Article Text

Download PDFPDF
Total electrical alternans in a patient with malignant pericardial tamponade
  1. Diede Verlaan1,
  2. Joris D Veltman2,
  3. Bart Grady1,3
  1. 1Internal Medicine, Academic Medical Center, Amsterdam, The Netherlands
  2. 2Respiratory Medicine, Academic Medical Center, Amsterdam, The Netherlands
  3. 3Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
  1. Correspondence to Dr Bart Grady, b.p.x.grady-2{at}


We present a case of a 59-year-old man with acute abdominal pain and progressive shortness of breath. A focused assessment with sonography for trauma scan showed free fluid in the hepatorenal recess and in the recto-uterine recess. Later, due to clinical deterioration and the differential possibility of a pulmonary embolism or aortic dissection, a CT scan was performed which revealed large pericardial effusion. This, together with a dilated vena cava inferior and portal system, raised the suspicion of cardiac tamponade. The diagnosis was confirmed by transthoracic echocardiography (TTE). In retrospect, the ECG at admission showed a sinus tachycardia, low-voltage QRS complexes and a total electrical alternans corresponding with the swinging heart seen on TTE. An electrical alternans on ECG is an important diagnostic clue but is often missed, causing an unnecessary delay to proper diagnostic and therapeutic measures.

  • lung cancer (oncology)
  • pericardial disease
  • emergency medicine
View Full Text

Statistics from


  • Contributors DV, BG: substantial contributions to the conception or design of the work, or the acquisition, analysis or interpretation of data. DV, JV, BG: drafting the work or revising it critically for important intellectual content and final approval of the version published. JV, BG: agreement to be accountable to all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Next of kin consent obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.