose for a flare during tapering: ESC 2025 says to continue colchicine and add an NSAID instead.^[1]
• Stopping colchicine early: it is maintained for at least 6 months in incessant or recurrent cases and withdrawn as the last drug only after stable remission.^[1]
• Sending new constriction straight to surgery: with pericardial inflammation in a haemodynamically stable patient, anti-inflammatory therapy is recommended first (Class I, Level C), and pericardiectomy is recommended for permanent constriction without active inflammation or after 3–6 months of unsuccessful anti-inflammatory treatment (Class I, Level C).^[1]
• Ruling out constriction on a normal pericardial thickness: constriction may be present with normal thickness in up to 20% of cases.^[1]
• Reading a near-normal natriuretic peptide as excluding constriction: the classic picture is usually isolated right heart failure with normal or nearly normal natriuretic peptide levels, and ESC 2026 lists constrictive pericarditis as a cause of decreased levels.^[1][3]
• Delaying surgery in advanced constriction: medical therapy is supportive, and surgery should never be delayed (ESC 2025).^[1]

Evidence, guidelines and regional differences

What changed from 2015 to 2025

2015 ESC rows and the ESC 2025 rows that now apply

^{[2] [1]}

• The 2015 guideline let stable patients with newly diagnosed constriction, without evidence of chronicity, have a 2–3 month trial of conservative management before pericardiectomy; ESC 2025 text gives 3–6 months.^[2][1]
• The 2015 rows above are history only; the 2025 rows replace them for practice, except that IVIG and azathioprine have no ESC 2025 recommendation row.^[2][1]

Gaps in evidence

• ESC 2025 names as a significant management issue the treatment of patients not responding to colchicine and anti-IL-1 agents, as well as the causes of drug dependence to maintain stable clinical remission, such as for corticosteroids and anti-IL-1 agents.^[1]

It also calls for research on the prognostic significance of persistent pericardial LGE.^[1]

In Australia and New Zealand

• No NHFA/CSANZ pericardial guideline is quoted, so the rows on this page come from the ESC guidelines listed below.^[1]
• The Australian data on this page are the New South Wales constriction cohort above.^[22]
• The Australian and New Zealand documents below are those with a held-status entry in the census for this topic.
• The NHFA/CSANZ Australian Clinical Guidelines for the Diagnosis and Management of Atrial Fibrillation 2018 (PMID 30077228) are not held as text in their version of record, so they were not checked for this topic.
• The NHFA/CSANZ Comprehensive Australian Clinical Guideline for Diagnosing and Managing Acute Coronary Syndromes 2025 (PMID 40180468) is not held as text in its version of record, so it was not checked for this topic.
• The 2024 CSANZ Position Statement on Indications, Assessment and Monitoring of Structural and Valvular Heart Disease With Transthoracic Echocardiography in Adults (PMID 38749800) is not held as text in its version of record, so it was not checked for this topic; only its PubMed abstract is quotable.
• Only the PubMed abstract of the 2023 Australian guideline for assessing and managing cardiovascular disease risk (PMID 38623719) is held; its full text is not held and was not checked for this topic.
• Only the PubMed abstract of the A summary of the 2023 Society of Obstetric Medicine of Australia and New Zealand (SOMANZ) hypertension in pregnancy guideline (PMID 38763516) is held; its full text is not held and was not checked for this topic.

Guidelines checked for this topic

• Rows on this page come from the 2025 ESC myocarditis and pericarditis guideline, with the 2015 ESC pericardial guideline as dated history.^[1][2]

• Other rows come from the 2026 ESC heart failure guideline (Recommendation Table 4) and narrative from the 2023 ESC cardiomyopathy guideline.^[3][4]

• Athlete statements come from the AHA/ACC 2025 competitive sports scientific statement, which gives no class or level for them.^[5]

• Study results are quoted from the PubMed abstracts of CORP, CORP-2, AIRTRIP, RHAPSODY and its extension and post hoc analysis, the goflikicept and hydroxychloroquine studies, and the cohorts named in the text.^{[6][7][8][9][10][11][12][13][14]}

• For the rows on this page, the same-month and newer guidelines of the same body in the census below were checked and give no revising row, except where a newer row is shown beside it (census 2026-10-24).

• The held guidelines below were checked, and no row from them is used here; each line gives the reason.

• ESC 2020 sports cardiology (PMID 32860412): its recommendation table for exercise in pericarditis is held only as an image, and its text says competitive sports and moderate- to high-intensity leisure activities should be avoided in constrictive pericarditis; the newer ESC 2025 physical-activity row is used instead.

• ESC 2022 non-cardiac surgery (PMID 36017553): it mentions constrictive pericarditis only in text on peri-operative pre-load, with no row on it.

• Heart failure guidelines other than ESC 2026 (AHA/ACC/HFSA 2022, PMID 35363499; NHFA/CSANZ 2018, Heart Lung Circ PMID 30077227, and its Med J Aust summary PMID 30067937): AHA/ACC/HFSA 2022 names pericardiectomy only among evidence gaps in HFpEF, and NHFA/CSANZ 2018 lists pericardial constriction only among causes of heart failure; neither gives a row on constriction.

• AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR 2021 chest pain (PMID 34709879): it mentions constriction only in imaging text for suspected pericarditis, with no constriction or recurrence row.

• ESC/EACTS 2025 valvular heart disease (PMID 40878295): radiation-related pericardial constriction appears only in text on surgical risk.

• Acute coronary syndrome and myocardial infarction documents (ESC 2023 ACS, PMID 37622654; ACC/AHA 2025 ACS, PMID 40014670; Fourth UDMI, PMID 30571511; Fifth UDMI, PMID 42661425): their pericarditis content is post-infarction pericarditis and ECG differentiation, covered in the acute pericarditis topic.

• Myocarditis and myocardial-disease documents (AHA 2020 fulminant myocarditis, PMID 31902242; ACC 2024 myocarditis decision pathway, PMID 39665703; ESC 2021 cardiac amyloidosis position statement, PMID 33825853; AHA 2021 mechanical complications of myocardial infarction, PMID 34126755): their held text has no recurrent-pericarditis or constriction wording in the census sweep.

• Atrial fibrillation documents (ACC/AHA/ACCP/HRS 2023, PMID 38033089; ESC 2024, PMID 39210723; EHRA/HRS/APHRS/LAHRS 2024 ablation consensus, PMID 38587017): no recurrent-pericarditis or pericardial-constriction row (the one ACC/AHA hit is vascular smooth muscle constriction).

• Coronary, pulmonary embolism and other register guidelines whose only sweep hits use "constriction" for vessels (ESC 2024 chronic coronary syndromes, PMID 39210710; AHA/ACC 2023 chronic coronary disease, PMID 37471501; ESC 2019 pulmonary embolism, PMID 31504429): outside this topic.

• ESC 2025 pregnancy (PMID 40878294), ESC 2020 (PMID 32860028) and ACC/AHA/HRS/ISACHD/SCAI 2025 (PMID 41411375) adult congenital heart disease: no recurrent-pericarditis or constriction wording in the census sweep; the pregnancy rows here come from ESC 2025 myocarditis and pericarditis.

• Prevention, lipid, blood pressure, diabetes, kidney, rehabilitation, aortic, peripheral, pulmonary hypertension, pulmonary embolism, valvular, endocarditis, rhythm and perioperative register guidelines (PMIDs 34458905, 31504418, 40878289, 41824552, 39210715, 40811497, 37622663, 42263157, 42661418, 36322642, 39210722, 36017548, 39209475, 39209476, 41712677, 33332150, 37622656, 38718139, 30412709, 31504425, 34455430, 36017572, 39316661, 41693087): no recurrent-pericarditis or constriction wording in the census sweep.

• Society documents checked through PubMed: the 2025 Italian Society of Cardiology position paper on pericardial diseases (PMID 39661544) and the 2015 EACVI position paper on multimodality imaging in pericardial disease (PMID 25248336) are held only as PubMed abstracts and give no graded rows there; none is used.

• The documents in the remaining lines are not used; each line gives the held status recorded in the census for this topic.

• The 2025 Concise Clinical Guidance: An ACC Expert Consensus Statement on the Diagnosis and Management of Pericarditis (PMID 40767817) is not held as text in the evidence caches, so it was not checked for this topic.

• The Pericardial Diseases: International Position Statement on New Concepts and Advances in Multimodality Cardiac Imaging (PMID 39111992) is not held as text in the evidence caches, so it was not checked for this topic.

• The [Management Strategy for Patients With Idiopathic Recurrent Pericarditis. Position Statement of the Experts of the Russian Society оf Cardiology and Eurasian Association of Therapists] (PMID 39526520) is not held as text in the evidence caches, so it was not checked for this topic.

• The [Expert consensus statement for the clinical diagnosis and management of recurrent pericarditis] (PMID 41402096) is not held as text in the evidence caches, so it was not checked for this topic.

• The Recommendations of the Brazilian Society of Surgical Oncology for the Treatment of Neoplastic Pericardial Effusion (PMID 39737532) is not held as text in the evidence caches, so it was not checked for this topic.

• The Views on the approach algorithm and scoring for 'definite cardiac tamponade' in the 2025 ESC guidelines for myocarditis and pericarditis (PMID 41290397) is not held as text in the evidence caches, so it was not checked for this topic.

• Only the PubMed abstract of the Workup and management of rhythm disorders in myocarditis and inflammatory cardiomyopathy: a clinical consensus statement of the European Heart Rhythm Association and the Heart Failure Association of the ESC, the ESC Working Group on Myocardial & Pericardial Diseases, the European Association of Preventive Cardiology of the ESC, the Heart Rhythm Society, the Asian Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society (PMID 42669046) is held; its full text is not held and was not checked for this topic.

• The 2018 ESC/EACTS Guidelines on myocardial revascularization (PMID 30165437) are not held as text in the evidence caches, so they were not checked for this topic.

• The 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes (PMID 31504439) are not held as text in the evidence caches, so they were not checked for this topic.

• The 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation (PMID 32860058) are not held as text in the evidence caches, so they were not checked for this topic.

• The 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation (PMID 32860505) are not held as text in the evidence caches, so they were not checked for this topic.

• The 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure (PMID 34447992) are not held as text in the evidence caches, so they were not checked for this topic.

• The 2021 ESC/EACTS Guidelines for the management of valvular heart disease (PMID 34453165) are not held as text in the evidence caches, so they were not checked for this topic.

• The 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization (PMID 34882435) is not held as text in the evidence caches, so it was not checked for this topic.

• The 2022 ESC Guidelines on cardio-oncology (PMID 36017568) are not held as text in the evidence caches, so they were not checked for this topic.

• The 2023 Focused Update of the 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure (PMID 37622666) are not held as text in the evidence caches, so they were not checked for this topic.

• The JCS/JPCPHS 2025 Guideline on Pulmonary Hypertension and Pulmonary Embolism/Deep Vein Thrombosis (PMID 42386545) is not held as text in the evidence caches, so it was not checked for this topic.

• The 2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the European Renal Association (ERA) (PMID 42661426) are not held as text in their version of record, so they were not checked for this topic.

• Only the PubMed abstract of the 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease (PMID 38743805) is held; its full text is not held and was not checked for this topic.

• Only the PubMed abstract of the Pulmonary hypertension associated with left heart disease (PMID 39209478) is held; its full text is not held and was not checked for this topic.

• Only the PubMed abstract of the European Respiratory Society clinical practice guidelines update for the treatment of pulmonary arterial hypertension (PMID 42705705) is held; its full text is not held and was not checked for this topic.

• Only the PubMed abstract of the 2026 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery (PMID 42804570) is held; its full text is not held and was not checked for this topic.

Exam pearls

• Stages (ESC 2025 Table 3): acute ≤4 weeks; subacute/incessant >4 weeks to ≤3 months; chronic >3 months; recurrent means new symptoms or disease activity after clinical remission.^[1]
• Recurrence after a first episode is 15%–30%, usually within 18 months, and may reach 50% after a first recurrence if the first episode was inadequately treated.^[1]
• Colchicine 0.5 mg twice daily, or once daily under 70 kg or with severe renal impairment, for at least 6 months in recurrent cases; in CORP-2, a double-blind trial that randomly assigned 240 adults with ≥2 recurrences to placebo or colchicine for 6 months added to conventional anti-inflammatory treatment, recurrence was 21.6% with colchicine versus 42.5% with placebo (relative risk 0.49).^[1][7]
• Anti-IL-1 agents (anakinra or rilonacept) are recommended for recurrent pericarditis after failure of first-line therapies and corticosteroids with elevated C-reactive protein (Class I, Level A); in incessant or recurrent pericarditis with pericardial inflammation on CMR after failure, contraindications and intolerance to first-line therapies and corticosteroids, they should be considered regardless of C-reactive protein (Class IIa, Level C).^[1]
• Constriction risk after pericarditis: <1% viral/idiopathic, 2%–5% immune-mediated or neoplastic, 20%–30% bacterial, especially purulent.^[1]
• Effusive–constrictive pericarditis: right atrial pressure fails to fall by 50% or to <10 mmHg after pericardiocentesis.^[1]
• Mayo echo criteria: septal bounce or shift plus medial e' >8 cm/s or hepatic vein expiratory diastolic reversal ratio >0.78 (sensitivity 87%, specificity 91%).^[1]

References22ShowHide

1. [1]Schulz-Menger J, et al. 2025 ESC Guidelines for the management of myocarditis and pericarditis. Eur Heart J, 2025.PMID 40878297
2. [2]Adler Y, 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)Endorsed by: The European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J, 2015.PMID 26320112
3. [3]Køber L, et al. 2026 ESC Guidelines for the management of heart failure. Eur Heart J, 2026.PMID 42661420
4. [4]Arbelo E, et al. 2023 ESC Guidelines for the management of cardiomyopathies. Eur Heart J, 2023.PMID 37622657
5. [5]Kim JH, et al. Clinical Considerations for Competitive Sports Participation for Athletes With Cardiovascular Abnormalities: A Scientific Statement From the American Heart Association and American College of Cardiology. J Am Coll Cardiol, 2025.PMID 39976316
6. [6]Imazio M, et al. Colchicine for recurrent pericarditis (CORP): a randomized trial. Ann Intern Med, 2011.PMID 21873705
7. [7]Imazio M, et al. Efficacy and safety of colchicine for treatment of multiple recurrences of pericarditis (CORP-2): a multicentre, double-blind, placebo-controlled, randomised trial. Lancet, 2014.PMID 24694983
8. [8]Brucato A, et al. Effect of Anakinra on Recurrent Pericarditis Among Patients With Colchicine Resistance and Corticosteroid Dependence: The AIRTRIP Randomized Clinical Trial. JAMA, 2016.PMID 27825009
9. [9]Klein AL, et al. Phase 3 Trial of Interleukin-1 Trap Rilonacept in Recurrent Pericarditis. N Engl J Med, 2021.PMID 33200890
10. [10]Imazio M, et al. Sustained Pericarditis Recurrence Risk Reduction With Long-Term Rilonacept. J Am Heart Assoc, 2024.PMID 38471825
11. [11]Brucato A, et al. Transition to rilonacept monotherapy from oral therapies in patients with recurrent pericarditis. Heart, 2023.PMID 36316102
12. [12]Myachikova VY, et al. Treatment of Idiopathic Recurrent Pericarditis With Goflikicept: Phase II/III Study Results. J Am Coll Cardiol, 2023.PMID 37380301
13. [13]Lazaros G, et al. Hydroxychloroquine for colchicine-resistant glucocorticoid-dependent idiopathic recurrent pericarditis: A pilot observational prospective study. Int J Cardiol, 2020.PMID 32312616
14. [14]Imazio M, et al. Risk of constrictive pericarditis after acute pericarditis. Circulation, 2011.PMID 21844077
15. [15]Welch TD, et al. Echocardiographic diagnosis of constrictive pericarditis: Mayo Clinic criteria. Circ Cardiovasc Imaging, 2014.PMID 24633783
16. [16]Talreja DR, et al. Constrictive pericarditis in the modern era: novel criteria for diagnosis in the cardiac catheterization laboratory. J Am Coll Cardiol, 2008.PMID 18206742
17. [17]Haley JH, et al. Transient constrictive pericarditis: causes and natural history. J Am Coll Cardiol, 2004.PMID 14736448
18. [18]Talreja DR, et al. Constrictive pericarditis in 26 patients with histologically normal pericardial thickness. Circulation, 2003.PMID 14517161
19. [19]Sagristà-Sauleda J, et al. Effusive-constrictive pericarditis. N Engl J Med, 2004.PMID 14749455
20. [20]Bertog SC, et al. Constrictive pericarditis: etiology and cause-specific survival after pericardiectomy. J Am Coll Cardiol, 2004.PMID 15093882
21. [21]Gillaspie EA, et al. A 20-year experience with isolated pericardiectomy: Analysis of indications and outcomes. J Thorac Cardiovasc Surg, 2016.PMID 27210468
22. [22]Kwan TN, et al. Epidemiology and Risk Factors for Constrictive Pericarditis in a Statewide Australian Cohort of Patients With Pericardial Disease. Can J Cardiol, 2026.PMID 40983194