Evaluation and Management of Right-Sided Pulsation at Fifth Intercostal Space with Palpitations

Initial Diagnostic Approach

The American College of Cardiology recommends obtaining a 12-lead ECG immediately to identify any underlying arrhythmia or conduction abnormalities, as this is the gold standard for diagnosis when palpitations are present 1, 2
A 12-lead ECG should be evaluated for pre-excitation patterns (delta waves) suggesting Wolff-Parkinson-White syndrome, which would require immediate referral to an arrhythmia specialist due to risk of sudden death 1
Epsilon waves in leads V1-V3 are highly specific for arrhythmogenic right ventricular cardiomyopathy (ARVC) and represent a major diagnostic criterion 3

The American Heart Association suggests that right-sided pulsation at the fifth intercostal space is anatomically significant and suggests right ventricular volume overload from conditions such as atrial septal defect with left-to-right shunting 2
Tricuspid regurgitation with right ventricular enlargement can also cause right-sided pulsation at the fifth intercostal space 2
ARVC with right ventricular dilatation is another possible cause of right-sided pulsation at the fifth intercostal space 3

The American College of Cardiology recommends that transthoracic echocardiography should be performed urgently to exclude structural heart disease, as this cannot be reliably detected by physical examination or ECG alone 1, 5
Echocardiogram must specifically assess right ventricular size and function to evaluate for ARVC, which requires comprehensive cardiac testing including cardiac MRI if abnormalities are found 3

Immediate referral to a cardiac arrhythmia specialist is mandatory if pre-excitation on resting ECG (WPW syndrome) is present, as these patients are at risk for sudden death 1
Epsilon waves suggesting ARVC also require immediate referral to a cardiac arrhythmia specialist 3
Syncope or near-syncope accompanying the palpitations indicates potentially life-threatening arrhythmia and requires immediate referral to a cardiac arrhythmia specialist 1

If ventricular arrhythmias are detected, comprehensive evaluation must include cardiac MRI with stress perfusion study to investigate for myocardial disease including HCM, DCM, LVNC, ARVC, myocarditis, or sarcoidosis 3
Exercise ECG test is also recommended to assess for exercise-induced arrhythmias 3
Minimum 24-hour ECG monitor is necessary to quantify arrhythmia burden 3
Signal-averaged ECG (SAECG) is recommended if ARVC is suspected 3