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A retrospective study on 126 patients with pericardial effusion showed cardiac tamponade to be present in 39 patients and absent in 87. We evaluated the distribution of the pericardial effusion as well as the effect of hydrodynamic compression on the different heart chambers. Small to large volumes of pericardial fluid were found in both groups of patients. Abnormal wall movements were only present if pericardial effusion was adjacent. Hydrodynamic compression signs consisted of abnormal wall movements of both atria at end-diastole continuing into systole, and of the right ventricle in early- and mid-diastole. Most of the patients with cardiac tamponade showed an abnormal motion pattern of both right atrium and ventricle (13 patients) or of the right atrial wall alone (12 patients). Abnormal motion of the right ventricle alone was seen in 6 patients, of both atria and right ventricle in 4 and of the left atrium alone in 1 patient. False-negative diagnoses of cardiac tamponade occurred in 3 of the 39 patients and false-positives in 2 of the 87 (sensitivity 92%, specificity 98%). Measurements of the duration of the inversion of both atria increased the specificity of these abnormal wall movements to 100%. Echocardiography can help to identify those patients who are clinically at risk and need pericardial drainage.