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2025 ESC Myocarditis & Pericarditis Guidelines

Clinical Quick Reference — Diagnosis, Classification & Management

Published: European Heart Journal (2025)
Task Force: ESC; Endorsed by AEPC & EACTS
DOI: 10.1093/eurheartj/ehaf192
View Full Guideline PDF

What's New in 2025

The 2025 ESC Guidelines represent the first comprehensive update since 2015, introducing significant paradigm shifts:

Inflammatory Myopericardial Syndrome (IMPS): Unified Framework

IMPS is an umbrella term encompassing a spectrum of inflammatory myocardial and pericardial diseases with shared etiologies and overlapping clinical presentations. Common causes include viral (EBV, enteroviruses, HHV-6), bacterial (Borrelia, TB), parasitic, and non-infectious aetiologies (autoimmune, drug-induced, genetic). Pathophysiology involves viral-induced myocardial/pericardial damage followed by innate immune activation, potential adaptive immune responses, and either remission or chronic inflammation/fibrosis.

Clinical Spectrum

Presentations range from completely asymptomatic/oligosymptomatic (excellent prognosis) to chest pain, arrhythmias, acute heart failure, fulminant cardiogenic shock, and sudden cardiac death. Risk stratification at presentation is critical for determining hospital admission, intensity of monitoring, and therapeutic approach.

Classification & Stages

Myocarditis Temporal Classification

Acute (<1 month)

Viral-induced damage + innate immune response; high symptom severity

Subacute (>1-≤3 months)

Adaptive immunity shift; variable inflammation; potential remission or progression

Chronic (>3 months)

Fibrosis, potential dilated cardiomyopathy evolution; arrhythmia risk

Pericarditis Temporal Classification

Acute (≤4 weeks)

Inflammatory onset; with/without effusion

Subacute (>4 weeks-≤3 months)

Persistent symptoms; requires tailored medical therapy

Chronic (>3 months)

Fibrotic changes; constrictive physiology possible

Special Pericarditis Phenotypes

Diagnostic Criteria & Comprehensive Workup

Updated Lake Louise Criteria for Myocarditis

Class I DEFINITE myocarditis requires clinical presentation plus:

  • CMR- or EMB-proven myocarditis, OR
  • ≥1 additional criterion (ECG changes, elevated biomarkers, imaging abnormalities)

Class I POSSIBLE myocarditis = clinical presentation + ≥1 criterion without CMR/EMB confirmation

Additional diagnostic criteria: ST-segment elevation/depression, T-wave inversion, elevated high-sensitivity troponin, elevated CRP, wall motion abnormalities on echo, CMR oedema/late gadolinium enhancement

First-Line Assessment (All Suspected IMPS)

  1. Clinical history & vital signs — recent viral illness, fever, chest pain character, dyspnoea, syncope
  2. 12-lead ECG — ST changes, PR-segment depression, conduction delays, arrhythmias
  3. Transthoracic echocardiography — LVEF, wall motion abnormalities, pericardial effusion, signs of constriction
  4. High-sensitivity troponin (hs-TnT or hs-TnI) — marker of myocardial necrosis
  5. C-reactive protein (CRP) — systemic inflammation marker
  6. Chest X-ray — rule out alternative diagnoses (pneumonia, pleural effusion, pulmonary oedema)

Advanced Diagnostic Modalities

Class I Cardiovascular magnetic resonance (CMR) is the gold standard for non-invasive myocarditis diagnosis. Updated Lake Louise CMR criteria include:

Class I Endomyocardial biopsy (EMB) strongly recommended in:

EMB analysis includes: Histopathology with inflammatory cell quantification (CD3+ T cells, CD68+ macrophages), immunohistochemistry, viral PCR/RT-PCR detection, and molecular pathology.

Pericarditis Diagnostic Criteria

Class I DEFINITE acute pericarditis requires clinical presentation (pleuritic chest pain, pericardial friction rub, elevated inflammatory markers) PLUS ≥2 additional criteria:

  • Elevated CRP or ESR
  • New or worsening pericardial effusion on imaging
  • New-onset widespread ST-segment elevation or PR depression on ECG
  • Pericardial tissue analysis (biopsy) showing inflammation

Acute Myocarditis: Presentations, Risk Stratification & Management

Clinical Presentation Spectrum

Oligosymptomatic

Minimal/incidental findings; preserved LVEF; excellent long-term prognosis

Chest Pain

Classic presentation (75%); ST elevation mimicking ACS

Arrhythmias

SVT, AF, VA; high sudden cardiac death risk

Acute HF

Dyspnoea, pulmonary oedema; reduced LVEF

Fulminant

Cardiogenic shock; ECMO/mechanical support needed

Aborted SCD

Resuscitated cardiac arrest; extreme arrhythmia risk

Risk Stratification (Guides Triage)

HIGH RISK (ICU Admission + Advanced Monitoring)

Acute HF/cardiogenic shock, NYHA III-IV refractory to medical therapy, sustained/extensive ventricular arrhythmias, VF/syncope, high-degree AV block, extensive late gadolinium enhancement (>2 segments), newly reduced LVEF <40%

INTERMEDIATE RISK (Admission/Close Follow-Up)

Newly mildly reduced LVEF (41-49%), non-sustained ventricular arrhythmias, persistent release relapsing troponin, LGE ≥2 segments on CMR

LOW RISK (Outpatient Management Possible)

Stable/oligosymptomatic presentation, preserved LVEF ≥50%, limited/no LGE, normal biomarkers at discharge

Management Approach by Risk Stratum

Low-Risk Myocarditis:

High-Risk / Fulminant Myocarditis (Requires Intensive Management):

Long-Term Follow-Up & Prognosis

Follow-up milestones:

  • Within 1 month: Clinical assessment, biomarkers, ECG, echocardiography
  • 3-6 months: CMR (assess oedema resolution, fibrosis burden), repeat echo
  • 12 months: Full cardiac evaluation, Holter monitoring if arrhythmias noted
  • Long-term: Tailored per clinical presentation and imaging findings

Prognosis: 75% of unselected myocarditis cases have excellent outcomes with preserved LVEF; 10-25% develop dilated cardiomyopathy; 1-7% mortality in fulminant presentations; arrhythmia-related sudden cardiac death is primary long-term risk in high-risk subsets.

Acute Pericarditis: Diagnosis, Stratification & Comprehensive Treatment

Clinical Presentation Spectrum

First-Line Therapy for Acute Pericarditis (Class I)

NSAIDs or Aspirin + Colchicine (Cornerstone Therapy)

  • Aspirin: 750-1000 mg TID × 1-2 weeks (preferred agent, especially post-AMI)
  • Ibuprofen: 600-800 mg TID × 1-2 weeks
  • Indomethacin: 25-50 mg TID × 1-2 weeks
  • Colchicine: 0.5 mg once daily (body weight ≤70 kg) or BID × 3-6 months
  • Gastric protection: PPI mandatory if on NSAIDs
  • NSAID tapering: Gradual decrease (250 mg every 1-2 weeks) over weeks 2-4

Incessant/Recurrent Pericarditis Management (Class IIa)

Low-to-Moderate Corticosteroids + NSAID + Colchicine

  • Prednisone: 0.2-0.5 mg/kg/day × 2-4 weeks, then gradual taper
  • Continue NSAID (low dose) + colchicine ≥3-6 months
  • Monitor CRP/ESR normalization and echocardiographic response

Refractory Recurrent Pericarditis: Anti-IL-1 Agents (Class I — NEW 2025)

Breakthrough therapy options:

  • Anakinra (IL-1 receptor antagonist): 1-2 mg/kg/day IV/SC (up to 100 mg/day) × ≥6 months; faster onset, high efficacy
  • Rilonacept (IL-1 trap): 320 mg SC once daily + 160 mg SC weekly × >12 months
  • Superior to traditional corticosteroid-based therapy; enables corticosteroid discontinuation
  • Consider in patients with frequent recurrences, corticosteroid dependence, or intolerance

Cardiac Tamponade: Urgent Pericardiocentesis (Class I)

Class I Emergent pericardiocentesis in patients with signs/symptoms of tamponade (hypotension, elevated JVP, muffled heart sounds, pulsus paradoxus).

Constrictive Pericarditis: Pericardiectomy Indications (Class I)

Surgical pericardiectomy is the definitive treatment for symptomatic constrictive pericarditis. Indications include:

Specific Aetiologies & Targeted Therapies

Giant-Cell Myocarditis (GCM)

Diagnosis: EMB showing multinucleate giant cells + CD68+ macrophages (≥20% inflammatory cell population); non-ischaemic CMR pattern; rapidly progressive HF or arrhythmias

Treatment (Class I): Immunosuppression — corticosteroids (methylprednisolone 1 mg/kg/day tapered) + calcineurin inhibitor (cyclosporine) or azathioprine. Consider mechanical circulatory support or heart transplantation if refractory.

Eosinophilic Myocarditis (EM)

Diagnosis: EMB with eosinophilic myocardial infiltration; screen for underlying systemic disease (EGPA, hypereosinophilic syndrome, parasitic infections)

Treatment: IV corticosteroids (methylprednisolone 500-1000 mg/day × 3 days, then 1 mg/kg/day tapered); treat any identified underlying eosinophilic disorder

Cardiac Sarcoidosis (CS)

Diagnosis: CMR with focal non-ischaemic LGE + FDG-PET showing uptake; elevated serum ACE level; EMB confirming non-caseating granulomas

Treatment (Class I): Corticosteroids; ICD for secondary prevention of SCD in patients with sustained VA or LVEF ≤35%

Immune Checkpoint Inhibitor (ICI)-Induced Myocarditis (Section 9.6.1)

Key Clinical Features: Anti-CTLA-4, anti-PD-1, anti-PD-L1 agents cause immune-related myocarditis; high mortality (25-50% of ICI-myocarditis cases if untreated)

Diagnosis <24 hours Critical: Elevated troponin + CMR findings + EMB if diagnostic uncertainty

Immediate Management (Class I):

  • Discontinue ICI immediately (may rechallenge later with close cardiac monitoring if mild toxicity)
  • High-dose corticosteroids: Methylprednisolone 500-1000 mg IV daily × 3 days, then 1 mg/kg/day oral tapered
  • Additional immunosuppression: Azathioprine or mycophenolate mofetil for steroid-refractory cases
  • EMB for diagnosis and viral/autoimmune workup
  • Standard HF therapy (ACEi/ARB, beta-blockers) as clinically indicated

Vaccine-Induced Myocarditis (Section 9.6.2)

Epidemiology: Rare; mRNA vaccines show small excess myocarditis risk (incidence ~1-4 per million), particularly in adolescents

Treatment: Supportive care, NSAIDs, colchicine if symptomatic; corticosteroids reserved for severe cases

Viral Myocarditis (Enterovirus, EBV, HHV-6)

Diagnosis: EMB with viral PCR/RT-PCR (enteroviruses, EBV, HHV-6 most common)

Treatment: Supportive care; no proven efficacy of specific antivirals in acute myocarditis except HIV (HAART for HIV-associated myocarditis)

Lyme Carditis (Borrelia burgdorferi)

Presentation: AV block (third-degree in ~10% of cases), myocarditis with arrhythmias (tick-borne spirochete)

Treatment: Doxycycline 100 mg BID × 14-21 days (mild disease); ceftriaxone 2 g IV daily × 14-21 days (severe myocarditis)

Chagas Disease (Trypanosoma cruzi)

Presentation: Myocarditis + arrhythmias; endemic in Central/South America

Treatment: Benznidazole 5-7 mg/kg/day × 60 days (early-stage disease preferred)

Tuberculosis Pericarditis

Incidence: 70% of pericarditis in high-burden countries; high mortality if untreated

Treatment: Standard anti-TB regimen (9 months minimum: RIPE/HRZE) + adjunctive corticosteroids (prednisone 1 mg/kg/day × 4 weeks tapered) to reduce constriction risk

Special Populations: Pregnancy, Athletes, Post-Cardiac Surgery

Pregnancy-Associated Myocarditis (PaM) & Peripartum Cardiomyopathy (PPCM)

PaM: Myocarditis occurring during pregnancy (rare); can present with myopericarditis or HF symptoms

PPCM: Idiopathic cardiomyopathy developing in late pregnancy or early postpartum period; higher mortality than PaM

Diagnostic challenges: Echocardiography is safe; CMR permissible if diagnostic uncertainty (avoid gadolinium unless essential)

HF Management Modifications: ACEi/ARB contraindicated during pregnancy; use beta-blockers (safe), hydralazine/nitrates. Avoid diuretics unless volume overload.

Novel therapy: Bromocriptine (dopamine agonist) shows LVEF improvement in PPCM patients; early initiation may improve long-term outcomes

Athletes with Myocarditis

Exercise Restriction Approach: Individualized based on clinical severity + imaging findings (NOT blanket 6-month restrictions)

Criteria for return to sports:

  • Normalization of troponin and inflammatory biomarkers
  • Resolution of ECG abnormalities
  • Preserved LVEF (>50%) + no wall motion abnormalities
  • No arrhythmias on stress testing
  • CMR showing resolution of myocardial oedema and limited/no fibrosis

Device considerations: Wearable defibrillator (WCD) as bridge to recovery in high-risk athletes during acute phase

Post-Cardiac Injury Syndromes (Dressler Syndrome)

Presentation: Post-myocardial infarction pericarditis developing weeks-months after cardiac surgery or AMI; fever, pleuritic chest pain, elevated CRP/ESR

Treatment: NSAIDs (ibuprofen 600-800 mg TID), colchicine (0.5 mg daily), low-dose corticosteroids (prednisone 0.2-0.5 mg/kg/day) if refractory

Arrhythmias & Prevention of Sudden Cardiac Death (Section 6.5)

Arrhythmia Risk in Myocarditis

Temporary Mechanical Support

Class IIa Wearable cardioverter-defibrillator (WCD): Consider for 3-6 months as bridge to recovery in acute myocarditis with haemodynamic compromise or documented arrhythmias

Implantable Device Indications

Catheter Ablation

Class IIa Catheter ablation considered in patients with recurrent symptomatic monomorphic VT or frequent ICD shocks. Repeat CMR within 6 months to assess ongoing myocardial inflammation.

Prognosis, Follow-Up Strategy & Long-Term Outcomes

Myocarditis Prognosis Spectrum

Excellent

Low-risk presentation; 75% preserve LVEF; spontaneous recovery days-weeks

Intermediate

25% progress to chronic myocarditis/DCM; recurrent arrhythmias possible

Guarded

Fulminant presentations; 1-7% mortality/HTx; arrhythmia death significant

Pericarditis Prognosis & Recurrence Rates

Standardized Follow-Up Schedule (Table 15)

Timing Clinical Assessment Investigations
Within 1 month Clinical exam, symptoms, vital signs Troponin, CRP, ECG, transthoracic echo (myocarditis); clinical exam + CRP (pericarditis)
3-6 months Functional capacity, biomarker trend Repeat CMR (myocarditis), troponin if abnormal, echo
12 months Full cardiac history + physical Holter ECG monitoring, imaging if prior abnormalities
>1 year Tailored per clinical status As clinically indicated; imaging for symptom changes

Clinical Do's and Don'ts

DO

  • Perform comprehensive multimodality imaging (ECG, echo, CMR/CT) in all suspected IMPS
  • Use colchicine as first-line adjunct in acute pericarditis combined with NSAIDs/aspirin
  • Consider EMB in high-risk myocarditis (fulminant, shock) or intermediate-risk unresponsive to therapy
  • Individualize exercise restriction based on troponin, CMR findings, arrhythmia testing (avoid blanket restrictions)
  • Use anti-IL-1 agents (anakinra, rilonacept) for refractory recurrent pericarditis (Class I)
  • Perform pericardiectomy for symptomatic refractory constrictive pericarditis
  • Screen genetic relatives in inherited myocarditis or familial recurrent pericarditis
  • Immediately discontinue ICI + initiate high-dose corticosteroids within 24 hours if myocarditis suspected
  • Use risk stratification to guide admission intensity and therapy initiation

DON'T

  • Perform routine serology for viral infections (EMB + PCR superior for aetiology identification)
  • Use high-dose corticosteroids as first-line in uncomplicated acute myocarditis
  • Delay pericardiocentesis in cardiac tamponade (ultrasound-guided, emergent intervention)
  • Miss ICI-induced myocarditis—maintain high clinical suspicion, rapid diagnostic workup, urgent intervention
  • Recommend ICD implantation without proper risk stratification in myocarditis
  • Overlook TB pericarditis in endemic regions—empiric anti-TB + adjunctive corticosteroids
  • Assume asymptomatic pericardial effusion is benign—always risk stratify for progression to tamponade
  • Restrict athletic activity indefinitely—tailor return-to-play decisions based on objective clinical/imaging recovery

Clinical Calculators & Risk Assessment Tools

The following evidence-based calculators support decision-making in myocarditis and pericarditis management:

MAGGIC Score

Heart failure mortality/morbidity risk; prognostic in myocarditis with reduced LVEF

GDMT Optimizer

Guideline-directed medical therapy optimization for HF post-myocarditis

Corrected QT (QTc)

QT prolongation assessment; critical in myocarditis-associated arrhythmia stratification

eGFR (Adult)

Renal function estimation for drug dosing (corticosteroids, colchicine, immunosuppressants)

Creatinine Clearance

Kidney function for colchicine dosing adjustments and renal-based therapy decisions

CHA2DS2-VASc Score

Atrial fibrillation stroke risk; relevant if myocarditis/pericarditis triggers AF

SCAI Shock Classification

Cardiogenic shock phenotyping and hemodynamic support decision-making in fulminant myocarditis

Full Citation: 2025 ESC Guidelines for the management of myocarditis and pericarditis. European Heart Journal (2025). DOI: 10.1093/eurheartj/ehaf192

This quick reference summarizes key clinical recommendations and diagnostic/therapeutic algorithms. Always consult the full guideline and adhere to local institutional protocols for comprehensive clinical context and individualized patient management.