The eagerly awaited 2025 European Society of Cardiology (ESC) guidelines for the management of myocarditis and pericarditis consolidate these conditions within a unified framework of inflammatory myopericardial syndromes (IMPS) to highlight the spectrum of disease and provide streamlined diagnostic algorithms that expedite diagnosis and treatment.1
The guidelines emphasise multimodal imaging, including an expanded role for cardiac MRI, and a more selective approach to endomyocardial biopsy. They advocate multidisciplinary team management, particularly in fulminant myocarditis with cardiogenic shock, and highlight the use of interleukin (IL-1) inhibitors for recurrent drug-refractory or steroid-dependent pericarditis.
For many Asian countries, these guidelines are both timely and necessary, given the projected rise in incidence and mortality associated with myocarditis and pericarditis over the next few decades.2,3
However, their translation into measurable clinical impact will require thoughtful adaptation to the region’s epidemiological patterns, and varying healthcare resource availability regarding advanced diagnostics and targeted anti-inflammatory therapies. Addressing these contextual challenges will be pivotal to implementing the IMPS-based framework effectively across Asia’s diverse healthcare systems.
Diagnosis and Imaging
While cardiac biomarker testing, electrocardiograms and transthoracic echocardiography (TTE) are widely available in Asia, access to cardiac MRI remains limited; however, it has a central role in the ESC diagnostic algorithm. A 2023 global survey identified key barriers to cardiac MRI uptake, including limited scanner availability, high costs and insufficient training for reporting physicians.4
In many Asian countries, MRI availability remains critically low. For instance, in Myanmar’s public hospitals, there are 0.26 MRI units per million population, compared with 17.19 MRI units per million population in Europe.5,6 Similarly, endomyocardial biopsy and genetic testing are limited to major academic and heart transplant centres in Asia.
Such disparities underscore the importance of adapting ESC’s diagnostic framework for lower-resource environments. Possible measures include the deployment of portable or low-field cardiac MRIs, rapid cardiac MRI protocols and teleradiology for image interpretation.7
Regional Phenotypes
Dengue myocarditis is an important phenotypic consideration in Asia, where dengue remains endemic.8 A 2023 meta-analysis reported a 21% prevalence of myocarditis among laboratory-confirmed dengue cases, underscoring the need for a high index of clinical suspicion.9 Evaluation should include troponin, ECG and TTE in symptomatic patients. Management is primarily supportive.
While the ESC guidelines do not address dengue, it is imperative that clinicians in endemic regions evaluate for dengue as a possible cause of myocarditis, and manage other systemic complications that could be fatal.
Similarly, tuberculosis (TB) is endemic in Southeast Asia, with TB pericarditis carrying high risks of early mortality and rapid progression to constrictive physiology.1 Diagnostic delays are common owing to slow and low-sensitivity testing. This warrants empiric anti-TB treatment in patients with exudative pericardial effusions in Southeast Asia, in accordance with the ESC guidelines. While these guidelines recommend pericardiectomy in cases refractory to anti-TB therapy, expertise in this surgical procedure is lacking in several parts of the region.
Mechanical Circulatory Support in Fulminant Myocarditis
The ESC guidelines emphasise a multidisciplinary, shock-team approach for rapid decision-making in patients with fulminant myocarditis and cardiogenic shock, including timely initiation of mechanical circulatory support (MCS).
Unfortunately, in Asia, access to MCS – both temporary and for the long term – is uneven. Furthermore, the limited number of trained advanced heart failure specialists and cardiac intensivists in many Asian countries may delay timely recognition and escalation of shock therapies.10
To address this, health systems should establish regional hub-and-spoke shock networks, supported by structured training programmes in cardiogenic shock and MCS management.
ICD Underuse
The ESC guidelines recommend ICD implantation in selected myocarditis patients presenting with ventricular arrhythmias. However, the Asia Pacific Heart Rhythm Society (APHRS) White Book reveals marked cross-country disparities in ICD implantation, with some Southeast Asian countries reporting almost no ICDs being implanted, and several better-resourced health systems achieving lower rates than their Western counterparts.11 Similarly, wearable cardioverter-defibrillators are rarely used in Asia outside Japan.12
Evidence for its widespread benefit also remains mixed, with outcomes dependent on appropriate patient selection and good adherence to device use.13
In this context, practical safeguards include inpatient telemetry, early Holter monitoring after discharge, expedited ICD implantation for patients meeting criteria and financial support mechanisms such as co-payment or subsidy schemes to enhance affordability.
Interleukin-1 Inhibitors in Recurrent Pericarditis
The ESC guidelines offer valuable insights into the pathophysiology of recurrent pericarditis and suggest IL-1 blockade for refractory or steroid-dependent pericarditis after two or more recurrences. While access to IL-1 antagonists is variable, hydroxychloroquine is an inexpensive and widely available alternative in Asia and may serve as a steroid-sparing agent, although supporting data remain limited.14
Safe Return to Physical Activity
Finally, the ESC guidelines recommend an individualised approach regarding a return to physical activity, suggesting at least 1 month of complete clinical remission beforehand, taking into account evidence of symptom resolution, normalised biomarkers and the absence of active inflammation on imaging.
In Asian contexts, guidance should balance patient safety with socioeconomic realities, especially among manual and migrant workers who often lack wage protection during convalescence. Pragmatic solutions, including troponin-guided reconditioning, targeted TTE follow-up, rapid cardiac MRI protocols and teleconsultations, can facilitate timely, evidence-based clearance for work, especially in remote or underserved regions.
Conclusion
The 2025 ESC IMPS framework offers a unified approach to diagnosing and managing the growing number of patients with myocarditis and pericarditis. However, its clinical impact in Asia will depend on adapting recommendations to regional epidemiology and resource constraints, ensuring equitable access to advanced diagnostics and therapeutics across diverse healthcare systems, and developing specialised multidisciplinary teams in comprehensive hub-and-spoke networks. Additionally, international multicentre collaboration and mutual learning will be vital to enable Asia to transform its myocarditis and pericarditis care to improve patient outcomes.