Electrical alternans occurs when every other QRS complex has varying amplitudes and

is from the heart swaying within a large pericardial effusion.

Electrical alternans is a pathognomonic ECG finding for pericardia! effusion. It is due
to the swinging motion of the heart in the pericardia! cavity that causes a beat-tobeat variation in QRS axis and amplitude (red arrows). Electrical alternans with sinus
tachycardia is highly specific (but not very sensitive) for pericardial effusion. Large
pericardia! effusions can also cause low voltage of QRS complexes on ECG. An
echocardiogram is used to confirm the pericardia! effusion in hemodynamically stable
patients. Treatment
involves emergency pericardiocentesis for rapid symptom resolution and
improvement of hypotension.

Physical exam findings in pericardial diseases

Electrical alternant