Inspection and palpation of the cardiac pulsations of the anterior chest have been practiced by physicians since ancient times and have a solid scientific basis. The results of precordial inspection and palpation have been correlated with noninvasive studies, hemodynamic data, and surgical and autopsy studies202,203 and remain an important part of the cardiovascular examination. Their usefulness depends on an understanding of cardiovascular physiology, the proficiency of the examiner, and his or her ability to integrate findings with history, the information obtained by other portions of the physical examination, the ECG, the chest roentgenogram, and other diagnostic tests.
1. The sternoclavicular area
2. The aortic area
3. The pulmonic area
4. The RV (left parasternal) area
6. The epigastric area
7. Ectopic (variable-location) areas
While the cardiac apex is usually produced by the left ventricle, it is sometimes produced by an enlarged right ventricle that displaces the left ventricle laterally and posteriorly. Occasionally, the cardiac position is abnormal due to dextroposition, dextroversion, dextrocardia, or other changes in intrathoracic structures. Although the cardiac apex impulse is commonly referred to as the point of maximal impulse (PMI), the two terms are not necessarily synonymous, since the maximal precordial pulsation may be produced by an enlarged or hypertrophied right ventricle, a dilated aorta or pulmonary artery, or a LV wall-motion abnormality. Therefore, precordial pulsations should be described by their location, timing, contour, and duration.
The examiner should first inspect the thorax from the foot of the bed with the subject supine, the legs horizontal, and the head and trunk elevated to approximately 300.205 The patient may have a barrel-shaped chest with an increased anteroposterior diameter, a straight-back syndrome, pectus excavatum, pectus carinatum, kyphoscoliosis, or ankylosing spondylitis. Each may produce or be associated with cardiac abnormalities. Asymmetry of the thorax due to convex bulging of the precordium suggests the presence of heart disease since childhood. Exaggerated movements of the cardiac apex often can be detected from this observation point.
Next, the examiner should move to the patient's right side and observe the patient's chest tangentially rather than from above. A light beam directed across the precordium may enhance subtle findings.205,206 Precordial movements frequently can be recognized more easily if the tip of an applicator stick, tongue blade, or light pencil is held against the impulse as a fulcrum. Motion of the underlying chest wall is transmitted to the free end of the instrument and exaggerated, making the movements more obvious.
In patients with an abnormally prominent apical impulse and in some thin, normal individuals, the apical impulse or apex beat can be seen. The presystolic apical motion associated with the atrial contribution to ventricular filling (a fourth heart sound) sometimes may be visualized, as may the diastolic waveform due to rapid ventricular filling (a third heart sound). A late systolic bulge either at the apex or in an ectopic area, usually located either medial and superior or lateral to the apical impulse, may be observed in patients with a large dyskinetic ventricular aneurysm.203 When precordial pulsations are exaggerated, they become visible as well as palpable. In general, however, outward movements are best discerned by palpation, whereas inward movements usually are seen more easily than felt.202,203
With Tietze's syndrome, pain, sometimes with swelling and tenderness, may affect the costochondral, chondrosternal, or xiphosternal joints and may be reproduced by touching. Palpation also may reveal tender superficial veins on the anterior chest (Mondor's disease), a rare etiology of chest discomfort.206 Collateral vessels in the posterior intercostal spaces may be palpable in patients with aortic coarctation.206
Palpation of the precordium is also best performed from the right side, with the patient supine and the upper trunk elevated 30°. Palpation with the right hand usually provides more information. Patients with suspected cardiovascular disease also should be examined in the left lateral decubitus position, rotated 45 to 900.207 In this position, the normal LV impulse may be displaced several centimeters leftward and may appear more prominent and sustained. The size of the apex impulse rather than its distance from the midsternal or midclavicular line determines its normality.207 Often, the apex impulse and other palpable events such as a LV rapid filling wave (S3) or presystolic a wave (S4) may be felt only in this position.
The location and size of the cardiac apex impulse should be defined, its contour characterized, and any abnormal precordial pulsations identified. The palm of the hand, ventral surface of the proximal metacarpals, and fingers should all be used for optimal appreciation of specific movements. The fingers appear to be particularly insensitive to movements of relatively large amplitude and very low frequency. This is consistent with the clinical observation that an examiner's hand occasionally can be seen to move up and down with precordial motion, although the same movements are imperceptible by palpation alone. By contrast, higher-frequency events, such as the vibrations associated with abnormally loud aortic or pulmonic components of the second heart sound, are easily palpable, even though the amplitude of their movement is not readily visible.204
The pads of the fingers are most useful for detecting LV and normal RV motion, whereas the palm and proximal metacarpals are usually best used for palpating larger, low-frequency movements such as the parasternal systolic lift of RV hypertrophy.204 Varying pressure with the hand is often quite useful. High-frequency movements such as ejection sounds, valve closure sounds, and mitral opening snaps are detected more easily with the hand held firmly against the chest, whereas low-frequency movements such as ventricular diastolic filling events are best recognized with light pressure with the fingertips.
Thrills are palpable vibrations from murmurs or bruits ordinarily associated with grade 4/6 murmurs or louder. The location of a thrill often helps identify its origin. Thrills are palpated most easily with the fingertips or with firm pressure, using either the palm of the hand or the proximal metacarpals. Sometimes thrills are felt better during a held end-expiration with moderate pressure applied from the right hand on top of the left hand, which is placed on the chest. Occasionally, palpable murmurs are more readily detected with the right palm placed over the anterior chest and the left hand supporting the posterior thorax with equal force.205
To detect abnormal RV motion, the heel of the hand should be placed over the lower half of the sternum with the patient's breath held at end-expiration. The parasternal lift due to RV hypertrophy is often better visualized than actually felt. In patients with chronic obstructive pulmonary disease, subxiphoid and epigastric palpation with the patient's breath held at endinspiration is useful for assessing RV motion.
Proper patient positioning is important. The location of the apex impulse is usually described in terms of its distance from the midsternal or midclavicular line and the intercostal space in which it is located. Although heart size is commonly estimated based on the size and location of the apex impulse with the patient supine, this is not always a reliable indicator of LV end-diastolic volume. The apex impulse is often faint or not palpable with the patient supine because of the distance of the ventricular apex from the chest wall. Palpation of the cardiac apex with the patient in the left lateral position, however, permits optimal assessment of the size (diameter) and contour of the systolic outward movement at the apex; diastolic movements are also best appreciated with the patient in this position. Since the apex impulse may shift several centimeters laterally when the patient rotates to the left lateral position, however, the location of the apex impulse may be incorrect in this position. Palpation with simultaneous cardiac auscultation often is useful for identifying the systolic or diastolic timing of precordial pulsations. Simultaneous palpation of the apical impulse and carotid pulse may be helpful in assessing the severity of aortic stenosis. An appreciable lag time between the onset of the apex impulse and carotid pulse usually indicates severe aortic stenosis.
Although only the apical impulse is palpable normally, a brief RV systolic motion can be felt at the left sternal edge in asthenic individuals. With the onset of isovolumic LV contraction, there is anterior movement of the left ventricle toward the chest walls (see Fig. 10-61). Counterclockwise rotation of the left ventricle along its longitudinal axis occurs as the cardiac apex moves anteriorly and makes contact with the chest wall in early systole.208 The maximal outward movement occurs coincident with or just after aortic valve opening. After rapid early ejection, the left ventricle moves away from the chest wall, and the apex retracts during latter systole and returns to baseline well before the second heart sound.204 The outward apex movement in early systole normally is palpable, but the later systolic inward movement is only visible (Fig. 10-61). Palpable movements of the apex in diastole result from LV filling. The early diastolic outward movement due to rapid ventricular filling (F wave), which corresponds to the normal S3, is occasionally palpable in normal children and young adults (see Fig. 10-61). Later diastolic filling due to left atrial contraction (a wave) is not normally palpable. Precordial motion is modified by age, chest wall thickness, lung disease, and pleural or pericardial effusion.
Graphic Representation (palpable features in heavy linel
Type of movement and Location and
•hoc¡ated flinicaI condition accompany!ng features
Type of movement and Location and
•hoc¡ated flinicaI condition accompany!ng features
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