Parasternal heave causes grading etc
Reading File
Finding Sources
Finding Sources
Searching the Web
parasternal heave causes grading clinical examination cardiology
Reading File
Finding Sources
Finding Sources
Reading File
Finding Sources
Finding Sources
Finding Sources
Reading Web Page
https://www.merckmanuals.com/professional/cardiovascular-dis…
Finding Sources
Reading File
Reading File
Now I have enough to give a thorough, well-sourced answer.
Parasternal Heave
What It Is
A parasternal heave (also called a left parasternal lift or right ventricular heave) is a palpable - and sometimes visible - outward lifting motion of the chest wall along the left lower sternal border during systole. It is caused by an enlarged or pressure/volume overloaded right ventricle pushing anteriorly against the sternum, given the RV's anterior position within the chest.
- Fuster & Hurst's The Heart, 15th Ed, p. 82: "Given its anterior position within the chest, an enlarged right ventricle can be palpated as a parasternal lift (or heave)."
- Harrison's 22E: "Right ventricular pressure or volume overload may create a sternal lift."
How to Elicit It
Place the heel or thenar/hypothenar surface of your right hand flat against the patient's left lower sternal border (3rd-5th left intercostal spaces), with the patient supine at 30°. Three approaches are recognized:
- Thenar/hypothenar method - heel of right hand on left lower sternal border (most common)
- Finger-tip method - index, middle, ring fingers placed over the 3rd, 4th, 5th intercostal spaces at the left parasternal line
- Subxiphoid method - right hand pressed under the xiphoid; especially useful in obstructive lung disease (COPD, emphysema) where the heart sits lower
The motion is felt as a sustained outward lifting of the examiner's hand during systole (as opposed to the more localized apical impulse).
Grading
There is no single universally agreed numeric grading scale for parasternal heave the way murmurs are graded, but the commonly used clinical descriptors are:
| Grade | Description |
|---|---|
| 0 | Absent - no heave palpable |
| +1 (Mild) | Barely perceptible lift; felt only with careful palpation in optimal position |
| +2 (Moderate) | Definite heave lifts the examiner's fingers; not visible |
| +3 (Marked/Severe) | Strong heave that visibly displaces the chest wall or lifts the examiner's whole hand |
In some clinical descriptions it is simply recorded as present/absent with a qualifier: mild, moderate, or marked. A visible heave (the chest wall moves on inspection) implies significant RV hypertrophy - this can even cause asymmetric precordial bulging in congenital conditions with severe RV enlargement.
Causes
Primary Causes (RV pressure overload - commonest mechanism)
| Cause | Notes |
|---|---|
| Pulmonary arterial hypertension (PAH) | Most common cause of prominent heave; also gives loud P2 and fixed/narrow split S2 |
| Pulmonary stenosis | Gives a sustained parasternal lift; associated with ejection click |
| Cor pulmonale | From COPD, ILD, recurrent PE; RV hypertrophy secondary to chronic hypoxic pulmonary vasoconstriction |
| Chronic pulmonary embolism | |
| Eisenmenger syndrome | Reversal of shunt with pulmonary HTN |
RV Volume Overload
| Cause | Notes |
|---|---|
| Atrial septal defect (ASD) | Classic cause; also gives fixed splitting of S2 |
| Tricuspid regurgitation | Large RV with cv waves in JVP |
| Pulmonary regurgitation | Often post-tetralogy repair |
| Ventricular septal defect (VSD) | Large left-to-right shunt |
Left-sided Conditions (Indirect - via pulmonary hypertension)
| Cause | Notes |
|---|---|
| Mitral stenosis | Raised LA pressure → pulmonary HTN → RV overload; heave is prominent |
| Mitral regurgitation | Chronic → pulmonary HTN → RV involvement |
| Left ventricular failure | Back-pressure pulmonary HTN |
Other / Less Common
| Cause | Notes |
|---|---|
| Tetralogy of Fallot | RV hypertrophy |
| Dilated cardiomyopathy | Biventricular dilation |
| Constrictive pericarditis | Diastolic constraint raises RV filling pressures |
Important Caveats
- In thin patients or those with pectus excavatum, a parasternal lift can be present with a structurally normal RV - the chest wall is simply closer to the heart
- In severe COPD with hyperinflated lungs, the RV may be enlarged but the heave can be difficult to feel anteriorly; the subxiphoid approach is more reliable
- A zone of retraction between the RV and LV impulses (felt with the patient in left lateral decubitus) can accompany RV overload
Associated Signs
When a parasternal heave is found, look for:
- Loud/palpable P2 - suggests pulmonary hypertension
- Fixed splitting of S2 - ASD
- Elevated JVP with cv waves - tricuspid regurgitation
- Right-sided S3 or S4 - RV dysfunction
- Hepatomegaly, peripheral edema - right heart failure
- Fuster & Hurst's The Heart, 15th Ed: "Presence of right ventricular heave suggests significant right ventricular dysfunction and/or pulmonary hypertension."
Sources: Fuster & Hurst's The Heart, 15th Ed (pp. 81-82); Harrison's Principles of Internal Medicine 22E; Merck Manual - Cardiovascular Examination
This is a shared conversation. Sign in to Orris to start your own chat.