Updates and Essential Messages from the 2025 ESC Guidelines on the Management of Myocarditis and Pericarditis

Written by Dr. Muhammed Mustafa Yıldız

Reference:Schulz-Menger J, et al. 2025 ESC Guidelines for the Management of Myocarditis and Pericarditis. Eur Heart J. 2025 Oct 22;46(40):3952–4041. doi:10.1093/eurheartj/ehaf192

Introduction:
Myocarditis and pericarditis represent a spectrum of inflammatory cardiac diseases with clinical presentations ranging from mild chest pain to malignant arrhythmias or cardiogenic shock. The latest ESC guidelines emphasize a risk-based diagnostic and therapeutic approach, highlighting the role of cardiac MRI, biomarkers, and clinical phenotyping. In recurrent pericarditis, colchicine remains the cornerstone of therapy, while biologic agents are recommended for selected cases. Notably, myocarditis has been included in the guidelines for the first time, introducing the concept of “inflammatory myopericardial syndrome (IMPS)”—a unifying framework designed to improve understanding of the myocarditis–pericarditis overlaps and to promote a multidisciplinary, integrated management approach.

Essential Messages

• Greater understanding, systematic evaluation, and new prospective data have increased awareness of the disease; the COVID-19 pandemic has been a major catalyst in this process.
• Advanced multimodality imaging, particularly cardiac magnetic resonance (CMR), has enabled patient-specific diagnostic and therapeutic approaches. A major paradigm shift is the ability to achieve a highly accurate non-invasive clinical diagnosis (especially for myocarditis using CMR). However, endomyocardial biopsy (EMB) remains essential in intermediate- and high-risk cases when targeted therapy based on specific histotypes or etiologies is required.
• IMPS represents a spectrum of inflammatory diseases—infectious or non-infectious—that can involve the myocardium, the pericardium, or both (myopericarditis, perimyocarditis).
• In most cases, myocarditis and pericarditis present with chest pain and preserved biventricular function, usually with good outcomes.
• Complicated myocarditis includes cases presenting with severe heart failure or arrhythmias. Even mild cases may rarely develop life-threatening complications, requiring prompt management.
• Complicated pericarditis includes incessant or recurrent forms. Many persistent cases may develop constrictive physiology, which is often reversible with appropriate therapy.
• Management of uncomplicated IMPS is empirical, aiming to control symptoms and prevent complications.
• Anti-inflammatory agents and colchicine are effective for chest pain control; additional guideline-directed therapies should be applied in complicated cases.
• If a specific etiology is identified, treatment should be targeted to the underlying cause.
• Physical activity restriction is recommended in the acute phase of IMPS; return to work and exercise should be individualized based on clinical recovery.
• The clinical course of IMPS is variable—chest pain–dominant cases usually have a favorable prognosis, whereas recurrences in pericarditis can impair quality of life. Cases with heart failure or arrhythmias require personalized therapy and long-term follow-up.
• Multidisciplinary team management is recommended, tailored to the clinical characteristics of each patient.
• The team should include imaging specialists, pathologists, rheumatologists, infectious disease experts, geneticists, interventional cardiologists, intensivists, and cardiac surgeons, all with expertise in cardiovascular diseases.

Updates
The 2025 ESC Guidelines on myocarditis and pericarditis introduce major changes in diagnostic and therapeutic approaches. The key updates are summarized below:

• Risk-Based Diagnostic Stratification: Patients are now classified as low-, intermediate-, or high-risk, guiding the intensity of evaluation and follow-up. Advanced diagnostics and close monitoring are recommended for those with ventricular arrhythmias, LV dysfunction, or sudden cardiac death risk.
• Enhanced Role of Imaging: Cardiac MRI (CMR) is established as the primary diagnostic tool for myocarditis, with Lake Louise criteria standardized for diagnosis. In pericarditis, echocardiography remains the first-line imaging modality, while CMR and CT are recommended for clinically suspected or complex cases.
• Clear Indications for Endomyocardial Biopsy (EMB): EMB is emphasized in fulminant myocarditis, cases with malignant arrhythmias, or when immunosuppressive therapy is being considered, as it provides crucial diagnostic and therapeutic guidance.
• Emphasis on Biomarkers: High-sensitivity troponin, CRP, ESR, and NT-proBNP are highlighted as supportive tools for both diagnostic and prognostic evaluation.
• Personalized Treatment Approach:
• In acute pericarditis, NSAIDs plus colchicine remain the standard therapy.
• In recurrent pericarditis, colchicine remains first-line, while IL-1 inhibitors (anakinra, rilonacept) are proposed for resistant cases.
• In myocarditis, treatment is etiology-driven — immunosuppressive therapy is avoided in viral cases but may be considered in autoimmune or inflammatory myocarditis.
• Updated Arrhythmia and Heart Failure Management: The risk of malignant ventricular arrhythmias in myocarditis is underscored. ICD implantation should be deferred in the acute phase, while wearable cardioverter-defibrillators (WCDs) may be considered for temporary protection.

Limitations

• Knowledge gaps persist across all stages of IMPS, from pathogenesis to therapy, though rising awareness has driven numerous ongoing studies.
• Advances in multimodality imaging have enhanced non-invasive, comprehensive understanding of the disease, paving the way for individualized approaches.
• Uncertainties remain particularly high in chronic disease, children, women of childbearing age, pregnancy and lactation, and the elderly.
• Return to work and physical activity should be individualized based on risk; current guidance aims to be less restrictive than before.
• Understanding of myocarditis etiology and mechanisms has improved, with viral, toxic, chemotherapy-related, and systemic causes investigated and targeted treatments proposed.
• Most antiviral treatments for myocarditis remain off-label, with limited controlled clinical evidence.
• Standardization of quantitative immunohistochemistry for endomyocardial biopsy is still under discussion.
• The pathogenic role of viral load (active vs. latent infection) requires further clarification.
• The link between genetic predisposition and recurrent myocarditis remains unclear, but growing research may reshape disease classification and therapeutic strategies.
• Overlapping conditions, especially dilated cardiomyopathy (DCM) and arrhythmogenic right ventricular cardiomyopathy (ARVC), are expected to become more recognized.
• Further studies are needed on prognosis and sudden cardiac death (SCD) risk stratification.
• There are major knowledge gaps regarding pathogenesis and individualized treatment in pericarditis, particularly the interaction between genetic background, inflammation, and autoimmunity.
• Elucidating the pathogenesis of recurrent pericarditis may support the development of more targeted therapies.
• The role of genetics in recurrent or complicated cases should be explored to understand mechanisms underlying persistent disease.
• New therapeutic options—especially for patients unresponsive to colchicine or anti–IL-1 agents—should be tested in clinical trials.
• Drug dependence (e.g., reliance on corticosteroids or anti–IL-1 agents for remission maintenance) remains a clinical challenge.
• The prognostic significance of persistent pericardial LGE is unclear and requires further investigation.
• More data are needed regarding timing of return to physical activity and work, ideally through prospective clinical or observational studies.

Commentary:
The latest ESC Guidelines on myocarditis and pericarditis introduce substantial innovations in the diagnosis, treatment, and patient management of these inflammatory cardiac conditions. They emphasize risk-based classification, the central diagnostic role of cardiac MRI, standardized use of biomarkers, and the importance of endomyocardial biopsy in selected cases. Therapeutically, the focus has shifted toward personalized medicine: colchicine remains the cornerstone for recurrent pericarditis, while IL-1 inhibitors are now recommended as a novel alternative for resistant cases. In myocarditis, an etiology-specific approach is encouraged, with close monitoring for patients at risk of malignant arrhythmias.
Given the unpredictable course of these diseases, the guidelines redefine not only diagnostic algorithms but also care organization, emphasizing multidisciplinary team management for high-risk patients. Collaboration between cardiology, advanced imaging, electrophysiology, heart failure, rheumatology, and infectious disease teams is critical for accurate diagnosis, etiologic treatment planning, and patient selection.
In fulminant myocarditis, integration of advanced heart failure and mechanical circulatory support teams is essential, whereas in recurrent or autoinflammatory pericarditis, rheumatology and immunology input improves treatment success.
Overall, the 2025 ESC Guidelines go beyond pharmacological updates — they propose a modern, team-based, and structured patient management model. This holistic and multidisciplinary approach is expected to contribute significantly to reducing mortality and morbidity in myocarditis and pericarditis care.