Nonauscultatory Cardiac Exam: Assessing the Elderly Person

Mark E. Williams, MD


July 08, 2011

In This Article

Examination and Palpation of the Apical Impulse (Point of Maximal Impulse)

After examining the neck veins, the next step is to see if the apical impulse, also called the apex beat and point of maximal impulse (PMI) is visible in the vicinity of the fifth intercostal space. Not seeing it is usually a normal finding. You can check to see the apical impulse in forced expiration or in the left lateral decubitus position. You can also check after palpation.

Examination of the Apical Impulse

Location and characteristics of the apical impulse. Obviously, the location of the apical impulse first depends on intrathoracic pressures, so check the trachea to see if it is midline. Finding a laterally displaced apical impulse with left tracheal displacement suggests mediastinal shift to the left.

Normally the PMI is just medial to the midclavicular line at the fifth intercostal space. (Note, the nipple is almost never in the midclavicular line and should not be used as a constant landmark.) Look for the following:

  • A PMI lateral to the midclavicular line or below the sixth intercostal space suggests left ventricular enlargement.

  • If the PMI is greater than 2 cm in size there is likely left ventricular hypertrophy or dilation.

  • The location in the epigastric area with fullness can be a clue to pericardial effusion (Auenbrugger's sign) or right ventricular hypertrophy.

  • Seeing the apical impulse on the right lower sternal border suggests dextrocardia or situs inversus. (Confirm situs inversus by percussing a right-sided gastric air bubble.)

  • A pulsation in the right upper sternal border near the aortic area implies an ascending aortic aneurysm.

  • Seeing a systolic retraction of the apical impulse or a diastolic impulse suggests pericardial constriction (Broadbent sign) or right ventricular hypertrophy. Systolic cardiac retraction in the setting of pericarditis is the Heim-Kreysig sign. Noting systolic retractions along the anterior axillary line suggests pericarditis (Bouillaud's sign).

  • Observing a double impulse implies asymmetric septal hypertrophy, right bundle branch block, left ventricular dyskinesia, an early diastolic filling wave (visible S3), or aortic stenosis (uncommon).

Palpation of Apical Impulse or PMI

Size. The PMI is normally the size of a penny. A quarter size PMI is abnormal and suggests left ventricular hypertrophy.


Normally the systolic impulse is one half to two thirds of systole. Regular rate and rhythm suggests sinus rhythm. An irregularly irregular rhythm suggests atrial fibrillation. Regularly irregular rhythm suggests bigeminy, trigeminy, or second-degree AV block.

Characteristics of the PMI

Sustained PMI. Feeling a sustained PMI suggests left ventricular hypertrophy usually due to increased afterload. You can verify this by listening to P2 at the left upper sternal border. The PMI is sustained if P2 is coincident with or later than the palpable PMI.

Double impulse. Feeling a double impulse suggests a palpable S3 gallop (only significant if you also hear an S3 gallop), a palpable S4 (more significant than an audible S4 and suggests ischemic heart disease and increased afterload), or ventricular aneurysm.

Lateral pulsation of the left hemithorax. This suggests left ventricular aneurysm.