ESC 2025 2025 ESC Guidelines for the management of myocarditis and pericarditis
European Society of Cardiology｜循環器 / 心不全・心筋疾患｜90 ページ｜チャンク 903｜推奨 153 件｜current
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| 頁 | クラス | レベル | 推奨文 | 表 |
|---|---|---|---|---|
| p.28 | I | C | Complete clinical evaluation, including history, physical examination, chest X-ray, biomarkersc, ECG, and echocardiography is recommended in all patients with a suspicion of myocarditis and/or pericarditis for the initial diagnostic assessment. | Recommendation Table 1 — Recommendations for clinical evaluation of myocarditis and pericarditis (see Evidence Table 1) |
| p.28 | I | B | CMR is recommended in patients with the clinical suspicion of myocarditis (using updated LL criteria)30 and/or pericarditis for the non-invasive diagnosis of inflammatory reaction.110,115,129 | Recommendation Table 1 — Recommendations for clinical evaluation of myocarditis and pericarditis (see Evidence Table 1) |
| p.28 | I | B | Hospital admission is recommended for patients with high-risk pericarditisd for monitoring and treatment.105,130 | Recommendation Table 1 — Recommendations for clinical evaluation of myocarditis and pericarditis (see Evidence Table 1) |
| p.28 | I | C | Hospital admission is recommended for patients with moderate- to high-risk myocarditisd for monitoring and treatment. | Recommendation Table 1 — Recommendations for clinical evaluation of myocarditis and pericarditis (see Evidence Table 1) |
| p.28 | I | C | EMBe is recommended in patients with high-risk myocarditisd and/or haemodynamic instability, and/or in patients with intermediate-risk myocarditis not responding to conventional therapy in order to detect a specific histologic subtype and to assess the presence of viral genome for treatment.34,63,73,131 | Recommendation Table 1 — Recommendations for clinical evaluation of myocarditis and pericarditis (see Evidence Table 1) |
| p.28 | I | C | Invasive coronary angiography or coronary CT, depending on clinical likelihood, is recommended in patients with IMPS if an acute coronary syndrome is suspected to rule out obstructive coronary artery disease. | Recommendation Table 1 — Recommendations for clinical evaluation of myocarditis and pericarditis (see Evidence Table 1) |
| p.28 | IIa | C | Hospital admission should be considered for patients with low-risk myocarditisd for monitoring and treatment. | Recommendation Table 1 — Recommendations for clinical evaluation of myocarditis and pericarditis (see Evidence Table 1) |
| p.28 | IIb | C | Pericardial or epicardial biopsy may be considered in relapsing pericardial effusion as part of the diagnostic work-up when the diagnosis cannot be reached with multimodality imaging and laboratory examinations. | Recommendation Table 1 — Recommendations for clinical evaluation of myocarditis and pericarditis (see Evidence Table 1) |
| p.28 | III | C | Routine serology is not recommended in patients with myocarditis and/or pericarditis for the evaluation of viral aetiology except for hepatitis C, HIV, and Lyme disease. | Recommendation Table 1 — Recommendations for clinical evaluation of myocarditis and pericarditis (see Evidence Table 1) |
| p.30 | I | C | It is recommended to obtain family history including pedigrees in cases of recurrent IMPS to provide clues to the underlying aetiology, determine inheritance pattern, and identify relatives at risk. Genetic testing should be considered in patients with definite myocarditis/pericarditis in | Recommendation Table 2 — Recommendations for genetic testing (see Evidence Table 2) |
| p.30 | IIa | B | cases of:50,51,64,94,150 • family history of IMPS, inherited or suspected cardiomyopathy • severe ventricular arrhythmiac • significant left/right LGE (e.g. ring-like pattern or septal LGE) or persistent LVEF systolic dysfunction • recurrent myocarditis or persistent troponin elevation • recurrent pericarditis with an inflammatory phenotype, refractory to conventional treatmentd, with the aim to detect an underlying genetic cause. | Recommendation Table 2 — Recommendations for genetic testing (see Evidence Table 2) |
| p.32 | I | B | Myocarditis CMR is recommended in patients with suspected myocarditis to reach a clinical diagnosis and to determine the cause of acute myocardial injury, including assessment of oedema, ischaemia, and necrosis/fibrosis/scarring.115,164,169–183 | Recommendation Table 3 — Recommendations for the use of cardiovascular magnetic resonance imaging (see Evidence Table 3) |
| p.32 | I | C | CMR is recommended for follow-up at least within the first 6 months in patients with myocarditis to identify a healed or ongoing process, for risk stratification and personalized therapy, and to enable a return to exercise.10,62,184–186 Pericarditis | Recommendation Table 3 — Recommendations for the use of cardiovascular magnetic resonance imaging (see Evidence Table 3) |
| p.32 | I | B | CMR is recommended in patients with suspected pericarditis when a diagnosis cannot be made using clinical criteria to assess evidence of pericardial thickening, oedema, LGE, and to assess the persistence of disease during follow-up in selected cases.110,129,165,187–194 | Recommendation Table 3 — Recommendations for the use of cardiovascular magnetic resonance imaging (see Evidence Table 3) |
| p.32 | I | C | CT is recommended to evaluate pericardial thickness, calcifications, masses, and loculated pericardial effusions, as well as concomitant pleuropulmonary diseases and chest abnormalities.193,197,199,200 | Recommendation Table 4 — Recommendations for computed tomography (see Evidence Table 4) |
| p.33 | IIa | C | Carb-free 18F-FDG-PET or 18F-FDG-PET/CT should be considered for the diagnostic work-up in patients with suspected myocarditis and/or pericarditis in whom echocardiography and CMR are inconclusive for the clinical diagnosis.201,206 | Recommendation Table 5 — Recommendations for nuclear medicine (see Evidence Table 5) |
| p.35 | I | B | NGS for detection of pathogenic variants in cardiac genes, traditionally associated with cardiomyopathies (especially © ESC 2025 Comprehensive autopsy is recommended in all patients <50 years of age with SCD to evaluate the desmosomal and sarcomeric/ cytoskeletal genes) presence of acute myocarditis as a cause and to detect potential underlying inherited cardiac diseases.87,243–246c | Recommendation Table 7 — Recommendations for autopsy (see Evidence Table 7) |
| p.35 | I | B | Retaining samples suitable for DNA extraction and consulting a cardiac pathologist is recommended in cases of SCD, when an inherited cause is suspected, or the cause of death remains unexplained.243,247c | Recommendation Table 7 — Recommendations for autopsy (see Evidence Table 7) |
| p.36 | IIa | C | Electro-anatomical mapping should be considered in cases of suspected myocarditis (especially cardiac sarcoidosis) to guide endomyocardial biopsy.218,220,221,253,256–258 aClass of recommendation. bLevel of evidence. 6 Therapy | Recommendation Table 8 — Recommendations for electro-anatomical mapping (see Evidence Table 8) |
| p.39 | IIa | B | myopericarditis to reduce recurrences.263 | Recommendation Table 9 — Recommendations for medical therapy in myocarditis (see Evidence Table 9) |
| p.39 | IIa | C | Management of symptoms NSAIDs (together with proton pump inhibition) should be considered in patients with associated symptoms of pericarditis to reduce symptoms. Colchicine should be considered in patients with | Recommendation Table 9 — Recommendations for medical therapy in myocarditis (see Evidence Table 9) |
| p.39 | I | C | Management of heart failure Adherence to the ESC HF guidelines is recommended in cases of myocarditis with LV systolic dysfunction and/or HF to reduce symptoms and to improve LV function.12 | Recommendation Table 9 — Recommendations for medical therapy in myocarditis (see Evidence Table 9) |
| p.39 | IIa | C | HF therapy should be considered in patients with myocarditis and LV systolic dysfunction for at least 6 months upon complete LV functional recovery to stabilize LV function. | Recommendation Table 9 — Recommendations for medical therapy in myocarditis (see Evidence Table 9) |
| p.39 | IIa | C | Management of arrhythmias β-Blockers, with a continuation for at least 6 months, should be considered in patients with acute myocarditis, especially those with troponin elevation, to control symptoms and prevent arrhythmias. | Recommendation Table 9 — Recommendations for medical therapy in myocarditis (see Evidence Table 9) |
| p.39 | IIa | C | Anti-arrhythmic treatment should be considered in post-myocarditis patients with recurrent, symptomatic VT to reduce arrhythmic burden.58 | Recommendation Table 9 — Recommendations for medical therapy in myocarditis (see Evidence Table 9) |
| p.39 | IIa | C | Immunosuppressive therapy Corticosteroids should be considered in patients with fulminant, non-infectious forms of myocarditis to stabilize the patients. | Recommendation Table 9 — Recommendations for medical therapy in myocarditis (see Evidence Table 9) |
| p.39 | IIb | C | Corticosteroids may be considered in patients with acute myocarditis with impaired LVEF if refractory to standard HF therapy to stabilize patients. | |
| p.39 | III | C | Routine use of immunosuppressive therapy is not recommended in acute myocarditis with preserved LV function because no outcome benefit has been shown. | |
| p.42 | I | A | Colchicine is recommended as first-line therapy in patients with pericarditis as an adjunct to aspirin/NSAID or corticosteroid therapy to reduce subsequent recurrences.24,25,108,275–278 | Recommendation Table 10 — Recommendations for medical therapy in pericarditis (see Evidence Table 10) |
| p.42 | I | A | Anti-IL-1 agents (anakinra or rilonacept) are recommended for patients with recurrent pericarditis after failure of first-line therapies and corticosteroids and elevation of C-reactive protein levels to reduce recurrences and allow corticosteroid withdrawal.108,275,282–284 | Recommendation Table 10 — Recommendations for medical therapy in pericarditis (see Evidence Table 10) |
| p.42 | I | B | High-dose aspirin or NSAIDs with proton pump inhibitors are recommended as first-line therapy in patients with pericarditis to control symptoms and reduce recurrences.291,292 | Recommendation Table 10 — Recommendations for medical therapy in pericarditis (see Evidence Table 10) |
| p.42 | IIa | C | A β-blocker should be considered in symptomatic patients, despite full anti-inflammatory therapy, and heart rate at rest >75 b.p.m. in order to improve symptom control.274 | Recommendation Table 10 — Recommendations for medical therapy in pericarditis (see Evidence Table 10) |
| p.42 | IIa | C | Anti-IL-1 agents (anakinra or rilonacept) should be considered in cases of incessant/recurrent pericarditis with evidence of pericardial inflammation on CMR after failure, contraindications, and intolerance to first-line therapies and corticosteroids regardless of C-reactive protein levels to reduce recurrences and allow corticosteroid withdrawal. | Recommendation Table 10 — Recommendations for medical therapy in pericarditis (see Evidence Table 10) |
| p.42 | IIa | C | Low- to medium-dosec corticosteroids should be considered for patients with pericarditis only in cases of contraindication/failure of aspirin/NSAIDs and colchicine, or when there is a specific indication to control symptoms and reduce recurrencesd. | Recommendation Table 10 — Recommendations for medical therapy in pericarditis (see Evidence Table 10) |
| p.42 | IIb | B | Hydroxychloroquine may be considered in patients with recurrent pericarditis refractory to standard therapy (including corticosteroids and anti-IL-1 agents) to prolong recurrence-free survival.290 | Recommendation Table 10 — Recommendations for medical therapy in pericarditis (see Evidence Table 10) |
| p.42 | III | C | Corticosteroids are not recommended as the first option for patients with pericarditis therapy without a specific indicationd. | Recommendation Table 10 — Recommendations for medical therapy in pericarditis (see Evidence Table 10) |
| p.42 | I | C | A timely and dedicated Shock Team discussion is recommended in patients with myocarditis in the presence of haemodynamic compromise, to decide on the need for escalation to MCS and to determine a long-term management plan. | Recommendation Table 11 — Recommendations for interventional techniques including circulatory support in myocarditis (see Evidence Table 11) |
| p.42 | IIa | C | Temporary MCSc should be considered in patients with myocarditis and cardiogenic shock or acute decompensation in chronic myocarditis to stabilize the patients. © ESC 2025 | Recommendation Table 11 — Recommendations for interventional techniques including circulatory support in myocarditis (see Evidence Table 11) |
| p.43 | I | C | Pericardiocentesis (echocardiography-, CT-, or fluoroscopy-guided) is recommended for cardiac tamponade, or suspected bacterial or neoplastic pericarditis, or symptomatic moderate to large pericardial effusion despite medical therapy. | Recommendation Table 12 — Recommendations for interventional techniques in pericarditis (see Evidence Table 12) |
| p.43 | I | C | Surgical pericardial drainage is recommended in patients with pericardial effusion when percutaneous pericardiocentesis is not feasible or with purulent pericardial effusion to allow complete drainage and to prevent constriction. | Recommendation Table 12 — Recommendations for interventional techniques in pericarditis (see Evidence Table 12) |
| p.43 | I | C | Surgical pleuro-pericardial window is recommended in patients with relapsing pericardial effusion despite medical therapy. CT, computed tomography. aClass of recommendation. bLevel of evidence. | Recommendation Table 12 — Recommendations for interventional techniques in pericarditis (see Evidence Table 12) |
| p.44 | I | C | Surgical pericardiectomy is recommended in patients with chronic pericardial constriction or persistent constrictive pericarditis despite medical therapy to improve symptoms and survival.312,313 | Recommendation Table 13 — Recommendations for surgical therapy (see Evidence Table 13) |
| p.44 | I | C | Tricuspid valve repair is recommended in patients with pericardial constriction and severe tricuspid valve regurgitation to improve symptoms and survival.316 aClass of recommendation. bLevel of evidence. | Recommendation Table 13 — Recommendations for surgical therapy (see Evidence Table 13) |
| p.45 | IIa | C | Pacing in myocarditis Temporary transvenous external pacing should be considered in patients with acute myocarditis and high-degree conduction disorders as a bridge to recovery.86,317,335 | Recommendation Table 14 — Recommendations for management of arrhythmias and prevention of sudden cardiac death in myocarditis (see Evidence Table 14) |
| p.45 | IIa | C | WCD in myocarditis A WCD should be considered for 3–6 months in patients with sustained ventricular arrhythmia during the acute phase of myocarditis as a bridge to recovery.323,325,327–330 Ablation in myocarditis | |
| p.45 | IIa | C | Catheter ablation, performed in specialized centres, should be considered in post-myocarditis patients with recurrent symptomatic SMVT or ICD shocks in whom AAD are ineffective, not tolerated, or not desired.58 ICD in myocarditis | |
| p.45 | I | C | Secondary prevention ICD implantation is recommended in patients with non-activec myocarditis and haemodynamically not-tolerated sustained VT to prevent SCD.78,79,322,336 | |
| p.45 | IIa | C | ICD implantation should be considered in patients with non-activec myocarditis and haemodynamically tolerated sustained VT to prevent SCD.78,79,322,336 | |
| p.45 | IIb | C | ICD implantation may be considered in patients with acute myocarditis and sustained VA (VT/VF) in the acute phase to prevent SCD.71,79,89,222,323–325 Primary prevention | |
| p.45 | IIb | C | ICD implantation may be considered in patients with myocarditis after the acute phase (3–6 months) and persistent risk factors for VAd to prevent SCD.89,332–334,336. 7 Prognosis | |
| p.47 | I | C | Follow-up with clinical assessment, biomarkersc, ECG, exercise test, Holter-ECG monitoring, echocardiography, and CMR at least within 6 months after the index hospitalization is recommended in all patients with myocarditis to identify a potential progression or new risk factors.62 | Recommendation Table 15 — Recommendations for risk stratification, complications, and outcomes of inflammatory myopericardial syndrome (see Evidence Table 15) |
| p.47 | I | C | Long-term follow-up is recommended for patients with complicated myocarditisd to identify a potential progression or new complications.28,74 | Recommendation Table 15 — Recommendations for risk stratification, complications, and outcomes of inflammatory myopericardial syndrome (see Evidence Table 15) |
| p.47 | I | C | Long-term follow-up is recommended for patients with incessant or recurrent pericarditis to identify a potential progression and new complications.104,347 CMR, cardiovascular magnetic resonance; ECG, electrocardiogram. aClass of recommendation. bLevel of evidence. cAt least troponin. dSee definition of complicated myocarditis in Table 3. | Recommendation Table 15 — Recommendations for risk stratification, complications, and outcomes of inflammatory myopericardial syndrome (see Evidence Table 15) |
| p.51 | I | C | recommended in patients with a diagnosed GCM.217 | Recommendation Table 16 — Recommendations for giant-cell myocarditis (see Evidence Table 16) |
| p.51 | I | C | EMB is recommended in patients with suspected GCM due to unexplained new-onset HF of up to 2 weeks associated with a normal or dilated left ventricle and new ventricular arrhythmias, secondor third-degree AVB, or failure to respond to usual care within 1 to 2 weeks to initiate specific treatment.402 Combined immunosuppressive therapy is | Recommendation Table 16 — Recommendations for giant-cell myocarditis (see Evidence Table 16) |
| p.52 | I | C | CS and LVEF ≤35% to prevent SCD.416,452,454,455 | Recommendation Table 17 — Recommendations for myocarditis in sarcoidosis (see Evidence Table 17) |
| p.52 | I | B | Diagnosis CMR, using tissue characterization techniques, is recommended in patients with suspected CS to assess cardiac inflammation and myocardial involvement.408,421–425 | Recommendation Table 17 — Recommendations for myocarditis in sarcoidosis (see Evidence Table 17) |
| p.52 | I | B | 18F-FDG-PET is recommended for the diagnostic work-up, including detection of inflammation, as well as for follow-up and assessment of therapeutic response in patients with CS.426–428 | Recommendation Table 17 — Recommendations for myocarditis in sarcoidosis (see Evidence Table 17) |
| p.52 | I | B | Therapy ICD implantation is recommended in patients with CS and sustained ventricular arrhythmia (VT/VF) or aborted CA to prevent SCD.58,396,416,454,455,466 ICD implantation is recommended in patients with | Recommendation Table 17 — Recommendations for myocarditis in sarcoidosis (see Evidence Table 17) |
| p.53 | IIa | C | ICD implantation should be considered in patients with CS and LVEF >35% after resolution of the active phase with significant LGE, a history of arrhythmias, unexplained syncope, inducible sustained VA at PVS, or with persistent high-degree AVB to prevent SCD.416,434,452,453,456–464,467 | |
| p.55 | I | C | Diagnostic triage within 24 h is recommendedc in patients with suspected myocarditis induced by ICI to initiate treatment rapidly.495,496,501,504 | Recommendation Table 18 — Recommendations for immune checkpoint inhibitor-associated myocarditis (see Evidence Table 18) |
| p.55 | I | C | Immediate disruption of ICI and administration of high-dosage corticosteroids are recommended in patients with ICI-associated myocarditis in order to stop the inflammatory reaction and stabilize the patient.504 | Recommendation Table 18 — Recommendations for immune checkpoint inhibitor-associated myocarditis (see Evidence Table 18) |
| p.55 | IIa | C | Second-line immunosuppression treatment should be considered in patients with steroid-refractory ICI-associated myocarditis.501,504 | Recommendation Table 18 — Recommendations for immune checkpoint inhibitor-associated myocarditis (see Evidence Table 18) |
| p.55 | IIb | C | Second-line immunosuppression treatment may be considered in patients with fulminant/severe ICI-associated myocarditis.501,504 ICI, immune checkpoint inhibitor. aClass of recommendation. bLevel of evidence. cSee Figure 5. | Recommendation Table 18 — Recommendations for immune checkpoint inhibitor-associated myocarditis (see Evidence Table 18) |
| p.56 | I | C | Guideline-directed heart failure treatments are recommended in patients with inflammatory cardiomyopathy to improve and/or stabilize left ventricular function. | Recommendation Table 19 — Recommendations for inflammatory cardiomyopathy (see Evidence Table 19) |
| p.56 | I | C | Specific medical therapy for the potentially underlying systemic disease is recommended in inflammatory cardiomyopathy. | Recommendation Table 19 — Recommendations for inflammatory cardiomyopathy (see Evidence Table 19) |
| p.56 | IIa | B | Immunosuppressive therapy, guided by endomyocardial biopsy, should be considered in virus-negative inflammatory cardiomyopathies to suppress the autoimmune response.34,131,551–555 aClass of recommendation. bLevel of evidence. | Recommendation Table 19 — Recommendations for inflammatory cardiomyopathy (see Evidence Table 19) |
| p.57 | III | C | recommended in patients living in non-endemic areas. | Recommendation Table 20 — Recommendations for tuberculous pericarditis (see Evidence Table 20) |
| p.57 | I | C | Diagnostic pericardiocentesis is recommended in all patients with suspected tuberculous pericarditis when diagnosis is not confirmed by non-invasive tests to identify the aetiological agent in pericardial fluid.570 | Recommendation Table 20 — Recommendations for tuberculous pericarditis (see Evidence Table 20) |
| p.57 | I | C | Empirical antituberculosis chemotherapy is recommended in patients living in endemic areas with exudative pericardial effusion after excluding other causes to treat the most likely cause.567,570 | Recommendation Table 20 — Recommendations for tuberculous pericarditis (see Evidence Table 20) |
| p.57 | I | C | Standard antituberculosis multidrug treatment for 6 months is recommended in patients with tuberculous pericarditis for the prevention of pericardial constriction.570 | Recommendation Table 20 — Recommendations for tuberculous pericarditis (see Evidence Table 20) |
| p.57 | I | C | Pericardiectomy is recommended in patients with tuberculous pericarditis if the condition is not improving or is deteriorating after 4–8 weeks of antituberculosis therapy to change the course of disease. | Recommendation Table 20 — Recommendations for tuberculous pericarditis (see Evidence Table 20) |
| p.57 | IIa | C | Adjunctive steroid therapy should be considered in HIV-negative cases to prevent the development of constrictive TB pericarditis.569 | Recommendation Table 20 — Recommendations for tuberculous pericarditis (see Evidence Table 20) |
| p.57 | IIb | C | In non-endemic areas a pericardial biopsy may be considered in patients with >3 weeks of illness without aetiologic diagnosis. Empirical antituberculosis treatment is not HIV, human immunodeficiency virus; TB, tuberculosis. aClass of recommendation. bLevel of evidence. | Recommendation Table 20 — Recommendations for tuberculous pericarditis (see Evidence Table 20) |
| p.58 | I | C | Pericardiocentesis is recommended for patients with cardiac tamponade to relieve symptoms and establish the diagnosis of malignant pericardial effusion.576,583 | Recommendation Table 21 — Recommendations for neoplastic pericardial involvement (see Evidence Table 21) |
| p.58 | I | B | Extended pericardial drainage (3–6 days) is recommended in patients with suspected or definite neoplastic pericardial effusion to prevent effusion recurrence.576,583 | Recommendation Table 21 — Recommendations for neoplastic pericardial involvement (see Evidence Table 21) |
| p.58 | I | C | Cytological analysis of pericardial fluid is recommended in patients with neoplastic pericarditis for the confirmation of malignant pericardial disease.581 | Recommendation Table 21 — Recommendations for neoplastic pericardial involvement (see Evidence Table 21) |
| p.58 | I | C | Systemic antineoplastic treatment is recommended in confirmed cases of neoplastic aetiology to treat the primary and secondary metastatic neoplastic involvement.582 | Recommendation Table 21 — Recommendations for neoplastic pericardial involvement (see Evidence Table 21) |
| p.58 | IIa | C | Pericardiocentesis should be considered in patients with moderate to large pericardial effusion to establish the diagnosis of malignant pericardial effusion when the diagnosis cannot be reached by multimodality imaging.584 | Recommendation Table 21 — Recommendations for neoplastic pericardial involvement (see Evidence Table 21) |
| p.58 | IIb | C | Pericardial or epicardial biopsy may be considered in patients with suspected malignant pericardial disease when the diagnosis cannot be reached by multimodality imaging or cytological analysis, to confirm the diagnosis. | Recommendation Table 21 — Recommendations for neoplastic pericardial involvement (see Evidence Table 21) |
| p.58 | IIb | C | Intrapericardial therapy, in agreement with the oncologist, may be considered in cases refractory to systemic antineoplastic treatment. aClass of recommendation. bLevel of evidence. | Recommendation Table 21 — Recommendations for neoplastic pericardial involvement (see Evidence Table 21) |
| p.59 | I | B | Anti-inflammatory therapy is recommended in patients with PCIS to hasten symptom remission and reduce recurrences.292,600 | Recommendation Table 22 — Recommendations for post-cardiac injury syndrome (see Evidence Table 22) |
| p.59 | I | B | IL-1 antagonists are recommended in patients with refractory PCIS to prevent recurrences and progression to constriction.604 | Recommendation Table 22 — Recommendations for post-cardiac injury syndrome (see Evidence Table 22) |
| p.59 | I | C | High-dose aspirin is recommended as the first-choice anti-inflammatory therapy for post-myocardial infarction pericarditis and in patients being already on antiplatelet therapy. | Recommendation Table 22 — Recommendations for post-cardiac injury syndrome (see Evidence Table 22) |
| p.59 | IIa | A | Colchicine, started 48 to 72 h before cardiac surgery, should be considered for 1 month in patients after cardiac surgery for the prevention of PCIS if there are no contraindications and if it is tolerated.594,596 | Recommendation Table 22 — Recommendations for post-cardiac injury syndrome (see Evidence Table 22) |
| p.59 | IIa | C | Careful follow-up should be considered in patients with PCIS to exclude possible evolution towards constrictive pericarditis.347 IL, interleukin; PCIS, post-cardiac injury syndrome. aClass of recommendation. bLevel of evidence. | Recommendation Table 22 — Recommendations for post-cardiac injury syndrome (see Evidence Table 22) |
| p.60 | I | C | Urgent pericardiocentesis and/or a surgical window is recommended in patients with suspicion of purulent pericarditis to establish a diagnosis.606 | Recommendation Table 23 — Recommendations for purulent pericarditis (see Evidence Table 23) |
| p.60 | IIa | B | Intrapericardial fibrinolysis should be considered in patients with purulent pericarditis to allow complete drainage of purulent fluid and to prevent constriction.573,610 aClass of recommendation. bLevel of evidence. | Recommendation Table 23 — Recommendations for purulent pericarditis (see Evidence Table 23) |
| p.64 | I | C | Diagnosis Multimodality imaging is recommended in all patients with suspected constrictive pericarditis to make the diagnosis and assess pericardial thickening, calcifications, and active inflammation.632 | Recommendation Table 24 — Recommendations for constrictive pericarditis (see Evidence Table 24) |
| p.64 | IIa | C | Cardiac catheterization for haemodynamic assessment should be considered in patients with suspected constrictive pericarditis when multimodality imaging is inconclusive.633 Therapy | Recommendation Table 24 — Recommendations for constrictive pericarditis (see Evidence Table 24) |
| p.64 | I | C | Anti-inflammatory therapy is recommended in haemodynamically stable patients with a transient or new diagnosis of constriction with concomitant evidence of pericardial inflammationc to prevent progression to constriction and avoid pericardiectomy.122,123 | Recommendation Table 24 — Recommendations for constrictive pericarditis (see Evidence Table 24) |
| p.64 | I | C | Pericardiectomy is recommended in patients with permanent constriction if there is no active inflammation or anti-inflammatory treatment is not successful after 3–6 months.635,636 | Recommendation Table 24 — Recommendations for constrictive pericarditis (see Evidence Table 24) |
| p.65 | I | C | Pre-conception counselling is recommended in women with recurrent pericarditis or myocarditis to assess disease activity and to review therapy. | Recommendation Table 25 — Recommendations for pregnancy, lactation, and reproductive issues (see Evidence Table 25) |
| p.65 | IIa | C | NSAIDs should be considered in pregnant patients with pericarditis until the 20th week to treat an incessant/recurrent course.664 | Recommendation Table 25 — Recommendations for pregnancy, lactation, and reproductive issues (see Evidence Table 25) |
| p.66 | IIa | C | Anti-inflammatory therapies should be considered in patients with pericarditis during lactation to treat and prevent pericarditis with timing adjusted to reduce drug exposure of the breastfed infant. | |
| p.66 | IIa | C | During pregnancy and breastfeeding, corticosteroids at the minimal effective dose (preferably up to 20 mg prednisone daily) should be considered in patients with active pericarditis, despite NSAID (if feasible), to prevent an incessant/recurrent course.664 | |
| p.66 | IIb | C | Colchicine may be considered in pregnant patients with pericarditis, especially in patients already receiving this drug to prevent recurrences. | |
| p.66 | IIb | C | therapies to prevent an incessant/recurrent course. NSAID, non-steroidal anti-inflammatory drug. aClass of recommendation. bLevel of evidence. | Recommendation Table 26 — Recommendations for physical activity and myocarditis/pericarditis (see Evidence Table 26) |
| p.66 | I | C | Restriction of physical exercise until remission, for at least 1 month, is recommended in athletes and non-athletes after IMPS using an individualized approach to accelerate recovery. IMPS, inflammatory myopericardial syndrome. aClass of recommendation. bLevel of evidence. | Recommendation Table 26 — Recommendations for physical activity and myocarditis/pericarditis (see Evidence Table 26) |
| p.66 | I | C | A multidisciplinary team discussion at a referral centre is recommended in patients with high-risk/ complicated IMPS to provide a patient-tailored approach.375,673 IMPS, inflammatory myopericardial syndrome. aClass of recommendation. bLevel of evidence. | Recommendation Table 27 — Recommendations for multidisciplinary teams in myopericardial syndromes (see Evidence Table 27) |
| p.69 | I | C | Complete clinical evaluation, including history, physical examination, chest X-ray, biomarkers, ECG, and echocardiography is recommended in all patients with a suspicion of myocarditis and/or pericarditis for the initial diagnostic assessment. | Table 19 lists all Class I and Class III recommendations from the text alongside their level of evidence. |
| p.69 | I | B | CMR is recommended in patients with the clinical suspicion of myocarditis (using updated LL criteria) and/or pericarditis for the non-invasive diagnosis of inflammatory reaction. | Table 19 lists all Class I and Class III recommendations from the text alongside their level of evidence. |
| p.69 | I | B | Hospital admission is recommended for patients with high-risk pericarditis for monitoring and treatment. | Table 19 lists all Class I and Class III recommendations from the text alongside their level of evidence. |
| p.69 | I | C | Hospital admission is recommended for patients with moderate- to high-risk myocarditis for monitoring and treatment. | Table 19 lists all Class I and Class III recommendations from the text alongside their level of evidence. |
| p.69 | I | C | syndrome is suspected to rule out obstructive coronary artery disease. | Table 19 lists all Class I and Class III recommendations from the text alongside their level of evidence. |
| p.69 | III | C | hepatitis C, HIV and Lyme disease. | Table 19 lists all Class I and Class III recommendations from the text alongside their level of evidence. |
| p.69 | I | C | determine inheritance pattern, and identify relatives at risk. | Table 19 lists all Class I and Class III recommendations from the text alongside their level of evidence. |
| p.69 | I | B | CMR is recommended in patients with suspected myocarditis to reach a clinical diagnosis and to determine the cause of acute myocardial injury, including assessment of oedema, ischaemia, and necrosis/fibrosis/scarring. | Table 19 lists all Class I and Class III recommendations from the text alongside their level of evidence. |
| p.70 | I | C | for risk stratification and personalized therapy, and to enable a return to exercise. | |
| p.70 | I | B | CMR is recommended in patients with suspected pericarditis when a diagnosis cannot be made using clinical criteria to assess evidence of pericardial thickening, oedema, LGE, and to assess the persistence of disease during follow-up in selected cases. | |
| p.70 | I | C | pleuropulmonary diseases and chest abnormalities. | |
| p.70 | I | B | and to detect potential underlying inherited cardiac diseases. | |
| p.70 | I | B | cause is suspected, or the cause of death remains unexplained. | |
| p.70 | I | C | and to improve LV function. | |
| p.70 | III | C | Routine use of immunosuppressive therapy is not recommended in acute myocarditis with preserved LV function because no outcome benefit has been shown. | |
| p.70 | I | A | reduce subsequent recurrences. | |
| p.70 | I | A | corticosteroids, and elevation of C-reactive protein levels to reduce recurrences and allow corticosteroid withdrawal. | |
| p.70 | I | B | High-dose aspirin or NSAIDs with proton pump inhibitors are recommended as first-line therapy in patients with pericarditis to control symptoms and reduce recurrences. | |
| p.70 | III | C | Corticosteroids are not recommended as the first option for patients with pericarditis therapy without a specific indication. | |
| p.70 | I | C | compromise, to decide on the need for escalation to MCS and to determine a long-term management plan. | |
| p.70 | I | C | Pericardiocentesis (echocardiography CT-, or fluoroscopy-guided) is recommended for cardiac tamponade, or suspected bacterial or neoplastic pericarditis, or symptomatic moderate to large pericardial effusion despite medical therapy. | |
| p.70 | I | C | with purulent pericardial effusion to allow complete drainage and to prevent constriction. | |
| p.70 | I | C | Surgical pleuro-pericardial window is recommended in patients with relapsing pericardial effusion despite medical therapy. | |
| p.70 | I | C | medical therapy to improve symptoms and survival. | |
| p.70 | I | C | symptoms and survival. | |
| p.71 | I | C | Long-term follow-up is recommended for patients with complicated myocarditis to identify a potential progression or new complications. | |
| p.71 | I | C | complications. | |
| p.71 | I | C | Combined immunosuppressive therapy is recommended in patients with a diagnosed GCM. | |
| p.71 | I | B | CMR, using tissue characterization techniques, is recommended in patients with suspected CS to assess cardiac inflammation and myocardial involvement. | |
| p.71 | I | B | 18F-FDG-PET is recommended for the diagnostic work-up, including detection of inflammation, as well as for follow-up and assessment of therapeutic response in patients with CS. | |
| p.71 | I | B | ICD implantation is recommended in patients with CS and sustained ventricular arrhythmia (VT/VF) or aborted CA to prevent SCD. | |
| p.71 | I | C | ICD implantation is recommended in patients with CS and LVEF ≤35% to prevent SCD. | |
| p.71 | I | C | Diagnostic triage within 24 h is recommended in patients with suspected myocarditis induced by ICI to initiate treatment rapidly. | |
| p.71 | I | C | in order to stop the inflammatory reaction and stabilize the patient. | |
| p.71 | I | C | ventricular function. | |
| p.71 | I | C | Specific medical therapy for the potentially underlying systemic disease is recommended in inflammatory cardiomyopathy. | |
| p.71 | I | C | non-invasive tests to identify the aetiological agent in pericardial fluid. | |
| p.71 | I | C | excluding other causes to treat the most likely cause. | |
| p.71 | I | C | pericardial constriction. | |
| p.71 | I | C | 4–8 weeks of antituberculosis therapy to change the course of disease. | |
| p.71 | III | C | Empirical antituberculosis treatment is not recommended in patients living in non-endemic areas. | |
| p.71 | I | C | Pericardiocentesis is recommended for patients with cardiac tamponade to relieve symptoms and establish the diagnosis of malignant pericardial effusion. | |
| p.71 | I | B | Extended pericardial drainage (3–6 days) is recommended in patients with suspected or definite neoplastic pericardial effusion to prevent effusion recurrence. | |
| p.71 | I | C | Cytological analysis of pericardial fluid is recommended in patients with neoplastic pericarditis for the confirmation of malignant pericardial disease. | |
| p.71 | I | C | neoplastic involvement. | |
| p.72 | I | B | Anti-inflammatory therapy is recommended in patients with PCIS to hasten symptom remission and reduce recurrences. | |
| p.72 | I | B | IL-1 antagonists are recommended in patients with refractory PCIS to prevent recurrences and progression to constriction. | |
| p.72 | I | C | already on antiplatelet therapy. | |
| p.72 | I | C | thickening, calcifications, and active inflammation. | |
| p.72 | I | C | concomitant evidence of pericardial inflammation to prevent progression to constriction and avoid pericardiectomy. | |
| p.72 | I | C | is not successful after 3–6 months. | |
| p.72 | I | C | Restriction of physical exercise until remission, for at least 1 month, is recommended in athletes and non-athletes after IMPS using an individualized approach to accelerate recovery. | |
| p.72 | I | C | A multidisciplinary team discussion at a referral centre is recommended in patients with high-risk/complicated IMPS to provide a patient-tailored approach. |