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3.3 Diagnostic criteria
After the original proposed diagnostic criteria from the consensus paper in 2013,10 multimodality imaging, in particular CMR, has made a clinical, non-invasive diagnosis of myocarditis feasible. In accordance with the paradigm change (Figure 2), the TF proposes new diagnostic criteria and a new classification, following the system introduced in the 2023 ESC Guidelines for the management of endocarditis (Table 4).29 This clinically driven approach is based on a clinical presentation, with additional supportive findings, and positive CMR or EMB for myocarditis. Histopathological criteria and updated CMR Lake Louise criteria (LLC)30 are given in Table 5 and Figure 4, respectively. Similarly, diagnosis of pericarditis can be made with a clinical presentation, and more than one additional criterion. Cardiovascular magnetic resonance can also provide the non-invasive confirmation of the presence of pericarditis beyond clinical criteria.
3.3.1 Diagnostic criteria for myocarditis
Myocarditis can be clinically diagnosed as definite/possible with an appropriate clinical presentation and additional criterion, including CMR-proven or EMB-proven result (see details in Table 4). The additional criteria include common parameters in basic work-up, such as an electrocardiogram (ECG), which may show unspecific changes, including the whole spectrum of presentations from mimicking a myocardial infarction with ST elevation in non-coronary distribution, as well as rhythm abnormalities, or findings in echocardiography (see Section 5.5). Laboratory analysis of serum biomarkers usually shows elevation of markers of myocardial lesion, such as hs-TnT or high-sensitivity troponin I (hs-TnI). Biomarkers of heart failure (HF) (such as N-terminal prohormone of brain natriuretic peptide, NT-proBNP) are also needed to identify the severity of the disease, and suggest myocardial involvement. Depending on the individual case and risk (see Section 4), definitive diagnosis of myocarditis can be based on CMR (Figure 4) or EMB (Table 5). For EMB analysis quantitative immunohistochemistry criteria for inflammatory cells in lymphocytic myocarditis (LM) are under development. Asymptomatic cases may exist, e.g. vaccine- or drug-related cases, such as immune checkpoint inhibitor (ICI)-induced myocarditis, and are often underdiagnosed.
Figure 3 Stages of inflammatory myopericardial syndrome. AHA, anti-heart antibodies; AIDA, anti-intercalated disc antibodies.
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