ESC · 2025

Pericarditis and Myocarditis — Management Guideline

Source: 2025 ESC Guidelines for the management of myocarditis and pericarditis, European Heart Journal

✓ Edition checked 3 Oct 2026 — ESC 2025 is the current edition as of this date.

Guideline: Strong Guideline: Conditional Guideline: Not recommended ClinicoQ pathway suggestion (not from the cited guideline)

Diagnosis

Diagnostic criteria Pericarditis and myocarditis are inflammatory diseases of the pericardium and myocardium that can overlap (inflammatory myopericardial syndromes). ESC 2025 uses a tiered diagnostic approach (definite, possible, unlikely) and allows atypical presentations without classic chest pain. Typical pericarditis features are pleuritic chest pain with one or more of: a pericardial friction rub, diffuse ST-segment elevation or PR depression on ECG, a new or worsening pericardial effusion, or raised inflammatory markers. Classification (ACC/ESC consensus wording): acute (episode under 4-6 weeks), incessant (beyond 4-6 weeks without remission), recurrent (a new episode after at least 4-6 weeks symptom-free), chronic (over 3 months). Myocarditis is supported by a troponin rise, ECG or echo changes, and CMR using the updated Lake Louise criteria (both a T1-based and a T2-based abnormality); endomyocardial biopsy is the histological reference.

⚠ Alarm features (investigate before diagnosing)

Temperature above 38 degrees C
Subacute onset
Large pericardial effusion or tamponade
Failure of NSAID therapy
Concomitant myocarditis (raised troponin, ventricular dysfunction, or arrhythmia)
Hemodynamic instability or fulminant presentation

Initial workup

Test	When to order
Full initial clinical evaluation (history, examination, biomarkers, chest X-ray, ECG, echocardiography)	In all patients with suspected myocarditis or pericarditis at the initial assessment.
Troponin and inflammatory markers (CRP)	Troponin if myocarditis is suspected; inflammatory markers support the diagnosis and monitoring of pericarditis.
Echocardiography	Preferred imaging method: evaluates pericardial effusion, tamponade, constriction, and myocardial involvement.
Cardiac magnetic resonance (CMR)	To diagnose myocarditis using the updated Lake Louise criteria (T1-based and T2-based abnormality) and to assess pericardial inflammation in complex or recurrent cases.

Decision Points

❓ Which syndrome best fits the presentation?

Pericarditis, first episode → Acute pericarditis (first episode)

Pericarditis that is recurrent or incessant → Incessant or recurrent pericarditis

Myocarditis (with or without pericardial involvement) → Myocarditis

Pericarditis in a pregnant patient → Pericarditis in pregnancy

Treatment

Acute pericarditis (first episode)

1 Aspirin or NSAID (ibuprofen, indomethacin) with gastroprotection Strong (Guideline recommendation) — first-line with colchicine (Class I, level A); proton pump inhibitor always recommended with aspirin or NSAIDs; tapering is recommended to reduce persistence and recurrence; aspirin is preferred with concomitant ischemic heart disease (ACC consensus)

Dose: ESC doses as summarized by Medscape: aspirin 750-1,000 mg, ibuprofen 600-800 mg, or indomethacin 25-50 mg every 8 hours for 1-2 weeks, then taper. ACC 2025 consensus doses differ slightly: aspirin 500-1,000 mg and ibuprofen 600-800 mg three times daily
Duration: Typically 1-2 weeks or until CRP normalizes, then taper
Evidence level: High
Avoid if: Aspirin or NSAID allergy; peptic ulcer or GI bleeding; renal impairment; use caution with anticoagulants and after the 20th week of pregnancy
If no response: Add colchicine; use corticosteroids only if aspirin and NSAIDs are contraindicated

2 Colchicine Strong (Guideline recommendation) — Class I, level A, with aspirin or an NSAID; tapering is usually not performed because of the 3-6 month or longer duration

Dose: ESC doses as summarized by Medscape: 0.5 mg twice daily (once daily if under 70 kg) for 3-6 months. ACC 2025 consensus: 0.6 mg twice daily, or 0.6 mg once daily if under 70 kg or with severe renal or hepatic impairment
Duration: At least 3 months for a first episode; the last drug to be stopped after sustained remission
Evidence level: High
Avoid if: Severe renal or hepatic impairment (dose reduce); interacting drugs (strong CYP3A4 or P-glycoprotein inhibitors); gastrointestinal intolerance
If no response: If aspirin and NSAIDs are contraindicated, consider low to moderate dose corticosteroids plus colchicine

3 Low to moderate dose corticosteroids plus colchicine (when aspirin and NSAIDs are contraindicated or for specific indications) Guideline recommendation (should be considered)

Dose: Prednisone starting at 0.20-0.50 mg/kg/day (or an equivalent steroid), then taper by dose band: above 50 mg/day reduce by 10 mg every 1-2 weeks; 25-50 mg reduce by 5-10 mg every 1-2 weeks; 15-25 mg reduce by 2.5 mg every 2-4 weeks; below 15 mg reduce by 1.25-2.5 mg every 2-6 weeks
Duration: Short course with slow taper
Evidence level: Moderate
Avoid if: Active infection (exclude tuberculosis and bacterial causes before steroids); diabetes; osteoporosis
If no response: A recurrence during steroid tapering is managed by continuing colchicine and adding an NSAID instead of raising the steroid dose

Incessant or recurrent pericarditis

1 Aspirin or NSAID with colchicine, tapered slowly with remission confirmed Strong (Guideline recommendation) — first-line therapy with colchicine continued at least 6 months; gastroprotection with a proton pump inhibitor

Dose: Same doses as the first-episode pathway
Duration: Colchicine for at least 6 months in incessant or recurrent cases; NSAID or aspirin for weeks to months with weekly tapering
Evidence level: High
Avoid if: NSAID or aspirin contraindications as above
If no response: If symptoms persist or recur, add or use corticosteroids carefully and escalate to an anti-IL-1 agent

2 Anti-interleukin-1 agents (anakinra or rilonacept) Guideline recommendation — recommended in recurrent pericarditis when first-line treatment fails

Dose: ACC 2025 expert consensus: anakinra 1-2 mg/kg/day up to 100 mg/day in adults; rilonacept per product labeling
Duration: Long-term, specialist-guided
Evidence level: Moderate
Avoid if: Active infection; neutropenia (check labeling)
If no response: Refer to a specialist center for further immunosuppressive options

Myocarditis

1 Symptom-guided initial management (paracetamol, aspirin, or NSAID) with colchicine if there are pericarditis symptoms Guideline recommendation — colchicine addition to prevent recurrence is Class IIa; applies unless myocarditis is fulminant or has a clearly defined etiology

Dose: Per product labeling
Duration: Short course, symptom-guided
Evidence level: Moderate
Avoid if: Left ventricular dysfunction or heart failure (NSAIDs are used cautiously; manage as heart failure)
If no response ClinicoQ pathway: Manage heart failure, arrhythmias, and exercise restriction according to the myocarditis pathway; refer to a specialist center if unstable

2 Corticosteroids for fulminant non-infectious myocarditis Guideline recommendation (should be considered) — for stabilization in fulminant, non-infectious forms

Dose: Per product labeling, specialist-guided
Duration: Specialist-guided
Evidence level: Low
Avoid if: Infectious myocarditis (exclude before starting)
If no response: Advanced hemodynamic support and transplant evaluation if refractory

Pericarditis in pregnancy

1 NSAIDs until week 20 for incessant or recurrent pericarditis Guideline recommendation (should be considered) — high-dose aspirin or NSAIDs can be used up to week 20; high-dose aspirin is the exception during lactation

Dose: High-dose aspirin or an NSAID such as ibuprofen or indomethacin, at the lowest effective dose
Duration: Up to the 20th week of pregnancy
Evidence level: Moderate
Avoid if: After week 20 of pregnancy; fetal renal risk
If no response: Colchicine can be continued to prevent recurrences

2 Colchicine Guideline recommendation — colchicine is compatible with pregnancy and breastfeeding and can be continued throughout pregnancy to prevent recurrences

Dose: As for non-pregnant patients (see the first-episode pathway)
Duration: Can be continued throughout pregnancy
Evidence level: Moderate
Avoid if: —
If no response: Corticosteroids at the minimal effective dose can be added in active pericarditis

3 Corticosteroids at the minimal effective dose, with or without other immunosuppressants Guideline recommendation — corticosteroids can be given throughout pregnancy in active pericarditis; the use of IL-1 blockers during pregnancy is controversial

Dose: Minimal effective dose, along with NSAIDs and, in selected cases, colchicine. Azathioprine and IVIG are compatible with pregnancy and breastfeeding
Duration: Throughout pregnancy when pericarditis is active
Evidence level: Low
Avoid if: —

✕ Treatments the guideline advises against

Raising the corticosteroid dose for a recurrence that occurs during corticosteroid tapering: ESC 2025 advises continuing colchicine and adding an NSAID instead of increasing the corticosteroid dose.

⚠️ This is an educational summary of current international clinical practice guidelines and does not replace individualized clinical judgment. Final treatment decisions remain the responsibility of the treating physician.