Chapter 15 / Pericardial Disease 231
Physical Examination
Pulsus paradoxus (inspiratory decrease in systolic blood pressure of >10 mm Hg)
and jugular venous distention are hallmarks of cardiac tamponade. Pulsus paradoxus
should be determined during normal breathing because deep breathing may result in a
false-positive diagnosis. The extent of the inspiratory decrease in systolic blood pres-
sure may reflect the severity of the hemodynamic compromise. In severe tamponade,
the Korotkoff sounds may disappear entirely during inspiration. Jugular venous disten-
tion is also essential to the diagnosis of cardiac tamponade unless the patient is
severely hypovolemic.
Echocardiography
Transthoracic echocardiography is the most useful method for detecting pericardial
fluid in patients with suspected tamponade. Good quality images that show no cardiac
tamponade virtually rule out this diagnosis, except for cardiac tamponade that is
related to localized cardiac compression. This is particularly important for preventing
unnecessary and potentially lethal pericardiocentesis. Once pericardiocentesis is
planned, transthoracic echocardiography is also used to delineate the pericardial sac
and select the puncture site.
When a pericardial effusion is detected, further echocardiographic investigation may
provide important, detailed information on its hemodynamic significance and potential
role in the development of shock. Two-dimensional echocardiography often reveals
right-atrial compression during late diastole and early systole (16). However, up to
92% of the patients with pericardial effusion, with or without tamponade, have an
inversion of ≥ 30% of the right atrial free wall (15). Therefore, this finding is not spe-
cific to cardiac tamponade and may simply indicate the accumulation of pericardial
fluid around the right atrium when it contracts and empties into the right ventricle.
Another echocardiographic finding, early diastolic right ventricular collapse (17), is
considered a more specific and reliable sign of pericardial tamponade. It is more pre-
dictive of tamponade than pulsus paradoxus in the context of hypovolemia (18); how-
ever, it may be absent in patients with pulmonary hypertension. Dilatation of the
inferior vena cava without an inspiratory collapse of > 50% has also been proposed as a
sign of tamponade (19).
The typical straightening and leftward shift of the interventricular septum into the
left ventricular cavity during inspiration can also be detected by echocardiography
(20). In addition, premature closure of the aortic valve and delayed, diminished, or late
diastolic mitral valve opening may be detectable on the echocardiogram when tampon-
ade is at an advanced stage and may indicate low output and severe hemodynamic
compromise.
Pseudohypertrophy of the left ventricle may be observed during tamponade and may
be proportional to the decrease in left ventricular volume. A swinging heart appearance
is not necessarily associated with tamponade but is often noted in patients with large
pericardial effusions.
In patients with tamponade, Doppler ultrasound typically reveals exaggerated pul-
monic and tricuspid flow velocities and markedly increased respiratory variation in
transmitral flow velocity, corresponding to the inspiratory decrease and expiratory
increase in left ventricular filling and output (7,21). Patients with cardiac tamponade
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