Pericarditis & Myocarditis

Inflammation of the pericardium, the myocardium, or both — most often viral or idiopathic. Pericarditis is diagnosed on 2 of 4 features: pleuritic chest pain, rub, ECG changes, new or worsening effusion. Myocarditis is the dangerous sibling: a…

ESC 2025 Myocarditis and Pericarditis

The pathway

1 · Diagnose pericarditis — 2 of 4

Pleuritic chest pain, better sitting forward, worse lying flat
Pericardial friction rub
Widespread saddle ST elevation or PR depression
New or worsening effusion

Supportive: raised CRP, inflammation on CT or CMR.

2 · The ECG — and telling it from a STEMI

Widespread concave ST elevation, not one coronary territory
PR depression, and PR elevation in aVR — the most specific sign
No reciprocal ST depression (except aVR and V1)
No Q waves, no loss of R-wave progression

If you cannot confidently exclude a STEMI, treat it as one. Thrombolysing pericarditis is a serious harm.

3 · Look for myocarditis

Troponin — raised means myopericarditis, not simple pericarditis
Suspect with breathlessness, heart failure, arrhythmia, syncope, viral prodrome in a young patient
Echo for wall motion and LV function
Cardiac MRI is the non-invasive standard

Myocarditis is not benign young-person chest pain. It can deteriorate over hours.

4 · Look for tamponade

Echo — effusion size, diastolic collapse of the right chambers
Hypotension, raised JVP, muffled sounds, pulsus paradoxus, tachycardia
New or enlarging effusion + becoming hypotensive = cardiology emergency, consider pericardiocentesis

5 · Treat — dual therapy from the start

Colchicine 0.5mg: OD if <70kg, BD if ≥70kg. 3 months first episode, ≥6 months after a recurrence
Plus aspirin 750–1000mg 8-hourly or ibuprofen 600mg 8-hourly, started high
Taper only once pain has settled AND CRP has normalised — tapering on symptoms alone causes recurrence
PPI is part of the prescription at these doses
Prefer aspirin if she also needs antiplatelet therapy or had a recent MI

Colchicine is first-line, not an optional extra.

6 · Steroids — second line, and why

Second line only — contraindication to or failure of aspirin/NSAIDs
Always with colchicine
Exclude infection first, particularly TB

Early steroids favour a chronic, recurrent course. Reaching for prednisolone because it works quickly makes the next twelve months worse.

7 · Recurrent and not settling

Anti-IL-1 agents — anakinra or rilonacept — for recurrent disease failing first-line therapy
Not your prescription, but knowing it exists is what gets a third recurrence referred to cardiology instead of given another course of steroids

8 · Admit or discharge

Fever >38°C
Subacute onset over days to weeks
Large effusion or tamponade
No response to a week of NSAID
Raised troponin
Immunosuppression, trauma, or on anticoagulation

Any one: admit. Otherwise low-risk idiopathic pericarditis can go home with early review.

9 · Advice on discharge

Restrict exercise ≥1 month and until remission — symptoms gone, CRP, ECG and echo normal. Keep heart rate below 100 during activity
Myocarditis and athletes: longer, at least 3 months, with cardiology sign-off to return
Recurrence is common (~30% without colchicine) and is not treatment failure
Return with breathlessness, syncope, palpitations or worsening pain
Cardiology follow-up for any raised troponin or effusion

Drugs

Drug	Dose	Route	Notes
Aspirin	750–1000mg	PO	Every 8 hours for 1–2 weeks, then taper. Preferred where antiplatelet therapy is also wanted.
Ibuprofen	600mg	PO	Every 8 hours for 1–2 weeks, then taper. Alternative first line to aspirin.
Colchicine	0.5mg	PO	Part of first-line dual therapy, not an add-on. OD if <70kg, BD if ≥70kg, for 3 months (at least 6 after a recurrence). Reduce in renal impairment. Diarrhoea is the usual limiting effect.
Omeprazole	20mg	PO	Gastric protection is part of the prescription, not optional, at these NSAID doses.
Prednisolone	0.2–0.5mg/kg	PO	Second line only. With colchicine. Slow taper. Exclude infection, especially TB, first.

When to escalate

Hypotension with a raised JVP and an effusion — tamponade, urgent echo and cardiology,Raised troponin — myopericarditis, admit and discuss with cardiology,New heart failure or arrhythmia in a young patient — suspect myocarditis, monitored bed,ECG you cannot confidently distinguish from STEMI — treat as STEMI, discuss with cardiology,Fever >38°C or subacute onset — high-risk features, admit

Reference: ESC 2025 Guidelines for the management of myocarditis and pericarditis (European Heart Journal 2025;46:3952, published 29 August 2025; replaced the 2015 pericardial diseases guideline)

This page is the reference half

The app adds what a web page cannot: a VINDICATE differential builder, worked on-call scenarios with full A–E findings, recall practice, and all of it offline.