| Aortic regurgitation |
| Apex impulse hyperdynamic in mild to moderate AR |
| Severe AR: LV dilatation results in sustained impulse that is displaced laterally and downward (especially in chronic AR) |
| Systolic retraction medial to PMI |
| Palpable a wave may be present |
| Mitral regurgitation |
| Apical systolic thrill in severe MR |
| Apex impluse hyperdynamic |
| Severe and/or chronic MR; impulse is sustained and laterally displaced |
| Can have late parasternal impulse with severe MR without pulmonary hypertension |
| Parasternal (RV) heave if significant pulmonary hypertension |
| S3 visible and palpable if severe MR |
| S4 palpable with acute onset MR |
| Congestive cardiomyopathy |
| Sustained and displaced LV impulse, usually felt over 2 interspaces |
| Palpable a wave (S4) and S3 common |
| Parasternal lift, midsystolic bulge common |
| Coronary artery disease |
| Usually normal at rest unless prior MI |
| Palpable S4 in left decubitus position |
| Ectopic LV thrust if dyssynergy or LV aneurysm. May have transient abnormalities (eg, bulge, heave) during acute infarction or attack of angina. |
