MioAtlas
Comparison

Constrictive pericarditis vs Restrictive cardiomyopathy (amyloidosis): clinical and ECG differences

Side-by-side comparison of Constrictive pericarditis and Restrictive cardiomyopathy (amyloidosis) according to the MioAtlas 3D cardiac simulator model.

Constrictive pericarditis
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Restrictive cardiomyopathy (amyloidosis)
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Findings by layer and diagnostic parameters

Layer / Finding Constrictive pericarditis Restrictive cardiomyopathy (amyloidosis)
Hemodynamics
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].
  • Atrial and pulmonary capillary pressures (mean pulmonary capillary wedge pressure, mean right atrial pressure): Severely elevated (> 15–20 mmHg) with diastolic equalization of right and left pressures [G5-05] [G5-06].
  • LV ejection fraction (left ventricular ejection fraction): Initially preserved (50–60%) with low stroke volume due to restricted filling; depresses in very advanced stages [G5-05].
  • Diastolic pressure morphology: 'Square root' pattern (dip and plateau) on invasive ventricular pressure tracings [M5] [G5-06].
Rhythm
  • 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].
  • Normal sinus rhythm, frequently associated with loss of effective mechanical atrial contractile function (atrial electromechanical dissociation / standstill) [G5-05] [G5-06].
  • Atrial fibrillation as a common supraventricular arrhythmia due to atrial amyloid infiltration and biatrial dilation [C1] [G5-05].
  • Atrioventricular conduction disturbances (1st degree AV block or fascicular block) [E2] [G5-05].
ECG
  • 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].
  • Diffuse peripheral low voltage: QRS amplitude < 5 mm in leads I, II, III, aVR, aVL, and aVF [G5-05] [G5-06] [E1].
  • Pseudoinfarction pattern (pseudoinfarct Q waves): Pathological Q waves or QS complexes in anteroseptal precordial leads (V1–V3) or inferior leads (II, III, aVF) in the absence of ischemic heart disease or transmural necrosis [G5-05] [G5-06].
  • Non-specific intraventricular conduction delay [E2] [G5-05].
Heart sounds and murmurs
  • 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].
  • Third heart sound (S3): Crisp protodiastolic gallop (restrictive sound) auscultated with bell in mesocardium and apex due to abrupt impact of transmitral flow against a stiff, unyielding myocardial wall [G1-12] [G5-06].
  • Characteristic absence of fourth heart sound (S4): Despite the stiff ventricle, S4 is typically not heard or absent due to mechanical contractile paralysis of the infiltrated atrium (atrial standstill) or presence of AF [G5-05] [G5-06].
  • Muffled heart sounds: S1 and S2 decreased in intensity due to tissue interposition/infiltration [G1-10] [G5-06].
  • Atrioventricular regurgitation murmurs: Soft apical holosystolic murmur of mitral regurgitation and tricuspid murmur due to valvular infiltration [G1-14] [G5-05].
Arterial pulse
  • 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].
  • Reduced-amplitude arterial pulse (pulsus parvus) due to low systolic stroke volume [B4] [G5-06].
Jugular venous pulse
  • 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].
  • Markedly elevated jugular venous pressure with Kussmaul sign (lack of inspiratory decline or paradoxical rise in JVP during inspiration) [B3] [G5-06].
  • Venous morphology with prominent 'a' wave (if atrial systole persists) and a deep, rapid, abrupt 'y' descent (steep y descent / rapid diastolic collapse), followed by a rapid diastolic plateau [B3] [G5-06].
Maneuvers
  • Inspiration: Elicits Kussmaul sign (visible increase in jugular distention) and intensifies pericardial knock [B3] [G6-13].
  • Inspiration: Paradoxical increase or failure of jugular distention to fall (positive Kussmaul sign) due to inability of the rigid right ventricle to accommodate increased venous return [B3] [G5-06].

Sources and bibliographic references

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

Restrictive cardiomyopathy (amyloidosis)

  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. [C1] 2023 ESC Guidelines for the management of cardiomyopathies . Eur Heart J (2023) . DOI: 10.1093/eurheartj/ehad194 PubMed: 37622657
  4. [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
  5. [E2] AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part III: intraventricular conduction disturbances: 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.108.191095 PubMed: 19228822
  6. [G1-10] The First Heart Sound . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250175
  7. [G1-12] The Third Heart Sound . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250184
  8. [G1-14] Systolic Murmurs . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250186
  9. [G5-05] Diagnosis and treatment of cardiac amyloidosis: a position statement of the ESC Working Group on Myocardial and Pericardial Diseases . Eur Heart J (2021) . DOI: 10.1093/eurheartj/ehab072 PubMed: 33825853
  10. [G5-06] Cardiac Amyloidosis: Evolving Diagnosis and Management: A Scientific Statement From the American Heart Association . Circulation (2020) . DOI: 10.1161/CIR.0000000000000792 PubMed: 32476490
  11. [M5] Pericardial disease . Circulation (2006) . DOI: 10.1161/CIRCULATIONAHA.105.561514 PubMed: 16567581