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Non-ischaemic myocardial inflammation can be diagnosed by CMR according to the updated LLC30 (see Figure 4). This is based on at least one T2-based criterion plus ideally one T1-based criterion. Having both a positive T2-based criterion and a T1-based criterion will increase specificity for diagnosing AM, but a diagnosis of possible myocarditis can still be made by having only one (i.e. T2-based or T1-based) criterion in an appropriate clinical scenario, although with less specificity. Supportive criteria include pericardial abnormalities (which, however, suggest concomitant pericarditis), and global or regional left ventricular (LV) systolic dysfunction on cine imaging. Table 4 Diagnostic criteria and classification for inflammatory myopericardial syndrome IMPS If diagnostic criteria for myocarditis and/or pericarditis are fulfilleda Myocarditis Pericarditis Definite Clinical presentationb and CMR- or EMB-proven Clinical presentationb with >1 additional criterion Possible Clinical presentationb with at least 1 additional criterion CMR- or EMB-uncertain or not available Clinical presentationb with 1 additional criterion Unlikely/rejected Only clinical presentationb without additional criteria Only clinical presentationb without additional criteria Additional criteria beyond clinical presentationsb Myocarditis Pericarditis Clinicalb Non-specific findings Pericardial rubs ECGc ST-T changes PR depression, widespread ST-segment elevation Biomarkers Troponin elevation C-reactive protein elevation Imagingd Abnormal strain, wall motion, reduced EF Myocardial oedema and/or LGE (CMR findings) New or worsening pericardial effusion Pericardial oedema and/or LGE (CMR findings) © ESC 2025 CMR, cardiovascular magnetic resonance; ECG, electrocardiogram; EF, ejection fraction; EMB, endomyocardial biopsy; IMPS, inflammatory myopericardial syndrome; LGE, late gadolinium enhancement; LLC, Lake Louise criteria. Clinical presentations include chest pain or infarct-like symptoms, arrhythmias, heart failure, aborted sudden cardiac death. Cardiovascular magnetic resonance categories: proven = 2 out of 2 updated LLC fulfilled (Figure 4); uncertain = only 1 out of 2 updated LLC fulfilled; rejected = negative CMR. EMB categories: proven, uncertain, rejected (according to pathologist consensus). aOne condition may be leading (see Section 8). bSee detailed description of clinical presentation in Section 4; rarely asymptomatic cases may be detected (e.g. drug-related with a distinct history, such as immune checkpoint inhibitors). cIf ECG changes always consider/exclude myocarditis. dSee additional Sections 5.4–5.7 for detailed description of imaging findings. Table 5 Histopathological criteria for myocarditis Term Predominant inflammatory cells Myocyte necrosis Infections PCR positive (viruses, etc.) Active lymphocytic myocarditis CD3+ T lymphocytes >7/mm2, CD68+ macrophages yes yes/no Persistent lymphocytic myocarditis CD3+ T lymphocytes >7/mm2, CD68+ macrophages yes yes/no Resolved lymphocytic myocarditis – no yes/no Eosinophilic myocarditis (acute stage) Eosinophils, CD3+ T lymphocytes, CD68+ macrophages yes yes/no Giant-cell myocarditis (acute stage) Eosinophils, CD68+ giant cells, CD3+ T lymphocytes, CD68+ macrophages yes no Sarcoidosis CD68+ giant cells, granuloma, CD3+ T lymphocytes, CD68+ macrophages yes/no no © ESC 2025 PCR, polymerase chain reaction. Downloaded from academic.oup.com/eurheartj/article/46/40/3952/8234483 by guest on 07 October 2026