Examination of the precordial pulsation

INTRODUCTION — Inspection and palpation of precordial cardiovascular pulsations are generally best performed with patients supine and with a modest elevation of the head and chest (not over 45°). Inspection and palpation are complementary since some precordial movements (such as inward pulsation) are best identified by inspection (including observation of the palpating hand) while other movements (outward pulsation) are best identified by palpation [1].

Other aspects of the cardiovascular examination are discussed separately. (See "Auscultation of heart sounds" and "Auscultation of cardiac murmurs in adults" and "Examination of the arterial pulse" and "Examination of the jugular venous pulse".)

INSPECTION — The examiner should observe by looking down at the chest and from the side.

A slight abrupt inward pulsation normally can be seen over the left ventricular apex at the fifth intercostal space in the left parasternal area, particularly in children and thin chested subjects. A hyperdynamic left ventricular impulse associated with severe aortic or mitral regurgitation is frequently visible and can cause occasional shaking of the entire precordium. In patients with severe dilated congestive cardiomyopathy, a double impulse may be visible over the apical region, usually due to a sustained left ventricular impulse and a prominent early diastolic filling impulse.

Cardiac pulsations that are visible lateral to the left midclavicular line usually suggest cardiac enlargement. Leftward cardiac displacement due to left pulmonary fibrosis, right-sided tension pneumothorax, massive pleural effusion, absent left pericardium, and thoracic deformity may also cause visible pulsation beyond the midclavicular line.

Systolic outward parasternal and left ventricular outward movements are better appreciated by palpation than by inspection. Such movements are often associated with aneurysms of the apex or anterolateral wall of the left ventricle and frequently indicates reduced left ventricular ejection fraction.

Epigastric and subxiphoid pulsations are usually abnormal and are related to right ventricular hypertrophy and dilation or to abdominal aortic aneurysm. However, in patients with emphysema, subxiphoid pulsations may not always indicate right ventricular hypertrophy. An abdominal aortic pulsation is frequently visible over the epigastrium in children and in persons with a scaphoid abdomen.

Pulsation over the right second intercostal space or right sternoclavicular joint may indicate aneurysm of the ascending aorta. Aneurysm of the aortic arch is occasionally associated with suprasternal pulsation. The most common cause of right supraclavicular pulsation is a kinked tortuous carotid artery.

Occasionally a pulsation is visible over the left second or third interspace. This is usually due to a dilated pulmonary artery.

Systolic retraction of the apical impulse may occur in patients with constrictive pericarditis [1]. Retraction of the 11^th and 12^th ribs in the left axilla and back (Broadbent sign) is a sign of pericardial adhesions to the diaphragm.

PALPATION — The primary objective of precordial palpation is to detect the character of the right and left ventricular impulse, which is helpful for assessing changes in cardiac dynamics and function. Palpation of the precordium should include the apical, mid precordial, lower left and right parasternal, pulmonary, aortic, suprasternal, and epigastric areas (table 1).

Left ventricular impulse — The left ventricular apical impulse or apex beat is the outward movement of the left ventricular apical region. It is normally localized to the fourth or fifth left intercostal space just medial to the left midclavicular line, and is no more than 2 to 3 cm in diameter. The apex impulse is best palpated when the patient lies in a left lateral decubitus position (rotated 45 to 90 degrees from supine) [1]. Both the systolic and diastolic portions of the apex impulse should be analyzed.

Generally, the apex beat is the point of maximal impulse, but occasionally a right parasternal pulsation or pulsation associated with a dilated pulmonary artery and aortic aneurysm may be more forceful than the left ventricular impulse. When the right ventricle is markedly dilated, as in some patients with a large atrial septal defect or severe mitral stenosis, the left ventricular apical impulse may not be palpable because of posterior displacement of the left ventricle.

The normal torsion of the left ventricular basal segments (counterclockwise as viewed from the base) and the apical (clockwise) results in normal character of the apical impulse. A sustained impulse is associated with abnormal torsion [2].

The physiologic correlations between the various components of the apical impulse (as recorded on an apex cardiogram) and the left ventricular dynamic events have been studied both in experimental animals and in humans [3-6].

●The initial upstroke of the apex cardiogram coincides with the onset of the isovolumic phase of left ventricular systole; the upstroke phase is usually completed before left ventricular ejection begins. During the isovolumic phase, the intraventricular pressure rises, associated with increased external cardiac circumference and alterations in ventricular shape. The upstroke portion of the apex cardiogram in normal subjects terminates with the beginning of left ventricular ejection.

There is a counterclockwise rotation of the heart in normal subjects during isovolumic systole, which brings the lower anterior portion of the left ventricle in close proximity to the anterolateral chest wall, causing an outward motion.

●The apex impulse on palpation normally corresponds to the onset of ventricular ejection or systole. The normal outward motion of the apex impulse is very brief and is followed by a gradual inward movement resulting from a decreasing ventricular volume during the ejection phase of systole.

●A more rapid inward movement begins just before S2 and continues up to the opening of the mitral valve; this corresponds to the left ventricular isovolumic relaxation phase.

●After mitral valve opening there is a rapid filling wave followed by a slow filling wave, corresponding to the rapid and slow ventricular filling phases. A palpable rapid filling wave is always abnormal; the most consistent hemodynamic association is augmented early diastolic filling and an elevated left ventricular diastolic pressure, as may be seen with mitral regurgitation, patent ductus arteriosus, and ventricular septal defect. A prominent rapid-filling wave also is observed in normal, young subjects.

●Atrial systole occurs after the slow filling phase. It generates a relatively small wave that has an amplitude that usually does not exceed 15 percent of the total height of the outward movement.

A palpable a wave, due to an increased amplitude, is always an abnormal physical finding. The most common hemodynamic association is an elevated left ventricular end-diastolic pressure and reduced compliance [7]. This may be present in patients with left ventricular hypertrophy (aortic stenosis, systemic hypertension, and hypertrophic cardiomyopathy), myocardial disease (cardiomyopathy), ischemic heart disease, and chronic left ventricular aneurysm. In patients with angina pectoris, an accentuated a wave can occur during angina pectoris or stress. The absence of a palpable a wave, however, does not exclude an abnormal left ventricular end-diastolic pressure.

An a wave is usually absent in conditions associated with marked restriction of inflow to the left ventricle, such as mitral valve obstruction or constrictive pericarditis. In patients with acute, severe aortic regurgitation, premature closure of the mitral valve can occur due to a rapid increase in left ventricular diastolic pressure exceeding aortic diastolic pressure. The a wave also may be absent in these circumstances [8].

The outward movement (systolic portion) in the apical impulse can be classified as normal, hyperdynamic, or sustained.

●Hyperdynamic – The hyperdynamic apex impulse is appreciated as a thrust of large amplitude that immediately disappears from the palpating fingers; it otherwise has a normal configuration and does not extend throughout systole. It is frequently associated with an accentuated rapid-filling wave.

A hyperdynamic apical impulse is found in conditions associated with an increased stroke volume or volume overload in the absence of significant left ventricular hypertrophy or depressed ejection fraction [9]. Examples include after exercise in normal subjects, in hypermetabolic states (thyrotoxicosis, anemia), in primary mitral regurgitation, in aortic regurgitation with normal systolic function, and in some patients with a large patent ductus arteriosus and ventricular septal defect.

●Sustained – The sustained outward movement is characterized by a plateau or a dome-shaped or rising movement after left ventricular ejection, in contrast to the normal systolic decline. A sustained apical impulse is felt as a prolonged heave throughout the systolic phase.

A sustained apex impulse is usually found when there is significant left ventricular hypertrophy, as in patients with left ventricular outflow obstruction or systemic hypertension. A sustained impulse is also appreciated when left ventricular systolic function (ejection fraction) is depressed, as in patients with dilated cardiomyopathy, ischemic heart disease, and aortic regurgitation associated with depressed left ventricular function [9].

●Bifid – In hypertrophic cardiomyopathy with midsystolic left ventricular outflow obstruction, the apical impulse may have a bifid outward movement [10,11]. Along with a prominent a wave, this may be felt as a triple impulse, although most frequently a double impulse consisting of a palpable a wave and a sustained outward movement.

Various abnormalities in the apical impulse may be appreciated in patients with coronary artery disease and a previous myocardial infarction or during ischemia. Early systolic, late systolic, or combined early and late systolic movements have been found [12]. At the bedside, however, these abnormal systolic motions are difficult to appreciate, although they may be precipitated by stress (eg, hand grip).

Right ventricular impulse — Normally, an inward movement (systolic retraction) is appreciated by palpation of the lower left parasternal area. In children, or in occasional adults with thin chest walls, a brief, gentle thrust may be palpable over the left third and fourth interspaces. A prolonged left parasternal upward or outward movement, palpable throughout systole, is distinctly abnormal.

A sustained systolic left parasternal lift is most frequently appreciated in the presence of significant right ventricular hypertrophy. Long-standing, severe pulmonary arterial hypertension, whether precapillary (eg, idiopathic pulmonary arterial hypertension or pulmonary valve stenosis) or postcapillary (eg, mitral stenosis, cardiomyopathy), produces right ventricular hypertrophy and a sustained lower left parasternal lift. It may also be associated with a palpable presystolic a wave preceding the right ventricular lift (heave); this finding suggests decreased right ventricular compliance.

A hyperdynamic but not sustained left parasternal systolic impulse may be palpable when right ventricular volume is increased, as with an atrial septal defect or tricuspid regurgitation. The left parasternal impulse becomes sustained during systole when pulmonary arterial hypertension is also present [13].

A left parasternal and midprecordial systolic outward impulse, similar to that associated with right ventricular hypertrophy, can be palpable in the absence of right ventricular hypertrophy; for example, in patients with significant mitral regurgitation. The systolic pulsation appears to result from left atrial expansion due to mitral regurgitation pressing the anterior structures forward toward the anterior chest wall [14]. In some patients with Ebstein's anomaly, a right parasternal systolic outward movement, presumably due to a large ventricularized right atrium, is appreciated.

An inward systolic movement and an outward movement during diastole are also palpable and recorded in some patients with constrictive pericarditis [15]. The diastolic movement usually coincides in timing with the pericardial knock. The precise explanation for this unusual precordial impulse in constrictive pericarditis remains unknown; it has been suggested that the usual outward movement during isovolumic systole is inhibited by the constriction and the outward movement during early diastole becomes accentuated. In patients with severe, long-standing constrictive pericarditis, the precordium may be quiet and no precordial impulse may be palpable or recorded.

Other precordial pulsations — Abnormal pulsations may be appreciated in other areas of the precordium.

●A chronic left ventricular aneurysm can produce systolic motion and an accentuated a wave in unusual locations, such as over the left midprecordium or at left anterior axillary area [16]. This abnormal precordial motion indicates decreased systolic function and compliance of the left ventricle.

●Pulsation in the left second interspace is usually associated with an enlarged pulmonary artery resulting from severe pulmonary arterial hypertension. Pulmonary artery pulsation is also palpable when the pulmonary artery is dilated from a marked increase in pulmonary flow, as in patients with atrial septal defect.

SUMMARY AND RECOMMENDATIONS

●Inspection and palpation of precordial cardiovascular pulsations are generally best performed with patients supine and with a modest elevation of the head and chest (not over 45°). Inspection and palpation are complementary since some precordial movements (such as inward pulsation) are best identified by inspection (including observation of the palpating hand) while other movements (outward pulsation) are best identified by palpation. (See 'Introduction' above.)

●A slight abrupt inward pulsation normally can be seen over the left ventricular apex at the fifth intercostal space in the left parasternal area, particularly in children and thin chested subjects. (See 'Inspection' above.)

●Cardiac pulsations that are visible lateral to the left midclavicular line usually suggest cardiac enlargement. Leftward cardiac displacement may also cause visible pulsation beyond the midclavicular line. (See 'Inspection' above.)

●The left ventricular apical impulse is normally localized to the fourth or fifth left intercostal space just medial to the left midclavicular line, and is no more than 2 to 3 cm in diameter. (See 'Left ventricular impulse' above.)

●A hyperdynamic apical impulse is found in conditions associated with an increased stroke volume or volume overload in the absence of significant left ventricular hypertrophy or depressed ejection fraction. Examples include after exercise in normal subjects, in hypermetabolic states, in primary mitral regurgitation, in aortic regurgitation with normal left ventricular function, and in some patients with a large patent ductus arteriosus and ventricular septal defect. (See 'Left ventricular impulse' above.)

●A sustained apex impulse is usually found when there is significant left ventricular hypertrophy. A sustained impulse is also appreciated when left ventricular systolic function (ejection fraction) is depressed, as in patients with dilated cardiomyopathy, ischemic heart disease, and aortic regurgitation associated with depressed left ventricular function. (See 'Left ventricular impulse' above.)

●Normally, an inward movement of the right ventricle (systolic retraction) is appreciated by palpation of the lower left parasternal area. A prolonged left parasternal upward or outward movement, palpable throughout systole, is abnormal and is a sign of right ventricular hypertrophy. (See 'Right ventricular impulse' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges the late Kanu Chatterjee, MD, who contributed to an earlier version of this topic review.