Decision support only — not a substitute for the 2025 ESC myocarditis & pericarditis guideline or your cardiology team. The 2025 framing treats heart and pericardium as one inflamed unit ("inflammatory myopericardial syndrome"): the two overlap, and the workup runs in parallel. Two shifts to know — troponin elevation alone no longer diagnoses myocarditis (CMR must confirm), and the recurrent-pericarditis pathway now ends in IL-1 inhibitors. Verify all doses.
1 Pericarditis — the escalation ladder
First-linemost cases
Acute pericarditis.
NSAID/aspirin + colchicine 0.5 mg od–bd for 3–6 months ICAP CORP. Taper the NSAID; colchicine is the last drug stopped.
Recurrent / incessantoptimise first
Relapse after remission, or never fully settling.
Confirm adherence, extend colchicine, exclude a systemic cause; restrict exercise until CRP normal & asymptomatic.
Second-lineuse sparingly
First-line failed or contraindicated.
Low-to-moderate dose corticosteroids — they promote recurrence and dependence, so avoid early and taper slowly with colchicine continued.
Third-line / refractorybiologic or surgery
Steroid-dependent or multiply recurrent.
IL-1 inhibitors — anakinra or rilonacept RHAPSODY. Pericardiectomy for refractory or constrictive disease.
Diagnose (≥2 of 4): pericarditic chest pain (sharp, pleuritic, worse supine / better sitting forward), friction rub, ECG (widespread saddle ST-elevation + PR depression), new/worsening pericardial effusion — supported by ↑CRP and imaging. Steroids are second-line precisely because they drive recurrence — the single most common management error.
2 Myocarditis — manage by risk
Uncomplicatedlow-risk
Preserved LVEF, no arrhythmia, no heart failure.
Supportive care, treat any HF with GDMT, monitor. Restrict exercise 3–6 months; re-evaluate before return to sport.
High-riskadmit & monitor
Reduced LVEF, arrhythmia, or high-grade AV block.
Telemetry + GDMT for HF; consider endomyocardial biopsy. Treat arrhythmia/conduction disease.
Fulminantcardiogenic shock
Haemodynamic collapse.
Mechanical circulatory support (ECMO/Impella), inotropes, urgent EMB, transplant-centre transfer.
Specific aetiologyEMB-guided
Biopsy-proven or drug-related.
Immunosuppression for giant-cell, eosinophilic, sarcoid, or autoimmune myocarditis. ICI myocarditis → stop the drug + high-dose steroids.
Diagnose: infarct-like chest pain / arrhythmia / HF / aborted SCD + ↑troponin, then CMR (Lake Louise 2.0 — a T2 oedema marker + a T1 injury marker/LGE). Troponin elevation alone is not enough. EMB (ideally <14 days) for fulminant, acute HF/shock, or when specific immunosuppression is considered.
3 Getting the diagnosis right
The shared workup
- BloodsTroponin, CRP, ECG, BNP; viral/autoimmune screen as guided.
- EchoLV function, wall motion, effusion, tamponade physiology.
- CMRThe central non-invasive test — characterises oedema & injury, maps LGE, confirms myocardial involvement.
- ExcludeCoronary disease (myocarditis is a frequent final diagnosis in the MINOCA workup).
When to biopsy
- StrongAcute heart failure or cardiogenic shock (fulminant) — EMB to find a treatable cause.
- ConsiderSuspected giant-cell/eosinophilic/sarcoid, or chronic inflammatory cardiomyopathy where immunosuppression would change management.
- TimingWithin ~14 days of onset for best yield; at an experienced centre.
4 The traps & the emergencies
Don't miss
- TamponadeBeck's triad, pulsus paradoxus, echo diastolic collapse → pericardiocentesis. A clinical emergency.
- ConstrictionEffusive-constrictive disease — if constriction persists after drainage and doesn't resolve on anti-inflammatories in 2–3 months, refer for pericardiectomy (don't wait indefinitely).
- ICI myocarditisCheckpoint-inhibitor myocarditis is rare but high-mortality — low threshold to suspect, stop the drug, high-dose steroids.
Don't get wrong
- TroponinA raised troponin alone does not diagnose myocarditis — confirm on CMR before labelling.
- SteroidsFirst-line in pericarditis is NSAID + colchicine; early steroids cause recurrence.
- ExerciseRestrict exercise for 3–6 months in myocarditis (arrhythmic risk) — re-assess before return to sport.
- ColchicineHalve the dose in renal impairment / with interacting drugs; it's the last agent withdrawn.
Sources.
2025 ESC Guidelines for the management of myocarditis and pericarditis (first combined ESC guideline; "inflammatory myopericardial syndrome"; CMR Lake Louise 2.0 — T1 + T2 — central, troponin alone insufficient; EMB reserved for high-risk/fulminant/specific-therapy, ideally <14 days; pericarditis NSAID + colchicine 3–6 months first-line, corticosteroids second-line, IL-1 inhibitors third-line; exercise restriction). eTG.
Key trials: ICAP / CORP / CORP-2 (colchicine for acute & recurrent pericarditis); RHAPSODY (rilonacept) and anakinra trials for recurrent pericarditis.
Caveats: this guideline overlaps with the cardiomyopathy guideline for chronic inflammatory cardiomyopathy. IL-1 inhibitors are specialist-initiated and access-restricted in Australia — confirm availability/PBS. Immunosuppression decisions are EMB- and centre-dependent. Verify all doses. Companion to the cardiac set (ACS, HFrEF, AF, hypertension, PH).