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be considered as having a low-risk presentation with an excellent longterm prognosis.4,28,62,66,67 There are possible exceptions to this general rule in a few cases with EM and GCM. Myocardial scarring as detected by CMR can be present in cases with preserved LVEF.3,68–70 Focal scarring of any cause was shown to be relevant for outcome, and small scars (e.g. <2 segments) after >6 months seemed to be more benign.71 Nevertheless, long-term outcome data are missing. For a proposed workflow see Figure 9. Patient with acute chest pain Clinical history and vital signs, 12-lead ECG, laboratory testinga, transthoracic echocardiography (Class I) CT angiography (Class I) Definite myocarditis Suggestive of non cardiac causes or cardiomyopathies Treat according to ACS GLc Risk stratificationd Further aetiological work-up Endomyocardial biopsy (Class I) Cardiovascular magnetic resonanceg (Class I) Further aetiological work-up requiredh No further work-up Further work-upi Red flags for IMPSb Aetiological work-up Coronary artery disease Normal findings No further work-up Invasive coronary angiography (Class I) Diagnostic criteria suggestive of myocarditis Diagnostic criteria suggestive of pericarditis Go to pericarditis algorithme Clinical likelihood/probability of obstructive coronary artery disease Clinical exclusion Moderate Low High riskf Non-high risk If CAD not the sole explanation for the symptoms Before discharge High Figure 9 Diagnostic algorithm for acute chest pain presentation. ACS, acute coronary syndrome; CAD, coronary artery disease; CRP, C-reactive protein; CT, computed tomography; ECG, electrocardiogram; GL, guideline; IMPS, inflammatory myopericardial syndrome; N, no; NT-proBNP, N-terminal prohormone of brain natriuretic peptide; Y, yes. aLaboratory testing including troponin, NT-proBNP, C-reactive protein, differential blood count. bSee Table 6. cReference: Byrne et al.72 dSee Table 7. eSee Figure 7. fConsider cardiovascular magnetic resonance. gConsider endomyocardial biopsy on a case-by-case basis. hDepending on the underlying cause and clinical need. iSee Sections 5, 8, 9, 10. Downloaded from academic.oup.com/eurheartj/article/46/40/3952/8234483 by guest on 07 October 2026