EpistemisLow left parasternal beat (Dressler sign)
Specialty: Cardiovascular.
Why it occurs
- Concentric hypertrophy and dilation of the right ventricle (secondary to severe pulmonary hypertension or pulmonary stenosis)
- Atrial septal defect with large-volume left-to-right shunt (right ventricular volume overload)
- Chronic decompensated cor pulmonale (secondary to COPD or pulmonary fibrosis)
- Massive functional tricuspid insufficiency with dilation of the right cavities
- Tetralogy of Fallot or other cyanotic congenital heart diseases with right ventricular hypertrophy
Initial workup
12-lead electrocardiogram to identify signs of right ventricular hypertrophy (right axis deviation >110°, high R wave in V1 >7 mm, R/S ratio in V1 >1, and overload pattern in right precordials V1-V3 with T wave inversion); Transthoracic Doppler echocardiogram to quantify the thickness of the free wall of the right ventricle (>5 mm indicates hypertrophy), evaluate the morphology and dimensions of the right chambers, measure the TAPSE and S' wave, and accurately estimate the systolic pressure of the pulmonary artery; Chest x-ray in lateral projection to observe the occupation of the retrosternal space by the dilated right ventricle.
red flags
Detection of a palpable, wide and sustained systolic elevation or elevation of the lower left parasternal region (the heel of the examiner's hand rises rhythmically with the heartbeat), associated with severe dyspnea at rest, central cyanosis (lips and mucous membranes), recurrent exertional syncope, oppressive substernal precordial pain (right ventricular angina), jugular engorgement marked with V wave giant, or deep pitting peripheral edema. It indicates extreme hemodynamic overload and right ventricular hypertrophy, with risk of acute right ventricular claudication and systemic circulatory failure.
Standard management
- Furosemide — first choice loop diuretic to reduce right ventricular preload, relieve systemic congestion and reduce painful hepatomegaly; 40 mg orally or intravenously daily, adjusting according to diuretic response and monitoring plasma ions
- Macitentan — endothelin receptor antagonist indicated in pulmonary arterial hypertension to reduce pulmonary vascular resistance and reduce right ventricular afterload; 10 mg once daily orally
- Sildenafil — phosphodiesterase-5 inhibitor indicated to induce selective pulmonary arterial vasodilation; 20 mg three times a day orally
- Spironolactone (aldosterone antagonist to optimize the management of volume overload and right myocardial fibrosis; 25 mg once daily orally).
Educational guidance for study. It is NOT a prescription recommendation. The actual choice depends on the cause, the patient, and current guidelines.
- Area
- Cardiovascular
- Listed causes
- 5
- Treatment options
- 4