Pericarditis is an inflammatory condition of the pericardium, diagnosed when at least two of the following criteria are present: chest pain, pericardial friction rub, pericardial effusion, and electrocardiographic changes. These findings may be supported by elevated inflammatory markers and imaging evidence.1 The etiology of pericarditis can be infectious (e.g., viral and bacterial) or noninfectious (e.g., autoinflammatory diseases, autoimmune conditions, neoplastic diseases, and post–cardiac injury syndromes). However, in developed countries, idiopathic pericarditis—presumed viral—accounts for 80–90 % of cases.2

Recurrent pericarditis is the most frequent complication following an initial episode of acute pericarditis, occurring in approximately 20–30 % of cases.3 It is diagnosed when signs and symptoms reappear after a symptom-free interval of at least 4 to 6 weeks. Although the exact mechanisms underlying recurrence are not fully understood, it is often suspected to be immune-mediated. However, most cases remain classified as idiopathic as no definitive cause can be identified.4

While recurrent pericarditis can significantly impact quality of life, idiopathic cases generally have a favorable long-term prognosis with a low risk (<1 %) of progression to constrictive pericarditis (CP). CP is a feared complication that depends more on the underlying etiology than on the number of recurrences.5

The management of acute and recurrent pericarditis consists of well-established pharmacological treatment and exercise restriction. Exercise limitation is recommended during active inflammation, as physical exertion may exacerbate pericardial irritation and trigger relapses. This phenomenon is hypothesized to result from increased shear stress across the pericardial layers at higher heart rates, which may prolong inflammation and disease duration.4,6 Consequently, a gradual RTP process must be dynamically guided by imaging, strict workload control, and periodic clinical assessments to confirm the resolution of inflammation before resuming exercise.

Current expert consensus recommends that non-athlete patients limit physical activity to a sedentary lifestyle until symptoms resolve and C-reactive protein (CRP) levels normalize. In athletes, return to competitive sports is advised only after three months from the initial episode, provided that symptoms have fully resolved and diagnostic tests—including CRP, electrocardiography (ECG), and transthoracic echocardiography (TTE)—show no abnormalities.1,2 This three-month restriction period has been arbitrarily defined based on expert consensus. Moreover, evidence-based RTP protocols for athletes remain limited.6–9 Additionally, expert analysis suggest that in athletes, a slower and more controlled pharmacological tapering process with continued pharmacological treatment overlap during the reintroduction of exercise may help prevent relapses.10

This report explores the challenges of managing recurrent pericarditis with transient constriction in an endurance athlete and highlights the importance of an individualized RTP strategy.

This case illustrates the challenges of managing idiopathic recurrent pericarditis with transient constriction in a national-level endurance athlete. While pericarditis is often self-limiting, recurrent episodes can be particularly difficult to address in athletes. This case accentuates the importance of an evidence-based, individualized approach to exercise restriction and RTP strategies in athletes with pericarditis.

Existing literature emphasizes the role of NSAIDs, colchicine, and exercise restriction as crucial components of pericarditis management. According to the guidelines of the European Society of Cardiology guidelines, exercise should be gradually resumed after resolution of inflammation. However, the precise implementation is unclear, particularly for elite athletes, whose training demands and cardiovascular stressors are substantially higher. The literature also suggests that persistent inflammatory markers, even in asymptomatic patients, may increase the risk of recurrence. Therefore, a cautious RTP strategy should be considered.

This case is noteworthy because the athlete required over a year of clinical follow-up and multimodal monitoring—CMR, TTE, blood biomarkers, Holter ECG, symptoms, and heart rate variability—before colchicine was withdrawn and exercise was progressively reintroduced. Multimodal monitoring allowed for precise tracking of disease progression and subsequent adaptation to exercise.

The stepwise “Graduated Return to Play after Onset of Acute Pericarditis” protocol outlined by Sivalokanathan & Chokshi in 2022 provided a useful framework, yet the inclusion of subjective energy levels and autonomic markers (e.g., heart rate variability, and resting heart rate) added an additional layer of safety in this case. This individualized approach may be used as a reference for future cases, emphasizing the need for athlete-specific modifications to standard guidelines.

In future cases, implementing periodized clinical assessments—such as CMR, TTE, blood inflammatory markers—along with regular monitoring of symptoms and heart rate variability at an earlier stage may improve the detection of subclinical inflammation, potentially reducing the overall recovery timeline. Additionally, for high-risk individuals, prolonged colchicine therapy during the gradual reintroduction of exercise may help prevent relapses. Further research is needed to establish optimal exercise restriction and return-to-play protocols specifically tailored for athletes with recurrent pericarditis.

This case contributes to the evolving understanding of pericarditis management in athletes and emphasizes the importance of careful load management, objective monitoring, and treatment compliance to ensure safety and athletic performance.

Recurrent pericarditis in athletes requires careful monitoring and a structured, individualized RTP approach to ensure safe reintegration into competitive sports. In order to guide recovery and reduce the risk of recurrence, this case emphasizes the urgency of objective functional assessments, customized exercise prescriptions, and serial imaging. Additionally, it underscores the value of a multidisciplinary team (including a sports physician, cardiologist, radiologist, and internist) in managing these complicated cases. Future research should focus on refining both the duration of exercise restriction and the criteria for normal test results (such as imaging, biomarkers, and functional tests) required before progressing to the next RTP stage in athletes with inflammatory cardiac conditions.