American Heart

Association~
Fighting Heart Disease
and Stroke

Examination of the
Precordimn: Inspection
and Palpation
Examination of the Heart
Part3
Examination of the Heart ~rt 3
Examination of the Precordium:
Inspection and Palpation

Prepared on behalf of the

Council on Clinical Cardiology
of the American Heart Association

Robert C. Schiant, MD
Professor of Medicine (Cardiology)
Emory University School of Medicine
Chief of Cardiology
Grady Memorial Hospital
Atlanta, Georgia

J. Willis Hurst, MD
Candler Professor of Medicine (Cardiology)
Emory University School of Medicine
Atlanta, Georgia
 Contents

2 Inspection
Examination of the Heart 3 Palpation
A Series of Booklets
12 Area 1: Sternoclavicular
Part 1 13 Area 2: Aortic
The Clinical History 14 Area 3: Pulmonic
Mark E. Silverman, MD 15 Area 4: Left ParasternaI -- Right Ventricular or Tricuspid
17 Area 5: Apical
Part 2
Inspection and Palpation of 21 Diastolic Event: Palpable Third Heart Sound
Venous and Arterial Pulses 21 Diastolic Event: Palpable Fourth Heart Sound
Michael H. Crawford, MD 23 Area 6: Epigastric
24 Area 7: Ectopic
Part 3
Examination of the Precordium: 25 Characteristic Precordial Abnormalities in Selected Cardiovascular
Inspection and Palpation Abnormalities
Robert C. Schlant, MD, and J. Willis Hurst, MD 25 Coronary Artery Disease
25 Dilated Cardiomyopathy
Part 4
Auscultation of the Heart 25 Hypertrophic Cardiomyopathy
James A. Shaver, MD, James J. Leonard, MD, 25 Aortic Stenosis
and Donald F. Leon, MD 27 Aortic Regurgitation
27 Chronic Mitral Regurgitation
Part 5
The Electrocardiogram 27 Mitral Stenosis
Masood Akhtar, MD 27 Atrial Septal Defect
28 Percussion Versus Inspection and Palpation
Available from your local American Heart Association
29 Inspection and Palpation in Perspective
31 Suggested Reading

©1972, 1978, 1990 American Heart Association

 The study of cardiovascular pulsations on the anterior surface of the
chest yields important diagnostic clues. The results of inspection and
palpation have been correlated with graphic recordings, accurate hemody-
namic studies at cardiac catheterization, angiographic and echocardiographic
studies, and surgical and autopsy findings. Consequently, inspection and
palpation of cardiovascular pulsations of the anterior chest have a solid
scientific basis.
As with other techniques of cardiovascular diagnosis, the value of
inspection and palpation depends on an understanding of basic cardio-
vascular physiology, the degree of skill achieved by the examiner, and the
ability to integrate findings with history and data obtained by other portions
of the physical examination, chest x-ray, and diagnostic laboratory proce-
dures. This publication describes techniques of inspection and palpation
of the precordium as well as physiologic and diagnostic implications
derived from this examination.
Inspection Palpation

Inspection of the chest may reveal visible abnormalities of the bony Pain, rarely with swelling, and tenderness may be present in the
thorax or skin. The patient may have a barrel-shaped chest with an costochondral or chondrosternal joints (Tietze’s syndrome) or the
increased anterior-posterior diameter, a straight-back syndrome, pectus xiphosternal joint. At times, palpation of these areas may reproduce the
excavatum with a depressed sternum, pectus carinatum (pigeon chest with exact chest pain that the patient is experiencing. Palpation may also reveal
a protruding sternum), kyphoscoliosis, or ankylosing spondylitis. Each may tender superficial veins of the anterior chest (Mondor’s disease), a rare
produce cardiac abnormalities. cause of chest pain. Patients with coarctation of the aorta may have
Patients with congenital heart disease may have a prominence of the palpable collateral vessels in the posterior intercostal spaces.
anterior chest that is frequently asymmetrical. It has been observed that in It is important for the examiner to realize that certain precordial
some patients with biventricular hypertrophy, the entire left precordium movements are seen and others felt. In general, outward movements are
moves anteriorly during systole. In patients with an abnormally prominent best discerned by palpation, whereas inward movements are usually more
apical impulse and in some thin, normal individuals, the apical impulse or
apex beat can be seen. In these patients, one may also occasionally see
movements or low-frequency vibrations associated with the atrial
contribution to ventricular filling (a fourth heart sound [$4] or atrial gallop)
just before the first heart sound ($1), or the wave produced at the time of
rapid filling during ventricular filling (a third heart sound [$3] or ventricular
gallop) at the end of the first third of diastole. A patient with coronary
artery disease and a large dyskinetic ventricular aneurysm may have a
visible late systolic bulge either at the apex or in an ectopic area, usually
located either medial and superior or lateral to the apical impulse.

Figure 1. Palpation of apical impulse with patient’s thorax elevated 30°. tt is frequently
necessary to wait several seconds for small discrete impulses to become apparent. At other
times, entire hand is moved by large anterior lift of precordium. Timing of impulses can be
accomplished by simultaneous auscultation of heart or, as shown, by simultaneous
palpation of right carotid artery.

2 3
easily seen than felt. The palpating hand should also be carefully
observed for motion that may be seen but not felt.
In general, inspection and palpation of the anterior chest is best
performed with the patient lying flat in the supine position or, more often,
with the upper trunk elevated 30° with the examiner on the right side of
the patient. In most instances, palpation is more precise with the right
hand (Figure 1). Patients with suspected cardiovascular disease should
also be examined in the left lateral decubitus position., rotated 45o-90°
(Figure 2). In this position, the normal apical impulse may be displaced
1-5 cm and may appear more prominent and sustained. Accordingly, the
normal range for the character of the apical impulse differs somewhat
when the patient is in the left lateral position. Often, the apical impulse
and other palpable events such as a palpable $3 (rapid filling wave) or $4
(atrial [a] wave) may be felt only in this position.
The apical impulse may first be located in the left lateral position, then
the patient can be rotated to the supine position for additional study. It is

Figure 3. Palpation by placing right hand on left and applying pressure with right to feel
impulses that are weak or small or both.

also occasionally useful to palpate the patient in the sitting or upright

position, particularly to determine the location of the apical impulse. When
the apical impulse cannot initially be seen or felt, it may be possible to
discern an impulse under a rib by pressing the right hand on top of the
left hand, which is placed on the chest (Figure 3). Light pressure of the
fingertips is best for brief, faint pulsations such as a palpable $3 or $4 or a
bifid apical impulse (Figure 4).

Figure 2. Palpation of apical impulse and precordium with patient in left lateral position.
Frequently, examination in this position reveals impulses not readily detected when patient
is supine. Location and duration of apical impulse are frequently altered (see text).

5
4
Figure 4. Examination of apical impulse with fingertips. This technique allows accurate
evaluation of very small impulses, such as those associated with third ($3) or fourth ($4)
heart sound.
Pulsations of the anterior chest are more easily visualized when the
examiner uses tangential light to look at the surface of the chest so that
movements inscribe a maximal arc to the examiner’s eye. Motions of the
apical impulse can often be amplified by using a thin applicator stick (or
tongue blade or light pencil) to act as a fulcrum; however, care must be
taken not to produce an artificial $3 or rapid filling wave (Figure 5). At
times, the motion of the head of the stethoscope on the chest wall will
reflect underlying pulsations. Pulsations should be examined at the end of
normal expiration or occasionally after forced expiration. In special
situations, however, they may be better seen during inspiration, for
example, when there is an increase in pulmonary artery pulsations due to
pulmonary hypertension.
6 7
Figure 5. Use of applicator stick to magnify precordial impulses for study. Care must be
taken to avoid artifacts.
Frequently, it is possible to feel heart sounds and heart murmurs.
Vibrations or precordial shocks associated with the loud $1 and the
opening snap of mitral stenosis, the loud aortic component (A2) of the
second heart sound ($2) of systemic arterial hypertension, and the loud
pulmonic component (P2) of the $2 of pulmonary hypertension may be
palpable. Ejection clicks and pericardial knocks can also be palpated. $3,
or rapid filling waves, and $4 vibrations, or a waves, can often be seen or
felt, frequently when they cannot be heard. Patients with a short PR
interval are less likely to have a visible or palpable $4 impulse or a wave.
 Figure 7. Palpation of precordium for evaluation of left parasternal impulses and thrills using
firm pressure through distal palm. At times, thrills and impulses may be better detected with
this technique than with heel of palm.
Figure 6. Palpation of precordium for evaluation of left parasternal impulses and thrills
using firm pressure from heel of palm. In most instances, it is preferable for patient to hold
full expiration. Amount of pressure should be varied to permit detection of different types
of impulses.

Thrills are palpable vibrations from murmurs or bruits ordinarily

associated with grade 3/6 and usually grade 4/6 murmurs or louder. The
location of a thrill often helps localize the origin of a loud murmur. Thrills
are best felt with the fingertips or firm pressure from either the proximal
heel (Figure 6) or distal palm (Figure 7) of the hand at the base of the
fingers. At times, thrills are better felt during held end expiration with
moderate pressure from the right hand on top of the left hand, which is
placed on the chest (Figure 8). At other times, thrills and some impulses
are better felt with the palm of the examining right hand over the
precordium and the left hand supporting the posterior thorax with an
equal amount of force (Figure 9).

Figure 8. Examination of precordium with right hand on left to detect cardiac thrills and
impulses. Pressure should be applied only with right hand.

8
9
 1. Sternoclavicular Area 5. Apical Area
Figure 9. Examination of precordium with patient in upright position. Examiner uses firm 2. Aortic Area 6. EpigastricArea
pressure from right hand to precordium and uses left hand to support thorax posteriorly. 3. Pulmonic Area 7. EctopicAreas
Occasionally, impulses or thrills are more readily felt with this technique. 4, Right Ventricular Area (location variable)
Figure 10. Seven areas to be examined for abnormal cardiovascular pulsations by
Once pulsations are identified, the exact point in the cardiac cycle in inspection and palpation.
which they occur must be determined. This is most effectively accomplished
by correlating the waves of the pulsations with heart sounds or carotid
artery pulsations or both. It is often necessary to see or feel a pulsation
while simultaneously listening to heart sounds or feeling the carotid artery.
Seven areas of the anterior chest should be examined for abnormal
cardiovascular pulsations by inspection and palpation (Figure 10). These
include the sternoclavicular, aortic, pulmonic, right ventricular, apical (left
ventricular), epigastric, and ectopic (variable location) areas.

10 11
Area 1: Sternoclavicular Area 2: Aortic

It may be possible to feel vibrations of the aortic component (A2) (Figure

The sternoclavicular area (Figure 10) includes the right and left sterno- 10) of the $2 when they are accentuated, as in arterial hypertension.
clavicular joints as well as the manubrium and the upper portion of the Patients with valvular aortic stenosis frequently have a palpable thrill in the
sternum. Normally, very little pulsation is noted in this area. In patients second right intercostal space near the sternum. This thrill may also be
with aortic regurgitation, a slight, quick pulsation of a sternoclavicular joint felt in the first and third right interspaces next to the sternum and will
or the manubrium may be present. Abnormal pulsations and movements frequently radiate in an upward direction toward the right side of the neck
are commonly produced by enlargement, dilatation, or diseases of the and to the suprasternal notch and right supraclavicular area. Less
aorta, particularly aortic dissection, atherosclerotic aneurysm, or syphilitic frequently, the thrill may be felt at the second or third left interspace next
aneurysm. Examination for pulsations is especially important in patients to the sternum or at the apex.
who have experienced chest pain since an abnormal pulsation of a sterno- Abnormal systolic pulsations in the aortic area may be produced by
clavicular joint may be an early clue to diagnosis of aortic dissection. dilatation of the ascending aorta due to various types of aneurysms or by
Occasionally, it is possible to suggest the diagnosis of a right-sided aortic dilatation of the ascending aorta due to chronic aortic regurgitation.
arch from the finding of a slight pulsation in the right sternoclavicular joint
region. Tetralogy of Fallot is the most common congenital lesion associated
with a right-sided aortic arch. Pulsation of the right sternoclavicular joint is
also occasionally noted in older patients with a tortuous innominate artery.
A kinked, tortuous right carotid artery may cause a visible and palpable right
supraclavicular or suprasternal pulsation. Dilatation and tortuosity of other
brachiocephalic vessels may produce visible and palpable pulsations in
the suprasternal notch or the supraclavicular areas. Aortic enlargement or
aneurysm may also produce a visible and palpable systolic impulse in the
suprasternal notch or the first or second right intercostal space near the
sternum.

13
12
Area 3: Pulmonic
Vibrations associated with a loud pulmonic component (Figure 10) of the
$2 are often palpable in patients with pulmonary hypertension from any
cause. In some patients, it is possible to palpate splitting of the $2. During
simultaneous palpation of the carotid pulse, a palpable P2 or A2 coincides
with the early downslope of the carotid pulse. A thrill in the second and third
left intercostal space near the sternum may be felt in patients with pulmonary
valve stenosis; occasionally, it may be determined that the thrill seems to
radiate toward the left side of the neck, in contrast to patients with aortic
stenosis, in whom the direction of the thrill appears upward and to the right.
Pulsations of a dilated pulmonary artery may be seen or felt in the
second or third left intercostal space near the sternum. In normal infants
and children or nervous adults with thin chest walls, it may also be possible
to see or feel a slight, brief, early systolic pulsation in this area. The slight
pulsation occasionally found in otherwise normal adults is accentuated by
conditions such as anemia, fever, exertion, hyperthyroidism, or pregnancy.
Idiopathic dilatation of the pulmonary artery may also produce a palpable
systolic impulse in the second or third interspace near the sternal edge.
The most common causes of an abnormal increased and sustained
systolic pulsation or lift in the pulmonary artery area are an increase in
pressure in the pulmonary artery, an increase in flow in the pulmonary
artery, or a combination of the two. In general, conditions associated with
an increase in pressure in the pulmonary artery produce a relatively slow,
sustained, and forceful pulsation of the pulmonary artery. In contrast,
conditions associated with a large flow in the pulmonary artery, such as
atrial septal defect, tend to produce an extremely active and more
vigorous pulsation that is usually less sustained. Valvular pulmonary
stenosis is often associated with poststenotic dilatation of the pulmonary
artery, which may produce a palpable, sustained pulsation in this area,
often with a slow rise of the initial phase.
14
Area 4: Left Parasternal -- Right Ventricular
or Tricuspid
A systolic thrill in the third, fourth, or fifth intercostal space in the
parasternal area to the left of the sternum (Figure 10) is characteristic of
ventricular septal defect, although on occasion tricuspid regurgitation can
also produce a thrill in this area.
The lower left parasternal region normally retracts very slightly during
systole; normally, right ventricular activity is not felt. Slight, gentle outward
pulsations of the lower portion of the sternum and areas lying to the left of
the sternum may occasionally be recorded in normal children and young
adults, in thin adults who have a small anterior-posterior thoracic diameter,
or in patients with pectus excavatum. In some instances, these pulsations
can be felt in the subxiphoid area. As with most other cardiac pulsations,
they are increased by hyperdynamic cardiac function.
Abnormal pulsations of the sternal area and the left parasternal area are
most commonly found in conditions associated with right ventricular
hypertrophy or dilatation. It is often possible to distinguish between a right
ventricular pulsation produced by right ventricular hypertension (pressure
load) and a hyperkinetic pulsation produced by a volume load on the right
ventricle. The pulsation associated with right ventricular hypertension
tends to be more sustained, to persist throughout systole, and to have a
somewhat slower lift than the pulsation produced by a volume load of the
right ventricle, which is associated with a more active and vigorous
pulsation that is often less sustained.
Conditions predominantly producing a pressure load on the right
ventricle include pulmonary stenosis, primary pulmonary hypertension,
severe pulmonary hypertension secondary to a left-to-right shunt (Eisen-
menger physiology), cor pulmonale, mitral stenosis, and chronic left heart
failure. Although isolated valvular pulmonic stenosis is frequently associated
with a sustained anterior precordial lift, Tetralogy of Fallot may not produce
such a movement because the thick right ventricle is not excessively
dilated. In a child with cyanosis, the presence of an anterior lift of the
precordium negates the diagnosis of tricuspid atresia, which character-
istically has a small right ventricle. Atrial septal defect and ventricular
septal defect are two congenital lesions frequently associated with a
volume load on the right ventricle.
15
 The presence of an abnormal systolic anterior lift of the sternal area and
left parasternal area is a sign of severe heart failure when the pulsation is
produced by pulmonary and right ventricular hypertension secondary to
disease on the left side of the heart, such as systemic hypertension, aortic
valve disease, mitral valve disease, or ischemic heart disease.
Moderate or severe mitral regurgitation may produce an abnormal
anterior precordial pulsation even in the absence of left heart failure and
pulmonary hypertension. In this situation, the sternal and parasternal lift
tends to be brisk and occurs with greatest force in late systole. This late
systolic impulse is presumably related to the large jet of blood regurgitated
from the left ventricle into the expanding left atrium, which is centrally
located behind the right ventricle and anterior to the spine.
Conditions associated with a decrease in right ventricular compliance,
such as right ventricular hypertrophy secondary to pulmonary hypertension
from any cause, may be associated with a palpable $4 in this area or,
occasionally, in the epigastric area. A palpable $3 in this area may be
produced by a large right ventricular volume load such as tricuspid
regurgitation or atrial septal defect with a large left-to-right shunt. In
general, however, a palpable left parasternal $3 implies right ventricular
dysfunction or failure. Right ventricular $3 and $4 vibrations may be
augmented during inspiration and may be attenuated or even disappear
during expiration. In general, these vibrations are more difficult to see or
feel than similar events at the apex (left ventricular events).
16
Area 5: Apical
Although the apical area (Figure 10) is sometimes referred to as the
point of maximum impulse or PMI, this terminology is not recommended
since the largest impulse may or may not be located at the apical area.
The following discussion considers the apical impulse without implying
that it is the largest or maximum impulse. The apical impulse is usually
produced by left ventricular and ventricular septal forces; however, in some
patients with marked right ventricular hypertrophy and dilatation, the apical
impulse is predominantly produced by activity of the dilated, hypertrophied
right ventricle.
The location, size, and character (duration, contour or shape, amplitude,
and apparent force) of the apical impulse should be determined. In the
past, the location of the impulse was often the major or only factor consid-
ered, while less attention was paid to the size of the impulse and the
character of apical movements. Proper examination of the apical impulse,
as with virtually all aspects of cardiovascular examination, requires that the
examiner concentrate on one period or phase of the cardiac cycle at a
time and that the examiner correlate the findings with other cardiovascular
events, namely, the heart sounds or the carotid artery pulse or both. Some
children and younger adults and approximately one half of older adults
may not have a palpable apical impulse, particularly obese patients or
those with a barrel-shaped chest, an increase in anterior-posterior chest
diameter due to chronic lung disease, or a heavily muscled chest.
The apical movement and the time relation of its events are described
below as seen and felt at the bedside. Special electronic recording devices
may record diagnostic details of the apical impulse that cannot always be
appreciated at the bedside. The trained physician can readily determine
many aspects (location, size, duration, contour or shape, amplitude, and
apparent force) of the apical impulse and can integrate these findings into
useful information that is immediately available at the bedside.
The normal apical impulse is usually located at or within the left
midclavicular line in the fifth intercostal space in adults. Occasionally, it
may be located lateral to the midclavicular line, for example, in association
with a high diaphragm, pregnancy, marked pectus excavatum, or other
conditions in which a normal heart is displaced to the left. The normal
apical impulse is less than 2 cm in diameter and, in most instances, is
considerably smaller. It is normally located within 10 cm of the sternal
17
midline, or at or within the midclavicular line. The early systolic outward
movement of the apical area is normally produced by isovolumic contraction
of the left ventricle and the counterclockwise rotation and anterior motion
of the heart. It begins at about the same time of the Sl, just before the
upstroke of the carotid pulse. Peak outward motion normally occurs with or
just after blood is ejected into the aorta, then the apex normally moves
inward (Figure 11). The outward movement of the apical impulse, which is
produced by the lower anteroseptal portion of the left ventricle and the
lower interventricular septum, is normally not excessively forceful and is
felt only during early systole (about the first third of systole). The outward
movement can usually be felt to move inward at least by the end of the
first third of systole and to return to baseline by the end of the first two
thirds of systole.
E impulse indicates either marked left ventricular hypertrophy or depressed
A apical impulse laterally and inferiorly.
Figure 11. Normal hyperdynamic and sustained left ventricular impulse. Heart sounds are
also illustrated. A: Normal apex cardiogram. The a wave, related to ventricular filling during
atrial systole, usually does not exceed 15% of total height. E point normally coincides with
beginning of left ventricular ejection. Gradual inward movement follows E point, explaining
brief duration of normal left ventricular impulse. O point coincides approximately with mitral
valve opening. B: Hyperdynamic left ventricular impulse is usually seen in left ventricular
volume overloaded conditions such as primary mitral regurgitation and aortic regurgitation.
Left ventricular ejection fraction is usually normal. Increased amplitude of the a wave may be
associated with palpable a waves, which ordinarily accompany increased left ventricular and
diastolic pressure. Accentuated rapid filling wave is frequently associated with audible third
heart sounds ($3). C: Sustained left ventricular impulse (outward movement continued during
ejection phase) is usually seen in presence of decreased ejection fraction or with marked
hypertrophy of left ventricle. $4, atrial sound; $1, first heart sound; A2, aortic component of
second heart sound; P~, pulmonary component of second heart sound; a, a wave; E, E point
beginning of ejection; OM, outward movement; O, O point; RFVV, rapid filling wave. From
Chatterjee K: Bedside examination of the heart: The physical examination, in Parmley VVW,
Chatterjee K (eds): Cardiology: Physiology, Pharmacology, Diagnosis. Philadelphia, JB
Lippincott, 1988, chap 31, p 17. Reproduced with permission.
18 19
The apical impulse may be hyperkinetic or hyperdynamic with increased
amplitude in normal individuals who have a thin chest wall, a flat chest, or
a depressed sternum. Lying on the left side may also cause a normal
apical impulse to have increased amplitude and duration. A hyperdynamic
apical impulse of increased amplitude and forcefulness may also be found
in anxious children or patients with anemia, anxiety, tachycardia, fever,
exertion, or hyperthyroidism. A hyperkinetic but not displaced apical
impulse may also occur in patients with a mild to moderate volume load
on the left ventricle from mitral or aortic regurgitation without significantly
decreased left ventricular systolic function. All these conditions may also
produce an increase in force and amplitude and a mildly sustained apical
impulse, although the prolongation is often less than two thirds of systole
when determined by palpation. The apical impulse is more sustained
when mitral or aortic regurgitation is more severe or when left ventricular
systolic function is decreased. In general, a markedly sustained apical
left ventricular systolic function. Left ventricular dilatation displaces the
Concentric left ventricular hypertrophy without an increase in left
ventricular cavity size may occur in systemic hypertension, valvular aortic
stenosis, and hypertrophic cardiomyopathy. Characteristically, the apical
impulse is not displaced but is both abnormally forceful and sustained. An
$4 vibration may be palpable or visible or both.
If left ventricular dilatation occurs, the apical impulse may be larger than
normal and laterally displaced. Marked left ventricular dilatation may
displace the apical impulse laterally and inferiorly and cause a significant
increase in size. Conditions that may be associated with marked left
ventricular dilatation include aortic regurgitation, mitral regurgitation, patent
ductus arteriosus, and dilated cardiomyopathy. The duration of the apical
impulse is sustained in patients with left ventricular systolic dysfunction,
particularly when associated with marked left ventricular dilatation.
Complicated, end-stage coronary heart disease and systemic hypertension
can also produce severe left ventricular dilatation in some patients.
Valuable information about relative amounts of ventricular hypertrophy
and ventricular dilatation can be obtained from the apical impulse. Thus, in
pure valvular aortic stenosis, which is characterized by marked concentric
hypertrophy of the left ventricle with little or no dilatation of the left ventric-
ular cavity, the apical impulse is characteristically small but forceful and
sustained. The impulse is not displaced and is often located within the
midclavicular line. A presystolic $4 is often palpable at the apex. In contrast,
severe aortic regurgitation, which is associated with massive dilatation of
the left ventricle in addition to considerable eccentric hypertrophy, produces
a diffuse apical impulse that has increased force, duration, and amplitude
and is usually significantly displaced laterally and inferiorly. The duration of
the apical impulse tends to be prolonged with a greater volume of
regurgitation and decreased ejection fraction and left ventricular function.
At times, patients with acute myocardial infarction may develop a
sustained apical impulse that mimics left ventricular hypertrophy. Some
patients develop mitral regurgitation secondary to a myocardial infarction,
often secondary to papillary muscle dysfunction and sufficient to result in
left ventricular dilatation and hypertrophy with a displaced and sustained,
forceful, large apical impulse. Other patients may have an area of left
ventricular dyskinesia that results in a functional aneurysm that may
produce a late systolic bulge at the apical impulse. Occasionally, this is the
cause of a palpable bifid apical impulse. In other patients, a late systolic
bulge may be palpable in an ectopic area between the apical impulse and
the left parasternal area. Rarely, it may be felt lateral to the apical impulse,
near the anterior ancillary line.
Other causes of a bifid apical impulse during systole include marked left
ventricular dilatation and hypertrophy (as in combined aortic stenosis and
regurgitation), in which the apical impulse may be displaced with a
"rocking," bifid character. Occasionally, patients with hypertrophic
obstructive cardiomyopathy (idiopathic hypertrophic subaortic stenosis)
may have a forceful, sustained impulse with a bifid character due to a
barely perceptible notch in midsystole, corresponding to a similar notch in
the carotid arterial pulse (pulsus bisferiens). Rarely, a faint systolic notch or
vibration is palpable in the apical impulse of patients with mitral valve
prolapse at the moment of nonejection midsystolic click. Systolic retraction
of the apical impulse usually signifies either constrictive pericarditis or
severe tricuspid regurgitation with marked right ventricular dilatation. A
systolic thrill in the apical area is most commonly produced by mitral
regurgitation and is often diffuse, whereas a diastolic thrill is most
commonly produced by mitral stenosis and is usually localized to a small
area at the apex.
Inspection and palpation of the apical impulse during diastole may also
reveal significant and clinically useful abnormalities.
2O
Diastolic Event: Palpable Third Heart Sound
During early diastole, brief outward chest wall movements corresponding
to a left ventricular gallop sound (rapid filling wave), left ventricular filling
sound, or $3 may occasionally be seen or felt, even if vibrations are not
heard with a stethoscope. In children and young adults, the presence of
an early diastolic ventricular filling sound ($3) and movement is usually
normal. On the other hand, development of such a movement or sound
(left ventricular gallop) in a sedentary adult or a patient with heart disease
usually signifies an elevation of left ventricular diastolic pressure and
volume and ventricular failure, often with a decreased ejection fraction.
Patients with acute transmural myocardial infarction or transient myocardial
ischemia during angina pectoris frequently develop a transient palpable
and audible ventricular filling $3 or gallop, which reflects the acutely
decreased ventricular compliance. This is usually associated with some
degree of left ventricular systolic dysfunction, although overt ventricular
failure may not be present. A palpable $3 may be present in patients with
left ventricular failure from any cause, including dilated cardiomyopathy,
coronary heart disease, systemic arterial hypertension, or valvular heart
disease. On the other hand, hemodynamic systolic ventricular failure is not
always present when a ventricular gallop occurs in the presence of volume
loading and dilatation of the left ventricle, such as mitral regurgitation,
aortic regurgitation, anemia, hyperthyroidism, peripheral arteriovenous
fistula, patent ductus arteriosus, or ventricular septai defect.
Diastolic Event: Palpable Fourth Heart Sound
During late diastole, immediately before the $1, the left atrial contribution
to the apical impulse--referred to as the atrial impulse or a wave--may
be detected. In most instances, a palpable atrial impulse coincides with an
audible atrial gallop sound, a wave, or $4. In most instances, the finding is
associated with increased end-diastolic pressure and decreased
compliance of the left ventricle. Some vibrations may also be produced by
the heart striking the chest wall. In general, an $4 is not palpable in
normal children or young adults. A palpable atrial impulse ($4) at the apex
with its associated sound may be found in some normal adults if the PR
interval is long and circulation is hyperdynamic. The presence of such an
a wave or $4 sound may have no significance if there is no other evidence
of heart disease. On the other hand, these findings may have
considerable significance in certain circumstances. For example, in some
patients with ischemic heart disease, a palpable $4 at the apex may
21
 develop or become more prominent during an attack of angina pectoris or
even during exertion without chest pain. An atrial gallop or a palpable Area 6: Epigastric
atrial impulse ($4) or both occurs frequently in patients with acute trans-
mural myocardial infarction and reflects the altered compliance of the left
ventricle. A prominent and palpable atrial impulse, usually with an audible
atrial gallop sound, is frequently associated with conditions producing a
decrease in left ventricular compliance and increased end-diastolic
pressure, particularly aortic stenosis, systemic arterial hypertension, hyper- Some normal individuals have visible or palpable pulsations of the aorta
trophic cardiomyopathy, coarctation of the aorta, and coronary heart disease. in the epigastric area (Figure 10). In addition, hyperactive cardiac activity
In a patient with mitral valve disease, the presence of a palpable atrial
due to fever, anemia, or thyrotoxicosis may produce pulsations.
impulse or atrial gallop ($4), a palpable ventricular filling sound or
Abnormally large pulsations of the aorta may be produced by an aortic
ventricular gallop ($3), or an abnormally sustained apical impulse is aneurysm or aortic regurgitation. Hepatic movements may be identified in
evidence against the diagnosis of pure significant mitral stenosis and the epigastric area, particularly in patients with tricuspid regurgitation,
suggests the presence of significant left ventricular disease. tricuspid stenosis, or marked right ventricular dilatation, hypertrophy,
A double, or bifid, apical impulse may be present in various circum- and hyperactivity.
stances, most commonly in the combination of an outward movement In some patients with cor pulmonale as a result of emphysema, right
during ventricular systole and a second outward pulsation during diastole. ventricular hypertrophy may not be detected by examining the anterior
The diastolic impulse may occur during either early diastole ($3) or late precordium since.the shape of the chest often conceals the enlarged right
diastole or presystole ($4). An impulse occurring in early diastole at the ventricle. To examine for abnormal pulsations of the right ventricle in
end of the phase of rapid ventricular filling corresponds to an audible patients with emphysema, the palm of the right hand should be placed on
ventricular gallop, $3, or left ventricular filling sound. An impulse during the epigastric area and moved cephalad while gently sliding the fingers
late diastole is related to atrial systole and corresponds to an a wave of the under the rib cage. This makes it possible to detect aortic events on the
apexcardiogram, the atrial contribution to ventricular filling, and an atrial palmar surface of the fingers, while pulsations due to right ventricular
gallop or $4.
hypertrophy can be felt in the fingertips.
A bifid apical impulse with two impulses, both occurring during ventric-
ular systole, may take place in certain conditions, notably, hypertrophic
obstructive cardiomyopathy (idiopathic hypertrophic subaortic stenosis),
complete left bundle branch block, or myocardial infarction with a dyskinetic
or functional aneurysm involving the apical area of the left ventricle and
producing a late systolic bulge. If these patients also develop a palpable
impulse during either early ($3) or late ($4) diastole, it may be possible to
see and feel a triple or trifid apical impulse. When these patients develop
both a palpable ventricular gallop or $3 in early diastole and a palpable
atrial gallop or $4 in late diastole, it may be possible to see and feel a
quadruple apical impulse. In general, however, it is rare to feel more than
two impulses, although three or four impulses can be recorded in these
clinical situations.
The finding of systolic retraction of the apical impulse suggests either
marked tricuspid regurgitation with right ventricular hypertrophy or
constrictive pericarditis. Patients with mitral valve prolapse occasionally
have a brief, palpable, inward motion of the apical impulse during systole
that corresponds to the systolic click heard on auscultation.

22 23
Area 7: Ectopic
Occasionally, cardiac pulsations are encountered in areas other than
those previously described; that is, between the pulmonary and apical
areas (Figure 10). Ischemic heart disease is the most common cause of
an ectopic systolic pulsation. When a patient is experiencing an attack of
angina pectoris, it may be possible to see or feel an abnormal outward
pulsation of the anterior chest during systole. The abnormal pulsation is
presumably related to a paradoxical systolic outward bulging of the
ischemic area of the heart. Occasionally, similar paradoxical outward
bulging during systole is detected after acute myocardial infarction. The
abnormal pulsation associated with acute myocardial infarction may
persist, but in the majority of patients, disappears within a few weeks. A
persistent paradoxical ectopic pulsation may also be found in patients who
develop a true anatomic ventricular aneurysm after a myocardial infarction.
It should be noted that the paradoxical bulging of the ventricle produced
by ischemic heart disease, whether acute or chronic, may also occur at
the apical area. When this occurs, the combination of an otherwise normal
apical impulse and the late systolic ectopic pulsation or late systolic bulge
may merge and simulate the sustained, forceful apical impulse of left
ventricular hypertrophy.
Ectopic pulsations on the anterior chest wall can also be found in
patients with cardiomyopathies of varying etiologies. In patients with severe
mitral regurgitation and a giant left atrium that extends to the right, an
ectopic systolic pulsation of the left atrium may occasionally be felt in the
right anterior or lateral chest or the left axilla.
24
Characteristic Precordial Abnormalities in
Selected Cardiovascular Abnormalities
(Figure 12)
Coronary Artery Disease
Palpation of the precordium is usually normal in most patients with
coronary artery disease unless there is associated disease such as
systemic arterial hypertension or the patient has had a myocardial
infarction. During attacks of angina, however, there may be a palpable $3
or S,~ and, occasionally, a palpable ectopic impulse. Patients with previous
infarction may have a persistent abnormal late systolic impulse or bulge
located at the apex or an ectopic area.
Dilated Cardiomyopathy
There may be a diffuse, generalized, outward impulse of the entire left
precordium and the sternum, and ectopic impulses may be palpated. The
apical impulse is characteristically displaced, forceful, enlarged, and
sustained. Visible and palpable $3 and S,~ vibrations are common.
Hypertrophic Cardiomyopathy
There may be a palpable thrill at either the apex or medially and
superiorly to the apical impulse. The apical beat is forceful and sustained
but may not be displaced laterally. A palpable S,~ is usually present and
may be visible. When the sustained apical impulse is bifid, due to a brief
midsystolic inward motion, the apical impulse may have three palpable
components produced by the palpable S,~ in presystole and the bifid
impulse during systole, producing a "triple ripple." Rarely, an $3 is also
palpable in early diastole, producing a quadruple impulse.
Aortic Stenosis
A systolic thrill may be felt in the first or second right intercostal space
or in the second and third left intercostal spaces at the sternal edge.
Occasionally, the thrill is felt at the apex. The thrill may radiate upward
above the clavicle and the suprasternal notch into the right carotid artery.
The apical impulse is forceful and sustained but usually not displaced or
large unless left ventricular dilatation is also present. An S,~, a wave, is
often visible and usually palpable if the obstruction is significant.
25
 Graphic
Representation
Aortic Regurgitation
(palpable features Location and The apical impulse is usually laterally and inferiorly displaced. It is
Type of movement in heavy line) accompanying features
NORMAL ADULT Cardiac apex. hyperdynamic with increased force and size but is only mildly prolonged if
Moderate systolic thrust. A and F regurgitation is mild or moderate and if left ventricular systolic function is
waves usually imperceptible. good. The apical impulse is significantly sustained if there is severe
regurgitation or left ventricular systolic dysfunction. Visible and palpable $3
and $4 vibrations may be present. Occasionally, the diastolic murmur is
HYPERKINETIC loud enough to produce a thrill that is palpable along the lower left sternal
Normal child Exaggerated thrust at cardiac border. The presence of a palpable or audible $3 in patients with aortic
Thyrotoxicosis apex. Fwave maybe palpable, regurgitation may indicate reduced left ventricular ejection fraction.
Mitral regurgitation coincident with third heart sound.
Anemia
Right SIDED HYPERKINETIC Same as above Maximal at left sternal edge in third Chronic Mitral Regurgitation
IMPULSE and fourth intercostal spaces.
SUSTAINED LEFTVENTRICULAR The apical impulse is usually laterally displaced and is hyperdynamic
HYPERTROPHY, as in with increased size and force. When regurgitation is severe, the apical
Aortic stenosis Maximal at cardiac apex. ~,’ wave impulse is sustained and may be quite large.~At times there is an impulse
Hypertension may be visible and palpable
Insert: a variation that may occur coincident with fourth heart sound. or lift of the entire left precordium. Patients with pulmonary hypertension
in hypertrophic may have a holosystolic sternal or parasternal heave or impulse. A late
cardiomyopathy.
RIGHT VENTRICULAR Same impulse as Maximal at left sternal edge in third systolic impulse may be felt in the sternal or left parasternal area in some
HYPERTROPHY in "Sustained" and fourth left intercostal spaces. patients without pulmonary hypertension. A systolic thrill palpable at the
above apical area or in the left axilla may be present. An $3 may be visible and
ECTOPIC LEFT VENTRICULAR Same impulse as Maximal over mid precordium palpable at the apical area. A visible or palpable $4 suggests mitral
IMPULSE in "Sustained" rather than at apex.
Ventricular aneurysm above regurgitation is of recent onset.
MITRAL REGURGITATION ’ ~ Whole precordium
(severe) (see text). Mitral Stenosis
A diastolic thrill may be felt at the apical area, especially with the patient
PULMONARY ARTERIAL Second left intercostal space. Note in the left lateral decubital position. The apical impulse is impalpable or
PULSATION palpable P2.
in pulmonary hypertension small. Characteristically, it is neither displaced nor forceful. Vibratory
shocks produced by the loud $1 and opening snap may be palpated. The
INWARD MOVEMENT DURING Whole precordium. Note reversal $2 may have a palpable P2 and a holosystolic left parasternal lift or heave
SYSTOLE of direction during systole as
Constrictive pericarditis compared with preceding if right ventricular and pulmonary hypertension are present.
Tricuspid regurgitation, pure examples.
Atrial Septal Defect
DIASTOLIC MOVEMENTS Cardiac apex.
Cardiomyopathy Systolic movement may be The impulse in the left parasternal and sternal areas is hyperdynamic
Inconspicuous. Diastolic
movements F and A correspond to and may be sustained if the shunt is large or if pulmonary hypertension is
3rd and 4th sound gallops which present. An impulse from the dilated pulmonary artery may be felt in the
may merge in tachycardia to form
a summation sound. second or third intercostal space near the sternal edge. The prominent P2
Figure 12. Graphic representation of apical movements in health and disease. Heavy line
of the $2 may be palpable. Occasionally, both components of the widely
indicates palpable features. P2, pulmonary component of second heart sound; A, atrial split $2 are palpable. The apical impulse is usually not remarkable but
wave, corresponding to fourth heart sound ($4) or atrial gallop; F, filling wave, corresponding may be abnormally sustained when it is produced by a markedly dilated
to third heart sound ($3) or ventricular gallop. From Willis P IV: Inspection and palpation of right ventricle.
the precordium, in Hurst JW (ed): The Heart, ed 7. New York, McGraw-Hill Book Co, 1990, p
164. Reproduced with permission.
 Percussion Versus Inspection and Palpation Inspection and Palpation in Perspective

When performed by a skilled examiner, percussion of the heart can

provide an estimate of cardiac size and shape. Even so, however, Although inspection and palpation of the anterior surface of the chest
percussion of the heart only gives information about the location of the may reveal information about the cardiovascular system not obtained from
borders of cardiac dullness. On the other hand, inspection and palpation auscultation or electrocardiographic, echocardiographic, or radiologic
of cardiac pulsations not only provide information about the location of the examination, it should be emphasized that the results of inspection and
outer limits of cardiac pulsations but also enable determination of the size palpation must be correlated with the patient’s history, the remainder of the
and character of pulsations, from which considerable anatomic and physical examination, the chest x-ray film, and other special procedures.
physiologic information is obtained.
Although some physicians have stated that percussion enables
diagnosis of pericardial effusion, percussion has limited value when the
results are objectively correlated with the diagnosis as determined by
cardiac catheterization, echocardiography, angiography, pericardiocentesis,
and exploratory pericardiotomy. Conversely, an abnormally large and
sustained apical impulse in a patient in whom pericardial effusion is
suspected indicates that the heart itself is abnormal, regardless of excess
fluid in the pericardial cavity.

28
29
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36
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