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Patient with new, recurrent or unexplained arrhythmias (any type) Haemodynamic instability Cardioversion/defibrillation/ transcutaneous pacing/ALS (Class I) Clinical history and vital signs, 12-lead ECG, laboratory evaluationb, transthoracic echocardiography (Class I) Active myocarditis (based on initial CMR/EMB) See specific sections Type of initial arrhythmia at presentation Repeat CMR within 6 months (Class I) Identify arrhythmia Risk stratificationd Further aetiological work-up Endomyocardial biopsy (Class I) Cardiovascular magnetic resonancef (Class I) Red flags for myocardial involvementc Definite myocarditis Specific aetiology ICD indicationsj (Class I) (Class IIa) (Class IIb) Further aetiological work-uph Suggestive of non-cardiac causes or cardiomyopathies Aetiological work-up Normal findings No further work-up Non-high risk Obstructive CADa Treat CAD PM indicationi Further work-up depending on activity (genetics, systemic disorders) Catheter ablation (Class IIa) High riske Before discharge Ventricular arrhythmiag Conduction blocks Figure 11 Diagnostic algorithm for arrhythmia presentation. ALS, advanced life support; CAD, coronary artery disease; CMR, cardiovascular magnetic resonance; CRP, C-reactive protein; ECG, electrocardiogram; EMB, endomyocardial biopsy; ICD, implantable cardioverter-defibrillator; N, no; NT-proBNP, N-terminal prohormone of brain natriuretic peptide; PM, pacemaker; Y, yes. aInvasive coronary angiography or computed tomography angiography depending on clinical likelihood/probability. bLaboratory testing including troponin, NT-proBNP, C-reactive protein, differential blood count. cSee Table 6. dSee Table 7. eConsider cardiovascular magnetic resonance. fConsider endomyocardial biopsy on a case-by-case basis. gSee Section 6.5 for wearable cardioverter-defibrillator. hSee Sections 5, 8, 9, 10. iSee Section 6.5 and Reference Glikson et al.86 jSee Section 6.5, Recommendation Table 14 and Reference Zeppenfeld et al.58 ESC Guidelines 3975 Downloaded from academic.oup.com/eurheartj/article/46/40/3952/8234483 by guest on 07 October 2026