What are the European Society of Cardiology (ESC) guidelines for managing myocarditis and pericarditis?

ESC Guidelines for Myocarditis and Pericarditis Management

Pericarditis: Diagnosis and Initial Management

The diagnosis of acute pericarditis requires at least 2 of 4 criteria: pericarditic chest pain (sharp, pleuritic, improved by sitting forward), pericardial friction rub, widespread ST-elevation or PR depression on ECG, and new or worsening pericardial effusion. 1

First-Line Treatment for Acute Pericarditis

• Aspirin (1500-3000 mg/day) or NSAIDs (ibuprofen 1200-2400 mg/day or indomethacin 75-150 mg/day) are the mainstay of therapy, distributed every 8 hours. 1

• Colchicine should be added as adjunctive therapy to improve response and reduce recurrence rates. 1

• Corticosteroids are NOT recommended as first-line therapy (Class III, Level B recommendation) and should only be used for contraindications, intolerance, or failure of aspirin/NSAIDs. 1

• C-reactive protein (CRP) should be monitored to guide treatment duration and assess therapeutic response. 1

Activity Restriction

• Non-athletes: Exercise restriction until symptom resolution and CRP normalization. 1

• Athletes: Minimum 3-month exercise restriction until symptom resolution and normalization of CRP, ECG, and echocardiogram. 1

Recurrent Pericarditis Management

• If symptoms recur during therapy tapering, increase aspirin or NSAIDs to maximum doses (distributed every 8 hours, intravenously if necessary), add colchicine, and add analgesics—do NOT increase corticosteroid doses. 1

• Colchicine therapy duration >6 months should be considered based on clinical response. 1

• Prognosis is excellent: constrictive pericarditis has never been reported despite numerous recurrences, and overall risk is <1%. 1

Myopericarditis: When Myocardial Involvement is Present

Myopericarditis is diagnosed when patients meet criteria for acute pericarditis AND have elevated cardiac biomarkers (troponin I/T, CK-MB) WITHOUT new focal or diffuse left ventricular dysfunction on echocardiography or cardiac MRI. 1

Mandatory Diagnostic Workup

• Coronary angiography is recommended (Class I, Level C) to rule out acute coronary syndromes, particularly when clinical presentation or risk factors warrant. 1

• Cardiac MRI is recommended (Class I, Level C) for confirmation of myocardial involvement and to exclude ischemic myocardial necrosis. 1

• Hospitalization is mandatory (Class I, Level C) for diagnosis, monitoring, and differentiation from acute coronary syndromes. 1

Treatment Modifications for Myopericarditis

• Empirical anti-inflammatory therapies at the LOWEST efficacious doses should be considered (Class IIa, Level C), as animal models suggest NSAIDs may enhance myocardial inflammation and increase mortality in pure myocarditis. 1

• Aspirin 1500-3000 mg/day or NSAIDs (ibuprofen 1200-2400 mg/day or indomethacin 75-150 mg/day) are prescribed primarily for chest pain control, but at reduced dosages compared to pure pericarditis. 1

• There is insufficient data to recommend colchicine in myopericarditis, unlike its established role in pure pericarditis. 1

Critical Activity Restriction

• Complete rest and avoidance of physical activity beyond normal sedentary activities is mandatory (Class I, Level C) for ALL patients (athletes and non-athletes) with myopericarditis for a minimum of 6 months from illness onset. 1

• This strict restriction is based on reported sudden cardiac death cases in military personnel and male athletes (football players, swimmers) after strenuous exertion, even without prodromic symptoms. 1

• This contrasts sharply with isolated pericarditis, where return to exercise is permissible after resolution of active disease in non-athletes or after 3 months in athletes. 1

Prognosis

• Myopericarditis has an excellent prognosis with no evolution to heart failure or mortality in observational series, despite troponin elevation. 1

Key Pitfalls to Avoid

• Never use corticosteroids as first-line therapy for pericarditis—this is a Class III recommendation. 1

• Do not apply the same activity restrictions to myopericarditis as to pure pericarditis—myopericarditis requires 6 months of strict rest due to sudden death risk. 1

• Do not assume NSAIDs are equally safe in myopericarditis as in pure pericarditis—use lowest effective doses due to potential harm in myocardial inflammation. 1

• Always perform coronary angiography and cardiac MRI in suspected myopericarditis to exclude acute coronary syndromes and confirm myocardial involvement. 1

• Reassure patients about the benign prognosis despite troponin elevation and multiple recurrences, as constrictive pericarditis risk is <1%. 1