Myocarditis and pericarditis in focus: A critical appraisal of the 2025 ESC vs ACC position statements from the Italian society of cardiology working group on cardiomyopathies and pericardial diseases

The 2025 European Society of Cardiology (ESC) guidelines and the 2024-2025 American College of Cardiology (ACC) consensus documents redefine the management of myocarditis and pericarditis, with notable convergence, yet key differences. Both emphasize early, accurate diagnosis, particularly through cardiac magnetic resonance (CMR), which now often supersedes immediate biopsy in stable, uncomplicated cases of acute myocarditis. The ESC introduces a unified "inflammatory myopericardial syndrome" (IMPS) framework encompassing myocarditis, pericarditis, and overlap syndromes, while the ACC provides separate pathways, including a novel four-stage clinical classification of myocarditis. Therapeutically, both endorse non-steroidal anti-inflammatory drugs (NSAIDs) and colchicine for pericarditis and myopericarditis, and heart failure-directed therapy for myocarditis, while reserving immunosuppression for select cases. Importantly, interleukin-1 (IL-1) blockade has emerged as a pivotal therapy in recurrent pericarditis, receiving a Class I recommendation in ESC guidelines and strong endorsement in ACC guidance. Prognostic assessment focuses on identifying high-risk features and structured follow-up with imaging and biomarkers. Divergences in terminology, staging, and diagnostic thresholds underscore opportunities for further harmonization. The ESC and ACC documents align in a patient-tailored, evidence-informed approach to management.