2025 ESC Guidelines for the management of myocarditis and pericarditis
31 Aug 2025
2025 ESC Guidelines for the management of myocarditis and pericarditis Myocarditis and pericarditis are covered in the same ESC Guidelines for the first time,1 as explained by the Chairs of the Guidelines Task Force, Professor Massimo Imazio (University of Udine - Udine, Italy) and Professor Jeanette Schulz-Menger (Charité Medical University Berlin - Berlin, Germany).
“ESC Guidelines on pericarditis were last published in 2015, while myocarditis has not been covered previously,” notes Prof. Imazio. “The combined document represents a new direction – it recognises that myocarditis and pericarditis are both inflammatory diseases with potential overlap and signals a paradigm shift to improve awareness of the spectrum of disease.”
Prof. Schulz-Menger explains a new term that has been introduced by the Task Force to reflect the possible overlap: “Inflammatory myopericardial syndrome (IMPS) is an umbrella term that we propose is used during the initial diagnostic process until a final diagnosis is made. IMPS ranges from isolated myocarditis to isolated pericarditis through mixed forms with possible reciprocal involvement, such as myopericarditis and perimyocarditis. IMPS is characterised by different stages, which not all patients experience, but an understanding of the respective stages is essential for appropriate therapeutic guidance.”
The diagnostic work-up in patients with suspected IMPS should be tailored based on the type and severity of presentation, response to medical therapy and individual risk. Assessments should include medical history, clinical/physical exam, biomarkers (myocardial injury, systemic inflammation and heart failure), ECG and imaging. “Multimodality imaging, particularly cardiovascular magnetic resonance, has become the cornerstone of non-invasive diagnosis of myocardial and pericardial inflammation and has changed the clinical workflow,” says Prof. Imazio. Although, he explains, there is still a place for endomyocardial biopsy for high-risk patients and in some intermediate cases where knowledge of the histotype is important for targeted therapies.
Since 2015, understanding of the pathogenesis of pericarditis has greatly improved, with new evidence on the importance of the interplay between inflammation and autoinflammatory mechanisms, the role of genetic background, and immune responses in patients with multiple recurrences. The identification of a positive family history, a poor response to colchicine in case of pericarditis and a recurrent clinical presentation with an inflammatory phenotype are useful tools to guide the selection of patients for genetic testing and, in some cases, for specific treatments (e.g. anti-IL-1 agents). In certain situations, interventional strategies are needed. Both experts point out that ‘one-size-fits-all’ is not suitable for guiding physical activity, but rather, a personalised approach is needed.
Prof. Schulz-Menger ends by noting that this ‘ESC first’ has brought experts from both fields together in a multidisciplinary approach that should now be mirrored by the multidisciplinary teams that support patients, particularly in complex cases. “These guidelines increase awareness about the full IMPS spectrum and the need for a combined expertise on both conditions to improve diagnostic and therapeutic capabilities and patient outcomes,” she concludes.
The Co-Chairs, in equal capacity, express their deep gratitude for the outstanding and dedicated teamwork of the task force and extend their thanks for the valuable input provided by reviewers.
References
- Schulz-Menger J, et al. 2025 ESC Guidelines for the management of myocarditis and pericarditis. Eur Heart J. 2025. doi:10.1093/eurheartj/ehaf192.
