Normal and Abnormal Findings of Inspecting the Precordium and Apical Impulse
The normal precordial examination reveals a symmetric chest with a single outward apical impulse located at the 5th intercostal space inside the mid-clavicular line, while abnormal findings include displaced, sustained, or hyperactive impulses that may indicate underlying cardiac pathology. 1
Normal Findings
Precordium
- Normal inspection reveals a symmetric thorax without visible malformations, asymmetry, or surgical scars 1
- The chest wall should be free from any infection or other forms of disease 1
- In normal adults, the precordium should not demonstrate any visible pulsations except for the apical impulse 1
Apical Impulse (Point of Maximal Impulse)
- Normally appears as a single outward impulse, usually located at the 5th intercostal space inside the mid-clavicular line 1
- In healthy adults, the apical impulse is palpable in approximately 87% of individuals when examined in the full left lateral position 2
- Normal diameter is approximately 2.5 cm (±0.5 cm) with an area of about 5.0 cm² (±2.5 cm²) 2
- The intensity is typically of medium degree in about 51% of healthy individuals, weak in 25%, and strong in 24% 2
- In children up to age 3 years, the apex beat is normally located in the 4th intercostal space, gradually moving to the 5th space with increasing age 3
Abnormal Findings
Displaced Apical Impulse
- Lateral displacement beyond the mid-clavicular line suggests left ventricular enlargement 1
- An apical impulse diameter ≥4.0 cm in the full left lateral position is highly sensitive (96%) and specific (96%) for left ventricular dilatation 2
- Percussion dullness distance >10.5 cm from the midsternal line in the left fifth intercostal space has a sensitivity of 94.4% for detecting cardiomegaly 4, 5
- Displacement of the apical impulse may occur in conditions such as:
Hyperactive Apical Impulse
- Characterized by a highly or excessively active/hyperkinetic impulse 1
- May be seen in hyperdynamic states such as:
Sustained Apical Impulse
- A sustained apical impulse correlates with moderate to severe left ventricular dysfunction in patients with coronary artery disease 6
- Typically associated with abnormal ejection phase slopes on apexcardiography 6
- May indicate pressure overload conditions such as aortic stenosis 1
Abnormal Precordial Pulsations
- Parasternal heave/lift suggests right ventricular hypertrophy or enlargement 1
- Visible pulsations in the epigastric area may indicate right ventricular enlargement or abdominal aortic pulsations 1
- Systolic retraction may indicate severe left ventricular dysfunction or aneurysm 1
Precordial Abnormalities in Specific Conditions
- In Takotsubo cardiomyopathy, apical ballooning may be detected as an abnormal apical impulse with hypokinesis of mid and apical segments 1
- In acute severe mitral regurgitation, the precordial impulse may be misleading as a normal-sized left ventricle does not produce a hyperdynamic apical impulse despite the severity of the condition 1
- In hypertrophic cardiomyopathy, a double or bifid apical impulse may be appreciated 1
Clinical Pearls and Pitfalls
- The apical impulse is best assessed with the patient in the left lateral decubitus position, which brings the apex closer to the chest wall 2
- Percussion of the precordium can help detect cardiomegaly when the apical impulse is not palpable, which occurs in approximately 47% of patients 5
- An increased amplitude of the A wave on apexcardiography (palpable as an "atrial kick") may be present without significant left ventricular dysfunction 6
- The presence of both a sustained apical impulse and a palpable atrial kick suggests moderate rather than severe left ventricular dysfunction 6
- Obesity, emphysema, or thick chest walls may obscure the apical impulse even when cardiac enlargement is present 1
- The traditional use of the mid-clavicular line as a reference point is not an accurate index of normal heart size at all ages; actual measurement from the midline is more reliable 3