Diagnostic Signs in Compressive Cardiac Disorders: Constrictive Pericarditis, Pericardial Effusion, and Tamponade

Thirty patients with primary cardiac compression due to constrictive pericarditis, lax effusion, or cardiac tamponade and an additional seven patients with spurious evidence of cardiac compression or with pericardial effusion playing an unimportant role in the circulatory disorder were studied. Rather stringently defined physical findings were sought which might allow discrimination between cardiac disorders. The following conclusions are drawn from the results.1. Constrictive pericarditis is associated with venous and auscultatory phenomena which do not allow separation from other forms of heart disease causing congestive heart failure. Kussmaul's sign is present in less than 40%; pulsus paradoxus as classically defined is rare.2. In lax pericardial effusion, Kussmaul'ssign and Friedreich's sign, along with thirdheart sounds, are not present. Pulsus paradoxus is inconstant with tranquil breathing but is regularly induced by deep inspiration. There is inspiratory decrease in venous pressure and pericardial pressure. Cardiac index is normal and venous pressure is less than 12 mm Hg. Circulatory distress is not apparent.3. Tamponade induces signs of circulatory distress and is regularly characterized by pulsus paradoxus but Friedreich's sign, a third heart sound, as well as Kussmaul's venous sign, are absent. The venous pressure exceeds 12 mm Hg. There is an inspiratory decrease in venous pressure and pericardial pressure. The low cardiac index is usually relieved by tap. When aortic stenosis is present, respiratory variation in left ventricular systolic pressure may not be reflected by clinical pulsus paradoxus.4. Spurious signs of cardiac compression may be due to (1) respiratory disease, (2) severe myocardial disease and incidental effusion, or (3) obesity. In the respiratory disease pulsus paradoxus, normal cardiac index, low venous pressure, and venous and pericardial-pressure decrease with inspiration are present. The second group does not show pulsus paradoxus and the elevated venous pressure, diastolic dip, and third heart sounds are due to heart failure. Obesity may cause pulsus paradoxus and increased peripheral venous pressure, which does not reflect central venous pressure. These findings seem related to inspiratory collapse of extrathoracic vessels.