Friedreich’s sign

An 82-year-old man with chronic atrial fibrillation treated with anticoagulation was admitted to the hospital for subacute progressive exertional dyspnoea. On examination, the jugular venous waveform was elevated to the mandibular angle with the patient sitting upright. Heart sounds were muffled. Transthoracic echocardiography (TTE) revealed a large circumferential pericardial effusion with early tamponade physiology. Pericardiocentesis yielded a large volume of sanguineous fluid. Following the procedure, there was improvement in jugular venous pressure to 14 cm H2O. The height of the waveform increased with inspiration (Kussmaul’s sign) and there was a prominent y descent, known as Friedreich’s sign (see video 1). Repeat TTE revealed thickened …