2025 ESC Guidelines for the Management of Myocarditis and Pericarditis (1st Edition, 2025) – PDF – Schulz-Menger

, European Heart Journal (2025) 00, 1–90 ESC GUIDELINES
https://doi.org/10.1093/eurheartj/ehaf192




2025 ESC Guidelines for the management
of myocarditis and pericarditis




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Developed by the task force for the management of myocarditis and
pericarditis of the European Society of Cardiology (ESC)
Endorsed by the Association for European Paediatric and
Congenital Cardiology (AEPC) and the European Association
for Cardio-Thoracic Surgery (EACTS)

Authors/Task Force Members: Jeanette Schulz-Menger †,*, (Chairperson)
(Germany), Valentino Collini ‡, (Task Force Co-ordinator) (Italy),
Jan Gröschel ‡, (Task Force Co-ordinator) (Germany), Yehuda Adler (Israel),
Antonio Brucato (Italy), Vanessa Christian (United Kingdom),
Vanessa M. Ferreira (United Kingdom), Estelle Gandjbakhch (France),
Bettina Heidecker (Germany), Mathieu Kerneis (France), Allan L. Klein
(United States of America), Karin Klingel (Germany), George Lazaros
(Greece), Roberto Lorusso (Netherlands), Elena G. Nesukay (Ukraine),
Kazem Rahimi (United Kingdom), Arsen D. Ristić (Serbia), Marcin Rucinski
(Poland), Leyla Elif Sade (United States of America), Hannah Schaubroeck
(Belgium), Anne Grete Semb (Norway), Gianfranco Sinagra (Italy),
†,
Jens Jakob Thune (Denmark), Massimo Imazio *, (Chairperson) (Italy), and
the ESC Scientific Document Group




* Corresponding authors: Jeanette Schulz-Menger, Charité—Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, ECRC
Experimental and Clinical Research Center, Berlin, Germany, and DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany, and Deutsches
Herzzentrum der Charité Berlin, Germany, and Cardiology and Nephrology, HELIOS Hospital Berlin-Buch, Berlin, Germany. Tel: +4930450540611, E-mail: jeanette.schulz-

Massimo Imazio, Department of Medicine, University of Udine, and Cardiothoracic Department, University Hospital Santa Maria della Misericordia, ASUFC, Udine, Italy. Tel: +393296524271,
E-mail:
†
The two Chairpersons contributed equally to the document and are joint corresponding authors.
‡
The two Task Force Co-ordinators contributed equally to the document.
Author/Task Force Member affiliations are listed in author information.
ESC Clinical Practice Guidelines (CPG) Committee: listed in the Appendix.
ESC subspecialty communities having participated in the development of this document:
Associations: Association of Cardiovascular Nursing & Allied Professions (ACNAP), Association for Acute CardioVascular Care (ACVC), European Association of Cardiovascular Imaging
(EACVI), European Association of Percutaneous Cardiovascular Interventions (EAPCI), European Heart Rhythm Association (EHRA), Heart Failure Association (HFA).
Councils: Council for Cardiology Practice, Council of Cardio-Oncology, Council on Basic Cardiovascular Science.
Working Groups: Cardiovascular Pharmacotherapy, Cardiovascular Surgery, Myocardial and Pericardial Diseases, Pulmonary Circulation and Right Ventricular Function.
Patient Forum
© The European Society of Cardiology 2025. All rights reserved.

,2 ESC Guidelines


Document Reviewers: Elena Arbelo, (CPG Review Co-ordinator) (Spain), Cristina Basso, (CPG Review
Co-ordinator) (Italy), Marianna Adamo (Italy), Suleman Aktaa (United Kingdom), Enrico Ammirati (Italy),
Lisa Anderson (United Kingdom), Eloisa Arbustini (Italy), Emanuele Bobbio (Sweden), Giuseppe Boriani (Italy),
Margarita Brida (Croatia), Robert A. Byrne (Ireland), Alida L.P. Caforio (Italy), Gh.-Andrei Dan (Romania),
Fernando Domínguez (Spain), Suzanne Fredericks (Canada), Geeta Gulati (Norway), Borja Ibanez (Spain),
Stefan James (Sweden), Alexander Kharlamov (Netherlands), Sabine Klaassen (Germany), Jolanda Kluin
(Netherlands), Konstantinos C. Koskinas (Switzerland), Petr Kuchynka (Czech Republic), Vijay Kunadian (United
Kingdom), Ulf Landmesser (Germany), Gregory Y.H. Lip (United Kingdom), Bernhard Maisch (Germany),




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Federica Marelli-Berg (United Kingdom), Pilar Martin (Spain), John William McEvoy (Ireland), Borislava Mihaylova
(United Kingdom), Richard Mindham (United Kingdom), Inge Moelgaard (Denmark), Saidi A. Mohiddin (United
Kingdom), Jens Cosedis Nielsen (Denmark), Agnes A. Pasquet (Belgium), Giovanni Peretto (Italy), Kalliopi Pilichou
(Italy), Nicolas Piriou (France), Eva Prescott (Denmark), Amina Rakisheva (Kazakhstan), Bianca Rocca (Italy),
Xavier Rossello (Spain), Anna Sannino (Germany), Franziska Seidel1 (Germany), Felix C. Tanner (Switzerland),
Witold Zbyszek Tomkowski (Poland), Ilonca Vaartjes (Netherlands), Sophie Van Linthout (Germany),
Christiaan Vrints (Belgium), Romuald Wojnicz (Poland), and Katja Zeppenfeld (Netherlands)
1
Representing the Association for European Paediatric and Congenital Cardiology (AEPC).

All experts involved in the development of these guidelines have submitted declarations of interest,
which are reported in a supplementary document to the guidelines. See the European Heart Journal online
or https://www.escardio.org/Guidelines for supplementary documents as well as evidence tables.

Disclaimer: The European Society of Cardiology (ESC) Guidelines represent the views of the ESC and were produced after careful
consideration of the scientific and medical knowledge and the evidence available at the time of their publication. The ESC is not responsible in
the event of any contradiction, discrepancy and/or ambiguity between the ESC Guidelines and any other official recommendations or guidelines
issued by the relevant public health authorities, in particular in relation to good use of healthcare or therapeutic strategies. Health professionals
are encouraged to take the ESC Guidelines fully into account when exercising their clinical judgement, as well as in the determination and the
implementation of preventive, diagnostic or therapeutic medical strategies; however, the ESC Guidelines do not override, in any way
whatsoever, the individual responsibility of health professionals to make appropriate and accurate decisions in consideration of each patient’s
health condition and in consultation with that patient and, where appropriate and/or necessary, the patient’s caregiver. Nor do the ESC
Guidelines exempt health professionals from taking into full and careful consideration the relevant official updated recommendations or
guidelines issued by the competent public health authorities, in order to manage each patient’s case in light of the scientifically accepted data
pursuant to their respective ethical and professional obligations. It is also the health professional’s responsibility to verify the applicable rules and
regulations relating to drugs and medical devices prior to making any clinical decision and to check whether a more recent version of this
document exists. The ESC warns readers that the technical language may be misinterpreted and declines any responsibility in this respect.

Permissions: The content of these ESC Guidelines has been published for personal and educational use only. No commercial use is
authorized. No part of the ESC Guidelines may be translated or reproduced in any form without written permission from the ESC.
Permissions can be obtained upon submission of a written request to Oxford University Press, the publisher of the European Heart Journal
and the party authorized to handle such permissions on behalf of the ESC ().




-Keywords
-----------------------------------------------------------------------------------------------------------------------------------------------------------
Guidelines • Myocarditis • Pericarditis • Myopericarditis • Perimyocarditis • Diagnosis • Therapy •
Echocardiography • Cardiac magnetic resonance • Multimodality imaging • Endomyocardial biopsy




Table of contents 3.3.2. Diagnostic criteria for pericarditis ................................................
3.4. Aetiology of myocarditis and pericarditis ..........................................
15
15
1. Preamble ...................................................................................................................... 7 3.4.1. Aetiology of myocarditis .................................................................. 15
2. Introduction ............................................................................................................... 8 3.4.2. Aetiology of pericarditis ................................................................... 15
2.1. What is new ..................................................................................................... 8 4. Clinical presentation of inflammatory myopericardial syndrome .... 15
3. Epidemiology, classification, stages, diagnostic criteria and aetiology 11 4.1. General symptoms and signs ................................................................... 19
3.1. Epidemiology .................................................................................................. 11 4.2. Clinical stages of myocarditis .................................................................. 19
3.2. Classification and stages ............................................................................ 11 4.2.1. Acute myocarditis ............................................................................... 19
3.3. Diagnostic criteria ........................................................................................ 12 4.2.2. Fulminant myocarditis ........................................................................ 20
3.3.1. Diagnostic criteria for myocarditis ............................................... 12 4.2.3. Subacute myocarditis ......................................................................... 20

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4.2.4. Chronic myocarditis ........................................................................... 20 6.3.1. Myocarditis ............................................................................................. 42
4.3. Clinical presentations of myocarditis ................................................... 20 6.3.1.1. Short-term mechanical circulatory support .................... 42
4.3.1. Chest pain presentation ................................................................... 20 6.3.1.2. Intra-aortic balloon pump ....................................................... 42
4.3.2. Heart failure presentation ................................................................ 22 6.3.2. Pericarditis .............................................................................................. 42
4.3.3. Presentation with arrhythmias ....................................................... 22 6.3.2.1. Pericardiocentesis and pericardial drainage ..................... 42
4.3.4. Sudden cardiac death ......................................................................... 22 6.3.2.2. Percutaneous balloon pericardiotomy ............................... 43
4.3.5. Presentation of myocarditis with a potential genetic 6.3.2.3. Intrapericardial drug administration .................................... 43
background ......................................................................................................... 22 6.3.2.4. Pericardioscopy ............................................................................ 43




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4.4. Clinical stages of pericarditis ................................................................... 22 6.3.2.5. Pericardial fluid analysis, pericardial and epicardial
4.4.1. Acute pericarditis ................................................................................. 22 biopsy ............................................................................................................... 43
4.4.2. Subacute pericarditis .......................................................................... 25 6.3.2.6. Circulatory support ................................................................... 43
4.4.3. Chronic pericarditis ............................................................................ 25 6.4. Surgical therapy ............................................................................................. 43
4.5. Clinical presentations of pericarditis .................................................... 25 6.4.1. Myocarditis ............................................................................................. 43
4.5.1. Dry pericarditis ..................................................................................... 25 6.4.2. Pericarditis .............................................................................................. 43
4.5.2. Effusive pericarditis ............................................................................. 25 6.4.2.1. Surgical pericardiocentesis ...................................................... 43
4.5.3. Effusive–constrictive pericarditis ................................................... 25 6.4.2.2. Pericardiotomy/pericardial window .................................... 43
4.5.4. Pericarditis with cardiac tamponade ........................................... 25 6.4.2.3. Pericardiectomy ........................................................................... 44
4.5.5. Constrictive pericarditis .................................................................... 26 6.5. Management of arrhythmias and prevention of sudden
4.5.6. Transient constrictive pericarditis ................................................ 27 cardiac death in myocarditis ............................................................................. 44
4.5.6.1. Constrictive pathophysiology ................................................ 27 6.5.1. Role of active devices (wearable and implanted devices) in
4.5.7. Pericarditis with polyserositis ......................................................... 28 acute myocarditis ............................................................................................. 45
4.5.8. Inflammatory vs non-inflammatory pericarditis ...................... 28 7. Prognosis .................................................................................................................. 45
4.5.8.1. Inflammatory phenotype of pericarditis ............................ 28 7.1. Complications and outcomes for myocarditis ................................ 45
4.5.8.2. Non-inflammatory phenotype of pericarditis ................. 28 7.1.1. Sequela and mortality in myocarditis .......................................... 46
5. Diagnosis and diagnostic work-up ................................................................. 28 7.1.2. Follow-up ................................................................................................ 46
5.1. Electrocardiogram ........................................................................................ 29 7.2. Complications and outcomes for pericarditis ................................. 47
5.2. Biomarkers ...................................................................................................... 29 8. Inflammatory myopericardial syndrome overlapping types:
5.2.1. Biomarkers in clinical routine ......................................................... 29 myopericarditis and perimyocarditis ................................................................. 48
5.2.2. Biomarkers beyond clinical routine ............................................. 29 8.1. Inflammatory myopericardial syndrome in systemic disorders 49
5.3. Genetics ............................................................................................................ 30 8.1.1. Rheumatoid arthritis .......................................................................... 49
5.4. Multimodality imaging ................................................................................. 31 8.1.2. Systemic lupus erythematosus ....................................................... 49
5.5. Echocardiography ......................................................................................... 31 8.1.3. Antiphospholipid syndrome ............................................................ 49
5.5.1. Echocardiography in myocarditis .................................................. 31 8.1.4. Sjögren’s syndrome ............................................................................. 49
5.5.2. Echocardiography in pericarditis ................................................... 31 8.1.5. Systemic sclerosis ................................................................................ 49
5.6. Cardiovascular magnetic resonance ..................................................... 32 8.1.6. Polymyositis and dermatomyositis ............................................... 49
5.7. Computed tomography ............................................................................. 32 8.1.7. Vasculitis .................................................................................................. 49
5.8. Nuclear medicine ......................................................................................... 33 8.2. Inflammatory myopericardial syndrome in COVID-19 disease 49
5.9. Endomyocardial and pericardial biopsy .............................................. 33 9. Specific types of myocarditis ............................................................................ 50
5.9.1. Endomyocardial biopsy ..................................................................... 33 9.1. Lymphocytic myocarditis .......................................................................... 50
5.9.2. Pericardial biopsy ................................................................................. 35 9.1.1. Presentation ........................................................................................... 50
5.10. Role of autopsy .......................................................................................... 35 9.1.2. Diagnosis and therapy ....................................................................... 50
5.11. Role of cardiac catheterization and coronary angiography ..... 35 9.2. Eosinophilic myocarditis ............................................................................ 50
5.12. Electro-anatomical mapping .................................................................. 36 9.2.1. Presentation ........................................................................................... 50
6. Therapy ..................................................................................................................... 36 9.2.2. Diagnosis ................................................................................................. 50
6.1. Non-pharmacological therapy for inflammatory 9.2.3. Therapy .................................................................................................... 50
myopericardial syndrome .................................................................................. 36 9.3. Giant-cell myocarditis ................................................................................. 50
6.2. Pharmacological therapy ........................................................................... 36 9.3.1. Presentation ........................................................................................... 51
6.2.1. Pharmacological therapy for myocarditis .................................. 36 9.3.2. Diagnosis ................................................................................................. 51
6.2.1.1. General principles ....................................................................... 36 9.3.3. Therapy .................................................................................................... 51
6.2.1.2. Fulminant myocarditis ............................................................... 38 9.4. Myocarditis in sarcoidosis ......................................................................... 52
6.2.1.3. Acute myocarditis ....................................................................... 38 9.4.1. Presentation ........................................................................................... 52
6.2.1.4. Subacute and chronic myocarditis ....................................... 39 9.4.2. Diagnosis ................................................................................................. 52
6.2.2. Pharmacological therapy for pericarditis ................................... 39 9.4.3. Therapy .................................................................................................... 52
6.2.2.1. General principles ....................................................................... 39 9.5. Specific infectious myocarditis (Viruses, Lyme, Chagas) ............. 53
6.2.2.1.1. Acute pericarditis (first episode) ................................. 39 9.5.1. Viruses ...................................................................................................... 53
6.2.2.2. Incessant and recurrent pericarditis ................................... 39 9.5.1.1. Presentation .................................................................................. 53
6.3. Interventional techniques including circulatory support ............. 42 9.5.1.2. Diagnosis ......................................................................................... 53