• Examination of Cardiac Apex Beat

    Apex beat is the palpable cardiac impulse. It is also defined as the lowermost and outermost (most lateral and most inferior) prominent cardiac pulsation. Examination of this cardiac impulse can give valuable inputs into the diagnosis of cardiac disease. Correct interpretation of the apex beat requires proper understanding of the cardiac anatomy and the cardiac cycle physiology.

    : Apex impulse; Point of Maximal Impulse (PMI)

    Normal location:

    It is normally located in the left fifth intercostal space, about 1 centimeter medial to the mid-clavicular line.

    In children less than 7 years of age, the apex beat is located in the 4th intercostal space, lateral to the mid-clavicular line.

    How it is produced:

    One of my students asked a very pertinent question. When the heart contracts, it expels blood towards the great arteries, that are towards the base of the heart. Then why does the apex move 'outward' in the chest? This defies logic as the perceived movement is in the opposite direction of the expected movement.

    The answer lies in the cardiac anatomy. Heart is a spirally arranged muscle in syncytium. When this muscle contracts, the heart rotates while it is contracting and the apex actually moves forward toward the chest wall and taps it.

    Method of examination:

    Position the flat of your hand so that the middle finger lies on the left 5th intercostal space of the patient, covering the anterolateral ribcage. Other fingers are positioned on the spaces above and below. If no pulsation is felt, move the hand in other directions, feeling for a pulsation.

    Once the apex is felt, ascertain whether it is the most prominent pulsation. Then to identify the position, palpate the sternal angle (angle of Louis). It is the angle between the manubrium and the body of the sternum. The second rib corresponds to this angle. Below the second rib is the corresponding intercostal space. Starting from that space, count the intercostal spaces and reach the palpable apex and identify the space in which it is located.

    Follow this by measuring the distance between the pulsation and the mid-clavicular line. If the pulsation is nearer to any other vertical landmark line, like the anterior or middle axillary lines, it is better to state the position in relation to those lines rather than mid-clavicular line. For example, instead of mentioning that the apex is 6 cm lateral to mid-clavicular line, it is better to document as 1 cm medial to mid-axillary line.

    Points to note in apex:

    • Presence
    • Location
    • Size (is it localized or diffuse?)
    • Amplitude (is it forceful?)
    • Duration (is it abnormally sustained?)
    • Type (assess based on above parameters, details are given below)
    • Thrill

    Causes for absence of apex beat:

    Absent apex may be due to physiological and pathological causes.
    Mnemonic: DR POPE

    Physiological causes:

    • Dextrocardia. Though it will be absent at the 'usual' location on the left side, it will be present on the right side.
    • Apex behind a Rib. In this case it may not be palpable in an intercostal space. Just turning the patient to the left lateral position will reveal the apex beat, confirming this cause.

    Pathological causes:

    • Pericardial effusion
    • Obesity and thick chest wall
    • Pleural effusion (left sided)
    • Emphysema

    Causes for displaced apex beat:

    This has to be assessed along with tracheal position. If trachea is also shifted along with the displacement of apex beat, then it is due to mediastinal shift as a result of lung fibrosis, collapse, pneumothorax etc.
    If the trachea is central but the apex is displaced, the causes may be:

    1. Left ventricular enlargement - the apex will be displaced downwards and laterally.
    2. Right ventricular enlargement - the apex will displaced laterally.
    3. Cardiomegaly due to significant enlargement of other chambers can also cause displacement
    4. Pectus excavatum
    5. Situs inversus/ dextrocardia

    Abnormal types (characters) of apex beat:

    The normal apex beat is localized pulsation in the normal location as described above. Here are some abnormal characters (please refer to the picture too):

    1. Tapping Apex - This is an almost normal apex beat with a palpable first heart sound. This is due to a loud first heart sound heard in mitral stenosis.
    2. Hyperdynamic Apex - This is classically seen in volume overload conditions where there is ventricular dilatation (aortic regurgitation, hyperdynamic circulation etc). This is a forceful but ill-sustained apex that is palpable over a larger area than normal (diffuse).
    3. Heaving Apex - Classically seen in pressure overload conditions that result in ventricular hypertrophy (aortic stenosis, systemic hypertension etc). This is a forceful and sustained apex that is usually localized.
    4. Double Impulse Apex - Two impulses felt during systole rather than the normal single upstroke. This is seen on HCM - hypertrophic cardiomyopathy).
    5. Dyskinetic Apex - An apex that is uncoordinated, seen in myocardial infarction when there are dyskinetic movements of the infarcted myocardium.

    Some apex related terminology clarified:

    1. Localized apex: Palpable in a single intercostal space and the longest diameter of the pulsation is within 2.5 cm. This is normal.
    2. Diffuse apex: Apex palpable in more than one intercostal space or longest diameter more than 2.5 cm, even within a single space.
    Comments 26 Comments
    1. sid's Avatar
      sid -
      Thank you very very much for this. For the first time now, I have 'understood' the types of apex beat and now I can also rattle 6 causes for absent apex! Hope to see more here...
    1. Misspaul's Avatar
      Misspaul -
      Same here... I liked the article here. For teh first time I understood the apex beat classification.
    1. Joel G Matthew's Avatar
      Joel G Matthew -
      That post was just great. I really wanted that mnemonic. Thanks a lot!
    1. clem's Avatar
      clem -
      hi thank u for overview. so many clinical med texts differ between hyperkinetic and hyperdynamic etc. my question is can u by palpating the apex, eliciting a hyperdynamic, volume overloaded ventricle, by inference, say the patient has a cardiomyopathy?thank u
    1. Harpent's Avatar
      Harpent -
      well I have liked that post and I think it is great. for a newbie like me.
    1. Dennis's Avatar
      Dennis -
      This is the best info I have seen on cardiac apex. I like especially the flow chart that you have created above. Absolutely clear, except that I was not sure how a S1 would be like to 'palpate'..
    1. Rajesh's Avatar
      Rajesh -
      very nice depiction.i liked it. but can u suggest any method to know if an apex beat is left ventricular in type or right ventricular???
    1. Rashid's Avatar
      Rashid -
      goody........can u tell more about THRILLS?
    1. Unregistered's Avatar
      Unregistered -
      makes cardiology interesting!
    1. Coolant's Avatar
      Coolant -
      Thank you for this excellent information about apex beat. Some books have given that we should make the patient sit up to palpate the apex beat when it is not palpable in supine position. However, now I am clear that it is better to make the patient turn to the left side...
    1. SARA's Avatar
      SARA -
      Thank you so much for this interesting article
    1. ABDULLAH's Avatar
      ABDULLAH -
      BEST APEX BEAT explanation I ever saw
    1. keerti's Avatar
      keerti -
      thankes very nice depiction.
    1. Yvonne A's Avatar
      Yvonne A -
      Good work,I must say.Very explanatory
    1. humaira's Avatar
      humaira -
      excellent explanation!
    1. karanistheone's Avatar
      karanistheone -
      Quote Originally Posted by clem View Post
      hi thank u for overview. so many clinical med texts differ between hyperkinetic and hyperdynamic etc. my question is can u by palpating the apex, eliciting a hyperdynamic, volume overloaded ventricle, by inference, say the patient has a cardiomyopathy?thank u
      eh...by my reasoning the simplest explanation would either be a regurgitant lesion(AR) or VSD.Cardiacmyopathy leads to pressure overload leading to outward downward displaced apex with heave...
    1. noname's Avatar
      noname -
      Why in some cases, apex beat is not displaced despite there is cardiomegaly (with left ventricle enlargement) ?
    1. gummygg's Avatar
      gummygg -

      I would like to confirm if the patient has cardiomegaly, when you auscultate for the apex beat, do you also place the stethoscope on the PMI?
    1. kamlendra verma's Avatar
      kamlendra verma -
      excellent explanation!
    1. wsssw's Avatar
      wsssw -
      Can we count ribs from below upwards?
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