MioAtlas
Comparison

Acute pericarditis vs Cardiac tamponade: clinical and ECG differences

Side-by-side comparison of Acute pericarditis and Cardiac tamponade according to the MioAtlas 3D cardiac simulator model.

Acute pericarditis
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Cardiac tamponade
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Findings by layer and diagnostic parameters

Layer / Finding Acute pericarditis Cardiac tamponade
Hemodynamics
Intracavitary pressures and hemodynamic parameters normal in the absence of effusion under tension [C2] [M5]:
  • Mean right atrial pressure: 2–6 mmHg (normal) [C2] [M5].
  • Systolic and diastolic blood pressure: Physiological normotension (systolic blood pressure 110–130 mmHg, diastolic blood pressure 70–85 mmHg) [C2].
  • Cardiac output: Normal (4.5–6.5 L/min) [C2].
  • LV ejection fraction (left ventricular ejection fraction): Preserved (≥ 55–65%) [C2].
  • Pulmonary capillary wedge pressure: Normal (6–12 mmHg) [C2].
Obstructive shock with hemodynamic collapse [C2] [G6-02] [M5]:
  • Mean right atrial pressure: Elevated (15–22 mmHg) [C2] [M5].
  • Mean pulmonary capillary wedge pressure: Elevated and equalized with right-sided pressure (16–22 mmHg) [M5].
  • Systemic blood pressure: Severe arterial hypotension (systolic blood pressure 75–88 mmHg, diastolic blood pressure 55–65 mmHg) with thready pulse [C2] [G6-02].
  • Cardiac output: Severely reduced (1.8–3.2 L/min) [C2].
  • LV end-diastolic volume: Severely diminished due to extrinsic compression (< 60–75 mL) [G6-01] [M5].
  • LV ejection fraction (left ventricular ejection fraction): Compensatory hyperdynamic (≥ 60–70%) in compressed chambers [C2].
Rhythm
  • Sinus tachycardia (sinus tachycardia, heart rate typically 100–115 bpm) reactive to chest pain and inflammation, or normal sinus rhythm [C2] [G6-12].
  • Marked sinus tachycardia (sinus tachycardia, heart rate typically 110–135 bpm) reactive to adrenergic stimulation to compensate for low stroke volume [C2] [G6-02].
ECG
Spodick stage 1:
  • Diffuse upwardly concave ST-segment elevation (diffuse ST-segment elevation) in almost all leads (I, II, III, aVF, V2–V6), with the exception of aVR and V1 [C2] [G6-12].
  • Generalized PR-segment depression in leads with positive P waves and reciprocal elevation in aVR [G6-12].
  • Absence of pathological necrosis Q waves [C2] [G6-12].
  • Low voltage QRS complex (low voltage): QRS voltage < 0.5 mV in limb leads [E1] [G6-02].
  • Electrical alternans: Beat-to-beat variation in QRS amplitude caused by pendular swinging motion of the heart within the pericardial fluid mantle [C2] [G6-02].
  • Constant sinus tachycardia [C2].
Heart sounds and murmurs
  • Pericardial friction rub: Pathognomonic superficial, scratching, grating auscultatory finding [C2] [G6-11].
  • In Spodick's prospective study of 100 patients [G6-11], the predominance of three-component rubs was demonstrated: «triphasic pericardial rubs (56 percent of patients with sinus rhythm)» [G6-11]. When the rub is not triphasic, it may present in two components or a single one: «Fourteen of 15 monophasic rubs were audible or recordable only during ventricular systole» [G6-11].
  • Regarding auscultatory location and dynamics, «Rubs were best heard along the left sternal border in 84 percent of cases and tended to be louder during inspiration than during expiration» [G6-11].
  • Normal S1 and S2 heart sounds; absent murmurs [C2].
  • Muffled, distant heart sounds (classic Beck triad: hypotension, jugular venous distention, and distant heart sounds) [G6-02].
  • Absent cardiac murmurs [C2].
  • Absence of third heart sound (S3) or pericardial knock [G6-02] [M5].
Arterial pulse
  • Normal peripheral arterial pulse [B4].
  • Preserved physiological respiratory variation, given that «Systolic blood pressure normally falls during quiet inspiration in normal individuals» [B5], with pulsus paradoxus absent (< 10 mmHg) [B5] [C2].
  • Severe pulsus paradoxus: Inspiratory systolic blood pressure drop > 10 mmHg (frequently > 15–25 mmHg) [B5] [C2] [G6-02].
  • Small-volume thready pulse (parvus) and tachycardic [B4].
Jugular venous pulse
  • Normal jugular venous pressure (mean venous pressure in cmH₂O 5–8 cmH₂O) with physiological waves and troughs [B3].
  • Extreme jugular venous distention with very high venous pressure (mean venous pressure in cmH₂O > 15–20 cmH₂O) [B3] [C2].
  • Pathognomonic venous morphology: Deep and prominent x descent with absent or practically flat y descent (absent y descent) due to continuous impediment to ventricular filling throughout diastole [B3] [G6-02] [M5].
Maneuvers
  • Leaning chest forward and held end-expiration: Increases audible rub intensity by bringing the heart closer to the anterior chest wall [C2] [G6-11].
  • Inspiration: Accentuates the drop in systolic blood pressure (> 10 mmHg) mediated by ventricular interdependence [B5] [M5].

Sources and bibliographic references

Acute pericarditis

  1. [B3] The jugular venous pressure revisited . Cleve Clin J Med (2013) . DOI: 10.3949/ccjm.80a.13039 PubMed: 24085809
  2. [B4] The Carotid Pulse . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250154
  3. [B5] Pulsus paradoxus . Eur Respir J (2013) . DOI: 10.1183/09031936.00138912 PubMed: 23222878
  4. [C2] 2025 ESC Guidelines for the management of myocarditis and pericarditis . Eur Heart J (2025) . DOI: 10.1093/eurheartj/ehaf192 PubMed: 40878297
  5. [G6-01] American Society of Echocardiography clinical recommendations for multimodality cardiovascular imaging of patients with pericardial disease: endorsed by the Society for Cardiovascular Magnetic Resonance and Society of Cardiovascular Computed Tomography . J Am Soc Echocardiogr (2013) . DOI: 10.1016/j.echo.2013.06.023 PubMed: 23998693
  6. [G6-11] Pericardial rub. Prospective, Multiple observer investigation of pericardial friction in 100 patients . Am J Cardiol (1975) . DOI: 10.1016/0002-9149(75)90847-1 PubMed: 1114993
  7. [G6-12] Acute pericarditis: diagnostic cues and common electrocardiographic manifestations . Cardiol Rev (2007) . DOI: 10.1097/01.crd.0000233777.62568.b5 PubMed: 17172880
  8. [M5] Pericardial disease . Circulation (2006) . DOI: 10.1161/CIRCULATIONAHA.105.561514 PubMed: 16567581

Cardiac tamponade

  1. [B3] The jugular venous pressure revisited . Cleve Clin J Med (2013) . DOI: 10.3949/ccjm.80a.13039 PubMed: 24085809
  2. [B4] The Carotid Pulse . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250154
  3. [B5] Pulsus paradoxus . Eur Respir J (2013) . DOI: 10.1183/09031936.00138912 PubMed: 23222878
  4. [C2] 2025 ESC Guidelines for the management of myocarditis and pericarditis . Eur Heart J (2025) . DOI: 10.1093/eurheartj/ehaf192 PubMed: 40878297
  5. [E1] AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part V: electrocardiogram changes associated with cardiac chamber hypertrophy: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society: endorsed by the International Society for Computerized Electrocardiology . Circulation (2009) . DOI: 10.1161/CIRCULATIONAHA.108.191097 PubMed: 19228820
  6. [G6-01] American Society of Echocardiography clinical recommendations for multimodality cardiovascular imaging of patients with pericardial disease: endorsed by the Society for Cardiovascular Magnetic Resonance and Society of Cardiovascular Computed Tomography . J Am Soc Echocardiogr (2013) . DOI: 10.1016/j.echo.2013.06.023 PubMed: 23998693
  7. [G6-02] Acute cardiac tamponade . N Engl J Med (2003) . DOI: 10.1056/NEJMra022643 PubMed: 12917306
  8. [M5] Pericardial disease . Circulation (2006) . DOI: 10.1161/CIRCULATIONAHA.105.561514 PubMed: 16567581