EpistemisPalpable epigastric pulsation of right ventricular origin
Specialty: Cardiovascular.
Why it occurs
- Severe hypertrophy and dilation of the right ventricle secondary to pulmonary hypertension
- Critical pulmonary valve stenosis
- Pulmonary emphysema or severe advanced COPD (chronic cor pulmonale)
- Massive tricuspid regurgitation
- Chronic intracardiac shunt with right chamber pressure overload
Initial workup
12-lead electrocardiogram to identify electrocardiographic signs of right ventricular hypertrophy (right axis >110°, tall R waves in V1-V2, deep S waves in V5-V6, and signs of right ventricular overload with T wave inversion in V1-V3); Transthoracic Doppler echocardiogram to confirm right ventricular dilation and hypertrophy (free wall thickness >5 mm), evaluate right ventricular function (TAPSE, S' wave), quantify tricuspid regurgitation, and accurately estimate pulmonary artery systolic pressure; Chest x-ray.
red flags
Presence of a palpable and prominent systolic beat in the epigastric region that is accentuated when the explorer presses his fingers below the xiphoid process upwards and backwards, associated with dyspnea at rest, central cyanosis (lips, tongue), jugular engorgement marked with giant V wave, persistent dull pain in the right upper quadrant due to congestive hepatomegaly, tense ascites, generalized edema, or oppressive substernal precordial pain on exertion (right ventricular angina). Indicates extreme systolic or diastolic overload of the right ventricle with established right ventricular dysfunction and imminent risk of generalized hemodynamic failure.
Standard management
- Furosemide — loop diuretic to reduce ventricular preload, relieve systemic congestion and reduce associated congestive hepatomegaly; 40 mg orally or intravenously daily, with doses titrated according to urine output and monitoring renal function and electrolytes
- Spironolactone — aldosterone receptor antagonist to help with water depletion and limit fibrosis in the right cavities; 25 mg once a day orally
- Macitentan — endothelin receptor antagonist indicated if the confirmed etiology is precapillary pulmonary arterial hypertension to reduce pulmonary resistance; 10 mg once daily orally
- Sildenafil (phosphodiesterase-5 inhibitor indicated to promote selective pulmonary vasodilation; 20 mg three times a day 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