MioAtlas
Comparison

Cardiac tamponade vs Constrictive pericarditis: clinical and ECG differences

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

Cardiac tamponade
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Constrictive pericarditis
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Findings by layer and diagnostic parameters

Layer / Finding Cardiac tamponade Constrictive pericarditis
Hemodynamics
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].
Systemic venous congestion and elevated, equalized filling pressures [C2] [M5]:
  • Mean right atrial pressure: Elevated (14–20 mmHg) [C2] [M5].
  • Mean pulmonary capillary wedge pressure: Elevated (15–22 mmHg) [M5].
  • Cardiac output: Moderately depressed (3.2–4.8 L/min) [C2].
  • LV ejection fraction (left ventricular ejection fraction): Preserved (50–65%) in early stages [C2].
  • Systemic arterial blood pressure: Normotension or borderline systolic pressure (systolic blood pressure 100–120 mmHg, diastolic blood pressure 65–80 mmHg) [C2].
Rhythm
  • Marked sinus tachycardia (sinus tachycardia, heart rate typically 110–135 bpm) reactive to adrenergic stimulation to compensate for low stroke volume [C2] [G6-02].
  • Normal sinus rhythm or atrial fibrillation [C2] [G6-06]. Ling et al. evaluated this clinical spectrum: «The contemporary spectrum of CP in 135 patients (76% male) evaluated at the Mayo Clinic from 1985 to 1995 was compared with that of a historic cohort.» [G6-06].
ECG
  • 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].
  • Low voltage QRS complex (low voltage): QRS voltage < 0.5 mV in peripheral limb leads [E1] [G6-06].
  • Diffuse T-wave flattening or inversion in precordial leads [C2] [G6-06].
  • Atrial enlargement (P mitrale wave) in sinus rhythm [E1].
Heart sounds and murmurs
  • 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].
  • Pericardial knock: High-frequency early diastolic sound recorded 90–120 ms after aortic component of S2, at the lowest nadir of the JVP y descent [G6-13].
  • S1 and S2 sounds of usual intensity; murmurs generally absent [C2].
Arterial pulse
  • 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].
  • Small-amplitude arterial pulse (parvus) due to stroke volume reduction [B4].
  • Pulsus paradoxus usually absent (< 10 mmHg in the vast majority of cases) [B5] [G6-06].
Jugular venous pulse
  • 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].
  • Marked jugular venous distention (mean venous pressure in cmH₂O 14–22 cmH₂O) [B3] [G6-06].
  • Deep and rapid 'y' descent (Friedreich sign, deep y descent): Accelerated early diastolic atrial emptying without initial resistance [B3] [G6-13] [M5].
  • Positive Kussmaul sign (kussmaul): Failure of JVP to collapse or paradoxical rise during inspiration [B3] [C2].
Maneuvers
  • Inspiration: Accentuates the drop in systolic blood pressure (> 10 mmHg) mediated by ventricular interdependence [B5] [M5].
  • Inspiration: Elicits Kussmaul sign (visible increase in jugular distention) and intensifies pericardial knock [B3] [G6-13].

Sources and bibliographic references

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

Constrictive 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. [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. [G6-05] Echocardiographic diagnosis of constrictive pericarditis: Mayo Clinic criteria . Circ Cardiovasc Imaging (2014) . DOI: 10.1161/CIRCIMAGING.113.001613 PubMed: 24633783
  8. [G6-06] Constrictive pericarditis in the modern era: evolving clinical spectrum and impact on outcome after pericardiectomy . Circulation (1999) . DOI: 10.1161/01.cir.100.13.1380 PubMed: 10500037
  9. [G6-13] Genesis of pericardial knock in constrictive pericarditis . Am J Cardiol (1980) . DOI: 10.1016/0002-9149(80)90510-7 PubMed: 7416016
  10. [M5] Pericardial disease . Circulation (2006) . DOI: 10.1161/CIRCULATIONAHA.105.561514 PubMed: 16567581