To assess the diagnostic value of three different two-dimensional echocardiographic signs of pericardial constriction (early diastolic septal bounce, plethora of the inferior vena cava with blunted respiratory response, and pericardial adhesion), two independent observers retrospectively evaluated echocardiograms in 100 patients, 39 of whom had pericardial constriction, 15 had hemodynamically insignificant pericardial thickening, 16 had restrictive cardiomyopathy, and 30 had normal hearts. Causes of pericardial disease included cardiac surgery, malignancy, and uremia. Sensitivity and specificity of the three signs for constriction were 62% and 93% for septal bounce, 79% and 80% for vena cava plethora, and 79% and 90% for pericardial adhesion, respectively. The presence of either vena cava plethora or pericardial adhesion increased sensitivity, whereas the presence of both plethora and adhesion increased specificity. Between the two readers, septal bounce was the most consistent and pericardial adhesion the least consistent sign. False positive results included right ventricular pacing or left bundle branch block (septal bounce), postpericardiotomy (pericardial adhesion), and right heart failure (vena cava plethora). False negative results were often caused by technical problems with imaging. We conclude that these three two-dimensional echocardiographic signs are useful in differentiating pericardial constriction from hemodynamically insignificant pericardial thickening or restrictive cardiomyopathy.