3-11 2 3 J 1—H-1-+—+-
Cardiac ape*; systolic movement may be inconspicuous; diastolic movements. F and A correspond to 3rd and 4tli heart sounds. which may merge in tachycardia tu torn a Aummatirtn qslinp
Figure 10-61: Graphic representation of apical movements in health and disease. Heavy line indicates palpable features. P2, pulmonary component of second heart sound; A, atrial wave, corresponding to a fourth heart sound (S4) or atrial gallop; F, filling wave, corresponding to third heart sound (S3) or ventricular gallop. (From Willis P IV. Inspection and palpation of the precordium. In: Hurst JW, ed. The Heart, 7th ed. New York: McGraw-Hill; 1990:164. Reproduced with permission from the publisher and author.)
AREA 1: STERNOCLAVICULAR AREA PULSATIONS
The sternoclavicular area (see Fig. 10-60) includes the right and left sternoclavicular joints, the manubrium, and the upper sternum. Usually, no pulsation is noted in this area. A slight, brief systolic pulsation of a sternoclavicular joint or the manubrium may be due to aortic regurgitation. Abnormal pulsations and movements in the sternoclavicular area are commonly produced by enlargement, dilatation, or diseases of the aorta, particularly aortic dissection, atherosclerotic aneurysm, or syphilitic aneurysm. An abnormal pulsation of a sternoclavicular joint in patients with chest pain may be an early clue to diagnosis of aortic dissection. A slight pulsation in the right sternoclavicular area may suggest a right-sided aortic arch in patients with cyanotic heart disease, particularly tetralogy of Fallot.204 A kinked, tortuous right carotid artery or dilatation and tortuosity of other brachiocephalic vessels may produce visible and palpable pulsations in the suprasternal notch or the supraclavicular areas.
AREA 2: AORTIC AREA PULSATIONS
Vibrations of the aortic component (A2) of the second heart sound may be palpated when they are accentuated, as in arterial hypertension. With valvular aortic stenosis, a systolic thrill is present frequently in the second and less commonly in the first and third right intercostal spaces near the sternum (see Fig. 10-60). It often radiates upward toward the right side of the neck and to the suprasternal notch and right supraclavicular area. Less frequently, the thrill is palpable at the second or third left interspaces next to the sternum or at the apex. A systolic thrill in the aortic area and in the right carotid artery also can occur in patients with severe aortic regurgitation without stenosis. Abnormal systolic pulsations in the aortic area may be due to dilatation of the ascending aorta due to aneurysm and/or chronic aortic regurgitation.
AREA 3: PULMONIC AREA PULSATIONS
Vibrations associated with a loud pulmonic component of S2 (see Fig. 10-60) often are palpable in patients with pulmonary hypertension from any cause. During simultaneous palpation of the carotid pulse, a palpable P2 or A2 coincides with the early downslope of the carotid pulse. A systolic thrill in the second and third left intercostal spaces near the sternum often occurs with pulmonic valve stenosis. The thrill often radiates toward the left side of the neck, in contrast to the thrill with aortic stenosis, which radiates 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 anxious adults with thin chest walls, a slight, brief, early systolic pulsation may be present in this area. This pulsation is accentuated by conditions that cause an increased cardiac output (e.g., fever, pregnancy). Idiopathic dilatation of the pulmonary artery also may cause a palpable systolic impulse in the same area.205
The common causes of an accentuated and sustained systolic pulsation in the pulmonary artery area are pulmonary hypertension, increased pulmonary blood flow, and their combination. In general, pulmonary hypertension causes a relatively slow, sustained, and forceful pulmonary artery pulsation, whereas a large pulmonary blood flow (e.g., ASD) produces an extremely active, more vigorous, but less sustained pulsation. Valvular pulmonary stenosis with poststenotic dilatation of the pulmonary artery may be associated with a palpable, sustained pulsation in this area, often with a slow rise of the initial phase.
AREA 4: LEFT PARASTERNAL-RIGHT VENTRICULAR OR TRICUSPID AREA PULSATIONS
A systolic thrill in the third, fourth, or fifth intercostal space in the parasternal area to the left of the sternum (see Fig. 10-60) is characteristic of VSD, although tricuspid regurgitation also can produce a thrill here.
Normally, the lower left parasternal region retracts very slightly during systole, and RV activity is not palpable. Slight, gentle outward pulsations of the lower sternum and left parasternal area may be recorded in normal children and young adults, in thin adults with a small anteroposterior thoracic diameter, or in patients with pectus excavatum. Sometimes, these pulsations can be palpated in the subxiphoid area and are increased by hyperdynamic cardiac function.
Abnormal pulsations of the sternal and left parasternal areas most commonly are due to RV hypertrophy or dilatation. The pulsation associated with RV hypertension is usually more sustained throughout systole and tends to rise more gradually than the pulsation produced by a RV volume load, which usually is more vigorous but often briefer.203,208
A predominant RV pressure load occurs with pulmonic stenosis and pulmonary hypertension due to LV failure, mitral valve disease, a left-to-right shunt, or pulmonary vascular disease. The sustained anterior precordial pulsation associated with isolated valvular pulmonic stenosis may not occur with tetralogy of Fallot because the thick right ventricle is not excessively dilated. ASD and VSD are two congenital lesions frequently associated with a RV volume load.
Moderate or severe mitral regurgitation may produce an abnormal late systolic anterior left parasternal pulsation even in the absence of pulmonary hypertension.209 This precordial lift is brisk, and its greatest force coincides with the accentuated v wave in the left atrial pressure wave. It likely is due to the large volume of blood regurgitated into the expanding left atrium, which is located centrally behind the right ventricle and anterior to the spine. While expansion of the left atrium may contribute somewhat to the anterior motion of the heart, it is likely that most of the anterior motion and force is the result of a jet or squid effect.
Conditions associated with a decrease in RV compliance, such as RV hypertrophy secondary to pulmonary hypertension, may be associated with a palpable "right sided" S4 in this area or, occasionally, in the epigastric area. Although a palpable S3 in this area may reflect a large RV volume load, it usually indicates RV dysfunction or failure. RV S3 and S4 vibrations may be augmented during inspiration and may be attenuated or even disappear during expiration (see below).
AREA 5: APICAL AREA PULSATIONS
As mentioned earlier, the apex impulse (see Fig. 10-60) is not synonymous with maximum impulse or point of maximum impulse (PMI). The location, size, and character (duration, contour or shape, amplitude, and apparent force) of the apex impulse should be determined.207 The examiner should focus on one phase of the cardiac cycle at a time and correlate the findings with other cardiovascular events.
The normal apex (apical) impulse usually is located within 10 cm of the sternal midline, at or within the left midclavicular line in the fifth intercostal space, when the patient is supine. It may be located lateral to the midclavicular line when associated with a high diaphragm, pregnancy, marked pectus excavatum, or other conditions that displace a normal heart to the left. The normal apex impulse is less than 3 cm in diameter and in most instances is considerably smaller. The early systolic outward movement of the apical area (Fig. 10-61) begins at about the same time as that of the S1, 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. The outward movement of the apical impulse is normally not excessively forceful and is felt only during the first third of systole.
The apex 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 cause a normal apical impulse to move laterally and to have increased amplitude and duration207; however, it still should not exceed a diameter of greater than 3 cm. A hyperdynamic apex impulse also may be found in anxious children, in patients with high cardiac output states, and in patients with a mild to moderate LV volume load from mitral or aortic regurgitation. The apex impulse is more sustained when mitral or aortic regurgitation is more severe or when LV systolic function is decreased.204 In general, a greatly sustained apex impulse indicates either marked LV hypertrophy or depressed LV systolic function, whereas LV dilatation displaces the apex impulse laterally and inferiorly207210 (see Fig. 10-61).
Concentric LV hypertrophy without an increase in LV cavity size may occur in systemic hypertension, valvular aortic stenosis, and hypertrophic cardiomyopathy. Characteristically, the apex impulse is not displaced but is both abnormally forceful and sustained.204,205 An S4 vibration may be palpable or visible or both.
Severe LV dilatation-whether due to volume load or ventricular failure-may displace the apex impulse laterally and inferiorly and cause a marked increase in size. The duration of the apex impulse is more sustained in patients with LV systolic dysfunction, particularly when associated with marked LV dilatation.
Important information about relative amounts of ventricular hypertrophy and dilatation often can be obtained from the apex impulse. Thus, in valvular aortic stenosis, with marked concentric LV hypertrophy but little or no dilatation, the apex impulse characteristically is small, forceful, and sustained but not displaced. A presystolic S4 often is palpable at the apex. By contrast, in severe aortic regurgitation with marked dilatation of the left ventricle plus considerable eccentric hypertrophy, there is a diffuse apex impulse with increased force, duration, and amplitude, and it is displaced laterally and inferiorly.205
In some patients with acute MI, a sustained apex impulse may simulate that due to LV hypertrophy.201 Those developing mitral regurgitation secondary to MI (papillary muscle dysfunction) may manifest LV dilatation and hypertrophy by a displaced and sustained, forceful, large apex impulse.211 A late systolic bulge at the cardiac apex may be due to a functional LV aneurysm, occasionally resulting in a bifid apex impulse. In other patients, a late systolic bulge may be palpable in an ectopic area between the apex impulse and the left parasternal area.
A bifid apex impulse during systole also may be due to marked LV dilatation and hypertrophy in patients with both aortic stenosis and regurgitation or in patients with hypertrophic cardiomyopathy.212 Infrequently, a faint systolic notch or vibration is palpable in the apex impulse of patients with mitral valve prolapse at the moment of a nonejection midsystolic click. Systolic retraction of the apical impulse usually indicates either constrictive pericarditis or severe tricuspid regurgitation with marked RV dilatation (see Fig. 10-61). An apical systolic thrill most commonly is produced by mitral regurgitation and often is diffuse, whereas a diastolic thrill is usually produced by mitral stenosis and is localized to a small, discrete periapical area.
Diastolic Events: Palpable Third and Fourth Heart Sounds
During early diastole, brief outward chest wall movement corresponding to a LV filling or a third heart sound (S3) occasionally may be seen or felt, even if it is not audible with a stethoscope (see Fig. 10-61). In children and young adults, the presence of an early diastolic ventricular filling sound (S3) and movement is usually normal. On the other hand, the presence of such a movement or sound in a sedentary adult or a patient with heart disease usually indicates an elevated LV diastolic pressure and volume and likely ventricular decompensation, often with a decreased ejection fraction. Patients with acute MI or transient myocardial ischemia during angina pectoris frequently develop a transient palpable and audible ventricular filling S3, which reflects the acutely decreased ventricular compliance. A palpable ventricular rapid filling wave (S3) may be present in patients with LV failure from any cause; however, hemodynamic systolic ventricular failure is often not always present when a ventricular filling wave or sound occurs in the presence of volume loading and dilatation of the left ventricle, as with mitral regurgitation or aortic regurgitation.
The presystolic left atrial contribution to the apical impulse (referred to as the atrial impulse or a wave) may be detected during late diastole, just prior to S1 (see Fig. 10-61). Usually, a palpable atrial impulse coincides with an audible fourth heart sound and is associated with an increased LV end-diastolic pressure and decreased compliance. In general, an S4 is not normally palpable but may be felt at the apex with its associated S4 in some normal adults if the PR interval is long and circulation is hyperdynamic.202 In some patients with ischemic heart disease, a palpable apical S4 may develop or become more prominent during an episode of angina pectoris or even during exertion without chest pain. A palpable presystolic impulse, S4, or both occur frequently in patients with acute MI, and these are also frequently present in other conditions producing a decrease in LV compliance and increased end-diastolic pressure.
In a patient with mitral valve disease, the presence of a palpable left-sided atrial impulse or S4, a palpable left-sided ventricular filling sound or S3, or an abnormally sustained apical impulse is evidence against the diagnosis of isolated important mitral stenosis and suggests the presence of coincident LV disease.
A double, or bifid, apical impulse may be present in various circumstances, most commonly in the combination of an outward movement during ventricular systole and a second outward pulsation during diastole.205 The diastolic impulse may occur either in early diastole (S3) or in late diastole or presystole (S4).
A bifid apical impulse with two systolic impulses may be present in patients with hypertrophic obstructive cardiomyopathy, complete left bundle branch block (LBBB), or MI. If these patients also develop a palpable impulse during either early (S3) or late (S4) diastole, a triple or trifid apical impulse may occur. When such patients develop both a palpable S3 and a palpable S4, it is occasionally possible to see and feel a quadruple apical impulse.
AREA 6: EPIGASTRIC AREA PULSATIONS
Some normal and many hyperkinetic individuals have visible or palpable pulsations of the aorta in the epigastric area (see Fig. 10-61). Abnormally large pulsations of the aorta may be due to an aortic aneurysm or aortic regurgitation. Hepatic movements may be identified in the epigastric area, particularly in patients with tricuspid regurgitation, tricuspid stenosis, or marked RV dilatation, hypertrophy, and hyperactivity.
In some patients with pulmonary hypertension due to chronic lung disease, the detection of RV hypertrophy by precordial palpation is difficult because the shape of the chest often conceals the enlarged right ventricle. To detect abnormal RV pulsations in patients with emphysema, the palm of the right hand should be placed on the epigastric area and moved cephalad while gently sliding the fingers under the rib cage. Aortic pulsations can be detected by the palmar surface of the fingers, and pulsations due to RV hypertrophy can be felt in the fingertips.
AREA 7: ECTOPIC AREA PULSATIONS
Occasionally, cardiac pulsations are encountered in areas other than those described previously, i.e., between the pulmonary and apical areas (see Fig. 10-61). Ischemic heart disease is the most common cause of an ectopic systolic pulsation, which may occur transiently during an episode of angina pectoris. A similar paradoxical systolic outward movement may be detected after acute MI and may persist; more commonly, it disappears within a few weeks. A persistent paradoxical ectopic pulsation also may be found in patients who develop a ventricular aneurysm after MI. Ectopic pulsations on the anterior chest wall also can 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 atrium occasionally may be felt in the right anterior or lateral chest or in the left axilla.205
Percussion versus Inspection and Palpation of the Precordium
When performed by a skilled examiner, percussion of the heart can provide an estimate of cardiac size and shape. Percussion of the heart only gives information about the location of the borders of cardiac dullness, whereas precordial inspection and palpation provide both information about the location of the outer limits of cardiac pulsations and a determination of the size and character of the pulsations. Although percussion has been used in the diagnosis of pericardial effusion, it has limited value when the results are objectively correlated with the diagnosis as determined by more sensitive and specific noninvasive and invasive testing.
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