Parasternal Lift: Clinical Significance and Assessment
A parasternal lift is a visible or palpable outward movement of the chest wall in the parasternal area during systole, which indicates right ventricular hypertrophy or pressure overload.
Definition and Mechanism
A parasternal lift occurs when the right ventricle is enlarged or under increased pressure, causing it to push against the chest wall during contraction. This clinical sign is detected during cardiac examination by:
- Placing the palm of the hand along the left sternal border
- Feeling for an abnormal outward movement during systole
- Noting its location (typically left parasternal region)
Clinical Significance
Parasternal lifts are important physical examination findings associated with several cardiac conditions:
1. Pulmonary Hypertension
- Considered a key physical sign in patients with pulmonary hypertension 1
- Often accompanied by an accentuated pulmonary component of the second heart sound
- May be one of the earliest detectable signs of right ventricular pressure overload
2. Congenital Heart Disease
- Commonly seen in congenital cardiac anomalies with right ventricular involvement
- In congenitally corrected transposition of the great arteries (CCTGA), the parasternal lift relates to the abnormal position of the ventricles 1
- May be accompanied by a palpable second sound due to the anterior position of the aorta in CCTGA
3. Right Ventricular Infarction
- Can occur in isolated right ventricular anterior wall infarction 2
- Represents an unusual cause of parasternal lift that should be considered in patients with myocardial infarction
Associated Findings
When evaluating a patient with a parasternal lift, clinicians should also assess for:
- Jugular vein distension
- Hepatomegaly
- Peripheral edema
- Ascites
- Cool extremities
- Tricuspid regurgitation murmur
- Pulmonary insufficiency murmur
- Right ventricular third sound
These findings may indicate advanced right ventricular dysfunction and help establish the underlying diagnosis 1.
Diagnostic Correlation
The presence of a parasternal lift should prompt further cardiac evaluation:
Electrocardiogram (ECG)
- May show right ventricular hypertrophy
- Right axis deviation
- Right atrial enlargement
- However, a normal ECG does not exclude severe pulmonary hypertension 1, 3
Echocardiography
- Can confirm right ventricular enlargement or hypertrophy
- Allows assessment of right ventricular function
- Helps identify associated structural abnormalities
- Doppler studies can estimate pulmonary artery pressure 1
Other Imaging
- Chest radiography may show enlarged central pulmonary arteries
- Advanced imaging (CMR, CT) may be needed to determine the cause of right ventricular pressure overload 3
Clinical Pitfalls
Missed Diagnosis: The parasternal lift may be subtle and overlooked during routine examination, especially in obese patients or those with chest wall deformities.
Misattribution: Not all parasternal movements are pathological; normal cardiac motion can sometimes be visible in thin individuals.
Incomplete Evaluation: Finding a parasternal lift should trigger a comprehensive cardiac assessment rather than being considered an isolated finding.
Failure to Recognize Urgency: In acute settings (such as pulmonary embolism), a new parasternal lift may indicate severe right ventricular strain requiring immediate intervention.
Conclusion
The parasternal lift is a valuable physical examination finding that provides important information about right ventricular function and pressure. When detected, it should prompt appropriate cardiac evaluation to determine the underlying cause and guide management decisions.