Examination of the precordial pulsation
- Bernard J Gersh, MB, ChB, DPhil, FRCP, MACC
Bernard J Gersh, MB, ChB, DPhil, FRCP, MACC
- Editor-in-Chief — Cardiovascular Medicine
- Section Editor — Coronary Heart Disease; Myopericardial Disease
- Professor of Medicine
- Mayo Clinic College of Medicine
Inspection and palpation of precordial cardiovascular pulsations is best performed with patients supine and with a modest elevation of the head and chest (not over 45º). The examiner should observe by looking down at the chest and from the side.
Other aspects of the cardiovascular examination are discussed separately. (See "Auscultation of heart sounds" and "Auscultation of cardiac murmurs in adults" and "Examination of the arterial pulse" and "Examination of the jugular venous pulse".)
A slight abrupt inward pulsation normally can be seen over the left ventricular apex at the fifth intercostal space in the left parasternal area, particularly in children and thin chested subjects. A hyperdynamic left ventricular impulse associated with severe aortic or mitral regurgitation is frequently visible and can cause occasional shaking of the entire precordium. In patients with severe dilated congestive cardiomyopathy, a double impulse may be visible over the apical region, usually due to a sustained left ventricular impulse and a prominent early diastolic filling impulse.
Cardiac pulsations that are visible lateral to the left midclavicular line usually suggest cardiac enlargement. Leftward cardiac displacement due to left pulmonary fibrosis, right-sided tension pneumothorax, massive pleural effusion, absent left pericardium, and thoracic deformity may also cause visible pulsation beyond the midclavicular line.
Systolic outward parasternal and left ventricular outward movements are better appreciated by palpation than by inspection. Such movements are often associated with aneurysms of the apex or anterolateral wall of the left ventricle and frequently indicates reduced left ventricular ejection fraction.
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