Toe beat shifted

Specialty: Cardiovascular.

• lateralized toe shock
• displacement of the point of maximum impulse (PMI)
• apex shifted

Why it occurs

• Hypertrophy and dilation of the left ventricle secondary to chronic hypertensive heart disease
• Dilated cardiomyopathy with severe cardiomegaly
• Severe aortic or mitral valve regurgitation with ventricular volume overload
• Acute extensive anterior myocardial infarction with remodeling and ventricular dilation
• Contralateral massive pleural effusion or tension pneumothorax (extracardiac mechanical displacement)

Initial workup

Complete transthoracic echocardiogram to accurately quantify left ventricular end-diastolic diameter (a diameter >55 mm in women or >62 mm in men confirms dilation), measure wall thicknesses, determine left ventricular mass and ejection fraction; Chest x-ray in two views (posteroanterior and lateral) to document the cardiothoracic index (>0.50 indicates cardiomegaly) and evaluate signs of pulmonary venous congestion; Cardiac Magnetic Resonance if exact quantification of volumes or characterization of the myocardium is required (late gadolinium enhancement fibrosis).

Standard management

• Enalapril — ACEI indicated to inhibit the renin-angiotensin-aldosterone axis, reduce afterload and limit remodeling and progression of left ventricular dilation; 5 to 10 mg twice daily orally, titrated according to blood pressure
• Metoprolol succinate — beta blocker indicated to counteract chronic sympathetic toxicity and promote reverse remodeling; 25 to 100 mg once daily orally, with the patient clinically stable
• Spironolactone — aldosterone receptor antagonist to mitigate myocardial fibrosis; 25 mg once daily orally, monitoring serum potassium
• Dapagliflozin (SGLT2i indicated to reduce volume overload and stop ventricular dilation; 10 mg once daily orally).