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5.4 Multimodality imaging

The non-invasive diagnosis of IMPS relies on advanced cardiovascular imaging. An overview of the capabilities of different imaging modalities for the identification of pathophysiological components is provided in Supplementary data online, Table S5. Echocardiography is usually the first-step imaging modality and provides functional and morphological information. Cardiovascular magnetic resonance can better differentiate myocardial tissue and shows myocardial and pericardial inflammation, as well as different patterns of fibrosis. Fluorodeoxyglucose positron emission tomography (FDG-PET) is useful to detect disease activity, especially for CS (see Section 5.8). Computed tomography allows detection of calcification of the pericardium and its extent, as well as exclusion of CAD. The application of non-invasive imaging should guide therapeutic decision-making (see Section 4).

5.5 Echocardiography

Transthoracic echocardiography (TTE) is usually the initial imaging modality of choice for individuals with suspected IMPS, given its ability to identify myocardial and pericardial abnormalities, as well as concomitant valvular disease.115,124

5.5.1 Echocardiography in myocarditis

Patients with a suspicion of myocarditis should usually undergo standard TTE including speckle tracking or tissue Doppler imaging (TDI) at presentation. Transthoracic echocardiography helps monitor changes in cardiac chamber size, ventricular function, wall thickness, and PEff. In myocarditis, global ventricular dysfunction, diastolic dysfunction with preserved ejection fraction (EF), and regional WMA may occur.154,155 Tissue Doppler imaging or strain imaging can be used in the setting of myocarditis and may indicate myocardial injury.156,157 Recent studies have shown that global longitudinal and circumferential strain (GLS and GCS) and strain rate were decreased in patients with AM, even with preserved EF.156 Strain may provide important prognostic information in AM.157 Regional GLS can be associated with scarring on CMR and can predict VA and outcomes in patients with AM.157

Abnormal RV strain158 and left atrial (LA) strain159 have been detected in AM with preserved EF.

5.5.2 Echocardiography in pericarditis

Transthoracic echocardiography can detect the presence of PEff and assess its haemodynamic importance, as well as constrictive pathophysiology (Supplementary data online, Figure S1 and Table S6).



 

 

 

 
  


	





 


 





	





Figure 14 The different courses of inflammatory myopericardial syndrome and the interplay between genetic background inflammation and autoimmunity beyond the initial infectious trigger. IMPS, inflammatory myopericardial syndrome.

Table 10 Classification of pericardial effusion

Onset Acute (≤4 weeks)

Subacute (>4 weeks to ≤3 months) Chronic (>3 months)

Sizea Mild: <10 mm

Moderate: 10–20 mm Large: >20 mm

Distribution Circumferential/loculated Composition Transudate/exudate © ESC 2025 aMaximal end-diastolic diameter. Downloaded from academic.oup.com/eurheartj/article/46/40/3952/8234483 by guest on 07 October 2026