HMN 2025: What are the New guidelines for myocarditis and pericarditis aim to improve diagnosis and treatment

New ESC Guidelines to improve the diagnosis and care of patients with myocarditis and pericarditis have been published at ESC Congress 2025 and also appear in the European Heart Journal.

This is the first time the ESC has published guidelines about myocarditis, and it is the first time that clinical guidance has been given about myocarditis and pericarditis at the same time.

The Guidelines give algorithms and easy-to-use flow charts to support medical professionals to better recognize, diagnose and treat myocarditis and pericarditis to improve clinical outcomes. They also give personalized recommendations for return to work and exercise.

The new guidance notes the potential overlap between myocarditis and pericarditis, and introduces the term “inflammatory myopericardial syndrome” (IMPS) to be used as an umbrella diagnosis until a more specific diagnosis is made. The new term will help increase the awareness of the spectrum of disease, and allow timely diagnosis and better management to improve patient outcomes.

“Myocarditis and pericarditis can be hard to recognize as they can present differently in different patients. Consequently, these conditions often go undiagnosed, which can have a very significant impact on patient health,” explains Professor Jeanette Schulz-Menger.

“To improve diagnosis, we have introduced a unifying term, inflammatory myopericardial syndrome, and we are giving new guidance on diagnosis and treatment for clinicians,” Professor Schulz-Menger added.

Myocarditis and pericarditis are inflammatory diseases of the myocardium, or heart muscle, and the pericardium, the fibrous sack surrounding the heart and major blood vessels. Their causes are varied, and can include genetic susceptibility and infectious disease.

Many patients will recover completely from these diseases, while others may need life-long monitoring and treatment. Myocarditis is thought to play a role in some cases of sudden cardiac death in some patients.

The important role of multimodality imaging, focusing on advanced cardiac magnetic resonance imaging methods, and the role of endomyocardial biopsy, were also discussed to give guidance to clinical cardiologists.

Having been diagnosed with myocarditis or pericarditis, patients will often be asked to refrain from daily activities. The new guidance recommends that additional testing, such as cardiac magnetic resonance imaging, can help assess whether it is advisable to return to exercise and work. This can aid recovery and support mental health.

While there has been an increase in medical knowledge about inflammatory myopericardial syndrome, the Guidelines also highlight significant evidence gaps. They identify a need for further large-scale prospective multicenter trials with predefined outcome measures.

New research is particularly needed to understand how best to treat those with chronic conditions and specific patient groups such as children, women of childbearing age, pregnant women and those that are breastfeeding, and the elderly.

“We hope this valuable new guidance will enable a paradigm shift for patient care, allowing the development of combined expertise in the diagnosis and therapy of myocarditis and pericarditis. This will also support a multidisciplinary team approach for more difficult cases,” said Professor Massimo Imazio.

“We also hope that these recommendations will help patients to get back to their normal lives, including starting to exercise and returning to work more quickly. This will improve their quality of life, may speed up their recovery, as well as reduce workplace sick days.”

Professor Imazio added, “We also hope that the evidence gaps we have identified can be urgently addressed by the research community and funders.”

The new ESC Guidelines also :

• Give a list of red flags for clinicians, including clinical signs and/or biomarkers, that may be clues for the detection of myocarditis and pericarditis improving the time to diagnosis
• Recommend that a complete clinical evaluation, including medical history, physical examination, chest X-ray, biomarker tests, electrocardiogram, and echocardiograph, for the initial diagnostic assessment for all patients suspected of having myocarditis and/or pericarditis
• Ask that a genetic cause, and genetic testing, is considered for patients with recurrent inflammatory myopericardial syndrome
• Recommend that complicated patients with inflammatory myopericardial syndrome are managed by a multidisciplinary team. The team should be composed of different clinicians, all with expertise in cardiovascular diseases, such as clinicians, imaging experts, infectious disease experts, surgeons, intensive care specialists and geneticists

Data about the prevalence of myocarditis and pericarditis across the general population are limited. One disease registry reported an incidence of acute myocarditis from 6.3 to 8.6 per 100 000 inhabitants, mostly in young men for hormonal factors.

Men and younger patients are more likely to be diagnosed, although it is not clear whether it is that these patients are more likely to receive a diagnosis. The incidence of acute pericarditis is estimated to be about three to 32 cases per 100,000 person-years. For sudden cardiac death in young adults, autopsies showed cases attributed to myocarditis in 1.1 to 12% of cases.

The “2025 ESC Guidelines for the management of myocarditis and pericarditis” have been endorsed by the Association for European Pediatric and Congenital Cardiology and the European Association for Cardio-Thoracic Surgery.