How to perform a parasternal heave (parasternal lift) examination?

From the Guidelines

To perform a parasternal heave assessment, place the palm of your right hand over the left parasternal area with your fingers pointing toward the patient's left shoulder, feeling for an abnormal, sustained outward movement or thrust during systole, as this technique is crucial for detecting right ventricular hypertrophy or enlargement, particularly in conditions like pulmonary hypertension 1. When assessing for a parasternal heave, it is essential to position the patient supine at a 45-degree angle and examine during quiet respiration. The use of the flat of the hand rather than just the fingertips is recommended, as it allows for a better appreciation of the heave. This examination technique is significant in detecting conditions that lead to right ventricular strain, such as pulmonary hypertension, which can present with non-specific symptoms including shortness of breath, fatigue, and syncope, as outlined in the 2015 ESC/ERS guidelines for the diagnosis and treatment of pulmonary hypertension 1. Key points to consider when performing a parasternal heave assessment include:

• Positioning the patient correctly to facilitate the examination
• Using the correct hand position to feel for the heave
• Examining during quiet respiration to minimize interference
• Correlating the intensity of the heave with the degree of right ventricular enlargement
• Considering the finding in the context of other cardiac examination elements, such as jugular venous pressure and heart sounds, to form a complete clinical picture, which is critical in managing conditions like pulmonary hypertension that can lead to significant morbidity and mortality if not properly diagnosed and treated 1.

From the Research

Parasternal Heave Procedure

To perform a parasternal heave, the following steps can be taken:

• The patient should be in a supine position with their head elevated to about 30-40 degrees.
• The examiner should stand on the right side of the patient and place the palm of their right hand on the patient's chest, with their fingers together and their hand flat.
• The examiner's hand should be positioned so that their fingers are parallel to the patient's sternum and their thumb is pointing towards the patient's left shoulder.
• The examiner should then apply gentle pressure to the chest, feeling for any abnormal movements or vibrations.

Clinical Significance

The parasternal heave is a clinical sign that can indicate right ventricular hypertrophy or enlargement, which can be associated with various cardiovascular conditions, such as pulmonary arterial hypertension or hypertrophic cardiomyopathy 2, 3.

• Right ventricular enlargement and dysfunction have been shown to be associated with increased all-cause mortality in patients with hypertrophic cardiomyopathy 2.
• ECG signs of right ventricular hypertrophy, such as an R/S ratio > 1 in V1, can help distinguish pulmonary arterial hypertension from pulmonary hypertension due to left ventricular diastolic dysfunction 3.

Limitations

There is limited information available on the specific procedure for performing a parasternal heave, and the provided studies do not directly address this topic.

• However, the studies do provide information on the clinical significance of right ventricular hypertrophy and enlargement, which can be detected through a parasternal heave examination 2, 3.
• One study on Fusarium solani is not relevant to the topic of parasternal heave or cardiovascular conditions 4.