How do you palpate for signs of left ventricular hypertrophy (LVH) in a patient?

How to Palpate for Signs of Left Ventricular Hypertrophy

Palpate the apical impulse in the left lateral decubitus position and measure its diameter—an apical impulse greater than 3 cm is highly accurate for detecting LVH (92% sensitive, 91% specific), while displacement lateral to the mid-clavicular line is sensitive but not specific. 1

Technique for Palpating the Apical Impulse

Patient Positioning

• Position the patient in the left lateral decubitus position to bring the apex closer to the chest wall and optimize palpation 1
• This position is essential for accurate assessment, as it enhances detection of the apical impulse 1

Location Assessment

• Identify the apical impulse and note its position relative to anatomical landmarks 2
• Measure the distance from the mid-sternal line—a distance greater than 10 cm suggests LV enlargement but has limited specificity 1
• Assess position relative to the mid-clavicular line—lateral displacement is sensitive for LV enlargement but not specific, as it can occur with other conditions 1

Diameter Measurement

• Measure the diameter of the apical impulse—this is the most reliable palpatory finding 1
• An apical impulse diameter >3 cm in patients without LVH has 92% sensitivity and 91% specificity for LV enlargement, with positive predictive value of 86% and negative predictive value of 95% 1
• This measurement is particularly accurate in patients without established LVH 1

Characteristics of the Apical Impulse in LVH

Quality of the Impulse

• Palpate for a prominent and sustained apical impulse, which indicates LVH, particularly in conditions like aortic stenosis 2
• In patients with moderate to severe aortic regurgitation and LV enlargement, the apical impulse is displaced laterally and hyperdynamic 2
• The sustained quality (prolonged duration) is more specific for pressure overload hypertrophy 2

Associated Findings

• Feel for a systolic thrill at the suprasternal notch or upper right sternal border, which may accompany severe aortic stenosis with LVH 2
• Assess carotid upstrokes for delayed and decreased volume, which suggests severe aortic stenosis as a cause of LVH 2

Critical Limitations and Pitfalls

When Location Alone Is Insufficient

• Do not rely solely on the location of the apical impulse relative to the mid-clavicular line or mid-sternal line, as these measurements are not reliable indicators of increased LV end-diastolic volume 1
• Lateral displacement can occur with chest wall deformities, mediastinal shift, or body habitus without true LV enlargement 1

When Palpation May Be Misleading

• In patients with established LVH, the apical diameter measurement loses specificity 1
• Obesity, chest wall thickness, and emphysema can make palpation difficult or impossible 1
• Palpation cannot distinguish between different patterns of LVH (concentric vs. eccentric, symmetric vs. asymmetric) 3

Integration with Other Clinical Findings

Complementary Physical Examination

• Auscultate for a systolic ejection murmur radiating to the carotids and an ejection click at the apex, which may indicate valvular causes of LVH 2
• Listen for an early diastolic high-pitched murmur along the mid-left sternal border, suggesting aortic regurgitation as a cause 2

When to Proceed to Imaging

• Echocardiography is the most accurate noninvasive method to detect and quantify LVH when palpatory findings are equivocal or absent 4, 5
• Physical examination has significant limitations—electrocardiography detects LVH in only 5% of hypertensive patients, while echocardiography detects it in 50% 5
• Proceed to comprehensive 2D echocardiography with measurement of maximum diastolic wall thickness in all LV segments from base to apex when LVH is suspected 6, 7