1. M. Lotrionte 1, C. Moretti 2, M. Imazio 3, A. Abbate 4, P. Di Pasquale 5, M. Raatikka 6, A. Brucato 7, I. Sheiban 2, G. Biondi-Zoccai 2 1 Unità di Scompenso Cardiaco e Riabilitazione, Complesso Integrato Columbus, Roma, Italy; 2 Divisione di Cardiologia 1, Ospedale San Giovanni Battista "Molinette", Torino, Italy (gbiondizoccai@gmail.com), 3 Divisione di Cardiologia, Ospedale Maria Vittoria, Torino, Italy 4 VCU Pauley Heart Center, Richmond, VA, USA, 5 Divisione di Cardiologia, Ospedale G. F. Ingrassia, Palermo, Italy 6 Department of Pediatrics, Children Hospital, Helsinki, Finland 7 Dipartimento di Medicina Interna, Ospedali Riuniti, Bergamo, Italy This work was supported by the Agenzia Italiana del Farmaco (AIFA), with grant FARM7X58KC

2. Acute pericarditis is common and can often recur. Despite widespread agreement on the usefulness of non-steroidal anti- inflammatory drugs (NSAIDs), uncertainty persists on the role of other agents on top or in lieu of NSAIDs. We thus aimed to conduct a comprehensive systematic review on pharmacologic treatments for acute or recurrent pericarditis.

3. Potentially relevant studies published up to September 2009 were searched in BioMedCentral, The Cochrane Collaboration Database of Randomized Trials (CENTRAL), ClinicalTrials.gov, EMBASE, Google Scholar, MEDLINE/PubMed, and Scopus. Studies were included provided they focused on pharmacologic agents for acute pericarditis or its recurrences. Random-effect odds ratios (OR) were computed for long-term treatment failure, pericarditis recurrence, rehospitalization, and adverse drug effects.

5. From 2078 citations, 7 studies were finally included (451 patients), but only 3 were randomized trials. Treatment comparisons were: colchicine vs. standard therapy (3 studies-265 patients), steroids vs. standard therapy (2 studies-31 patients), low-dose vs. high-dose steroids (1 study-100 patients), and statins vs. standard therapy (1 study-55 patients). Colchicine was associated with a reduced risk of treatment failure (OR=0.23 [0.11-0.49]), and recurrent pericarditis (OR=0.39 [0.20-0.77]), but with a trend toward more adverse effects (OR=5.27 [0.86-32.16]).

6. Overall, steroids were associated with a trend toward increased risk of recurrent pericarditis (OR=7.50 [0.62-90.65]). Conversely, low-dose steroids proved superior to high-dose steroids for treatment failure or recurrent pericarditis (OR=0.29 [0.13-0.66]), rehospitalizations (OR=0.19 [0.06-0.63]), and adverse effects (OR=0.07 [0.01-0.54]). Data on statins were inconclusive.

13. Clinical evidence informing decision-making for the management of acute pericarditis and its recurrences is still limited to few, small, and/or low-quality clinical studies. Notwithstanding such major caveats, available studies routinely employing non- steroidal anti-inflammatory agents in both experimental and control groups suggest a beneficial risk-benefit profile for colchicine and a detrimental one for steroids, especially when used at high dosages.