The uncommon observation of alternation of the first heart sound in intensity, associated with mechanical and electric alternans is reported in a patient with cardiac tamponade due to large hemorrhagic pericardial effusion. Following pericardiocentesis and removal of 400 millilitres of fluid, all alternation phenomena disappeared. The combination of three alternation phenomena may be a helpful physical diagnostic sign of cardiac tamponade. The possible mechanisms of the "alternans" are discussed. It is suggested that variations in ventricular filling and emptying are the relevant pathogenetic factors.
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