20 Lifestyle changes Physical activity can contribute to the pathophysiology of pericarditis through various proposed mechanisms. Exercise may worsen inflammation through increased oxidative stress and shear stress within the pericardium. Increased blood flow can also elevate the concentrations of circulating antigens.63 Patients who are not athletes should be advised to avoid exercise and strenuous activities until symptoms resolve and hs-CRP normalizes. It is recommended that patients who are athletes adhere to a more prescriptive 3 months of exercise restriction and refrain from all competitive sports during this time. In cases of myopericarditis, both athletes and non-athletes should limit physical activity to low-intensity or normal sedentary activities for 3 to 6 months. Reassessment of pericardial effusion should also be conducted before returning to exercise.64 Incessant pericarditis This term is used to describe pericarditis lasting more than 4 to 6 weeks but less than 3 months (at which point the term chronic pericarditis is used).1 It is also used if there is a symptom-free period of only less than 4 to 6 weeks, which is the interval traditionally used to define remission. The term “recurrence” is reserved for circumstances in which there is acute pericarditis after a period of remission, i.e., 4 to 6 weeks without symptoms or inflammation. The 4- to 6-week interval cited is arbitrary but reflects the typical duration of firstline anti-inflammatory treatment, typically with NSAIDs, including tapering. Common causes of apparently incessant or pseudo-incessant disease include: Inadequate initial control of inflammation, either through under-dosing of NSAIDs or abrupt cessation of therapy without a taper, or tapering purely based on duration of treatment rather than guided by symptoms/inflammatory markers. (See “Management of Acute Pericarditis” on page 16.) The failure to initiate colchicine or continue this for 3 months following apparent resolution may be another apparent cause. The use of colchicine can potentially halve the risk of recurrence and can also accelerate the attainment of remission when used with NSAIDs. Although often very effective at rapidly controlling inflammation and symptoms, the early use of corticosteroids in lieu of NSAIDs can also result in recrudescence of symptoms, particularly if tapering is too abrupt or rapid, often with a threshold dose at which recurrence can occur. This risk can be reduced through slow and gradual tapering, particularly at a daily dose of about 12.5-15 mg prednisone (or equivalent). Finally, another common cause of apparent recurrence may be exercise. Increased cardiac motion and friction within the pericardial sac in conjunction with heart rate and cardiac contractility in response to physical activity may promote recrudescence of inflammation. Truly incessant disease, which fails to respond to initial therapy despite adequate dosing, appropriate tapering, adjunctive use of colchicine and avoidance of additional An incessant disease trajectory has been reported to occur in up to 12% of patients presenting to a tertiary pericardial service.69
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