How to localise the apex beat?

Apex beat is situated in the 5th intercostal space just medial to MCL; palpate with fingertips
well localised,area of impulse size of R5 coin
Displaces inferolaterally in ventricular enlargement or as a result of chest deformity, pleural / pulmonary disease

What is displaced Apex?

Cardiac causes of displaced apex beat

• Cardiomegaly—chamber enlargement or aneurysm

Respiratory causes of displaced apex beat

• Fibrosis and collapse (same side of pathology)
• Pneumothorax and pleural effusion (opposite side of pathology)

Skeletal causesof displaced apex beat

• Kyphosis
• Scoliosis
• Pectus excavatum

Abdominal causes of displaced apex beat

• Pregnancy
• Ascites

Displaced apical impulse – dextrocardia push and pull of pleuropulmonarv disease.

Bifid apex beat

Two impulses are felt during each cardiac cycle
Apical impulse + palpable shock produced by the presence of 3rd or 4th heart sound.
Causes of bifid apexbeat

• HOCM
• Left ventricular aneurysm
• Aorticstenosis with Aortic regurgitation
• Left bundle branch block

Diffuse apex beat

Apex beat felt equally with more than 4 finger or in more than 1 intercostal space

Causes of diffuse apex beat

• Left ventricular dilatation
• Left ventricular aneurysm
• Leftventricular dysfunction

How will you differentiate between left ventricular and right ventricular apex

Left ventricular type of apex

• Here the apex beat goes downward and outward.
• Impulse is felt in large area
• Impulse maximum felt at apex
• If there is left parasternal heave it is asynchronous with apex beat

Right ventricular type of apex

• Apex goes outwards
• Impulse is maximum over the lower left sternal border
• Left parasternal heave is consistent with the apex beat.

Forcible apex beat

Apex beat is forceful and illsustained
In foreful apexbeat palpating finger is lifted above the plane of the adjoining rib, but it is ill sustained.This is due to diastolic overload of left ventricle. There is no obstruction of blood flow from left ventricle

Mechanism of forceful apex beat

It is due to diastolic overload of leftventricle leading to increased force of contraction
Causes are

• Aortic regurgitation AR
• Mitral regurgitation -MR
• Patentductus arteriosus-PDA
• Ventricular septaldefect-VSD 
• Hyperdynamic state.

Heaving apical impulse

Apex beat is forceful and well sustained
It is forceful and well sustained due to systolic overload of ventricle.
It is well sustained due to obstruction of left ventricular outflow.
There is sustained lift of palpating finger above the plane of adjoining ribs
Mechanism  of heaving apex beat
This is due to pressure overload of Leftventricle ,force and duration of left ventricular contraction is increased
Causes of heaving apex are 

• Aortic stenosis
• Systemic hypertension
• Hypertrophic obstructive cardiomyopathy HOCM.

Hypokinetic apex beat

Thrust of apex beat is minimal.
Hypokinetic apex beat is seen in 

• Myocardial infarction
• Pericardial effusion 
• Constrictive pericarditis
• Myxoedema shock.

Rightventricular type of apex

Apical impulse formed by rightventricle
Precordial surface of heart is mainly occupied by grossly enlarged right ventricle (RV) as in ASD, which will produce the apical impulse also.

Retractile apical impulse

Retractile apical impulse is seen in

• Constrictive pericarditis 
• Severe Tricuspid regurgitation.

Impalpable apex beat

Apex beat may not be palpable due to following reasons.

• Apex beat lying behind the rib
• Obesity or thick chest wall
• Emphysema
• Pleural effusion
• Pericardial effusion
• Constructive pericarditis
• Pneumothroax
• Deformity of chest wall – kyphoscoliosis
• Pendular breast in females
• Acute myocardial infarction
• Heart failure
• Dextro cardia

Procedures to be followed if apex beat is not palpable.
1.Postural change.

First patient is put in the supine position and palpate for the apex.
If still not felt patient is put in the sitting and stooping forwards position.
In both  these situations the term apical impulse is  used instead of apex beat because the true position of apex beat is altered.

2.Percussion

See saw apex beat

This is a diffuse apex beat confined to more than one intercostal spaces.
When two fingers are placed over each intercostal spaces, there is upward movement of one finger and downward movement of the other finger
Cause of see saw apex beat

• Ventricular aneurysm.

Tapping apex beat

Apex beat is of low amplitude
It is ill sustained occur in mitral stenosis and tachycardia
Palpating finger is not lifted, the distinct palpable shock of accentuated first heart sound is felt as tap by which the apex beat is located.
Mechanism of tapping apex beat
Tapping apex beat is present only in mitral stenosis where the leftventricular size and filling is less. Apical impulse produced by the leftventricle is less which cannot be felt by the palpating finger, instead the accentuated 1st heart sound produced at the mitral valve is transmitted  to the apex and give the feel of tap. Later,Pulmonary artery hypertension ( PAH )and RV enlargement produces clockwise rotation of the heart pushing the LV further posteriorly, hence  further impeding the forward movement of the anatomical apex
Cause of tapping apex beat
Mitral stenosis

Triple or wavy apex beat

Triple or wavy apex beat 

It is a feature of HOCM

This is due to systolic bifid apical impulse + palpable shock of 4th heart sound.
Three impulses are felt in systole.
Hypertrophic obstructive cardiomyopathy

Significance of Apex beat

Mechanism of production

Apexbeat is produced due to the counter-clockwise rotation of the left ventricle in early systole followed by recoil back in late systole
Normal apical impulse is produced bv left ventricle and the left vuntricular portion of the interventricular septum.

What are the factors affecting the apical impulse formation:

• Left ventricular size
• Left ventricular filling, force and duration of contraction

How to localise the apex beat-video?

Golden Rules for examination of apex beat

Before commenting on the position and character of apical impulse,you should search for the presence of chest wall or spinal deformities, and the tracheal position.
When the apical impulse is not localisable on the left side, palpate the right hemithorax for its presence dextrocardia or pseudo-dextrocardia

How to localise the apex beat?

• Ask the patient to be in supine position
• Stand on the right side of patient
• Place your right palm over the pericardium. First, you should palpate the apex with the palm, then digital localization is done with the finger tip
• With the pulp of the finger localise the definite impulse
• Locate the thrust by counting the ribs and measure how far it is from midclavicular line.
• Watch the amplitude and duration of the lift of the palpating finger.
• If the apex beat is not palpated in dorsal deculbitus posture,make the patient sit and lean forward and try.
• If not palpated in sitting also look for apical thrust on right side of the chest this is to rule out dextrocardia.
• If then not palpable comment as could not be localised properly.
• You should not localise the apex beat in the left lateral position because there is shift of apex beat to the left side for about 1-2cm in the left lateral position

Chraracteristics of normal apex

Normal apex beat features

• Site is in 5th left intercostal space 1cm inside the midclavicular line
• It is confined to one intercostal space
• Size of normal apical impulse is 2 cms
• Force and duration of normal apex beat-A gentle nonsustained tap elevating the finger not above the level of ribs and duration less than half of systole.Palpating finger is lifted, but not above the plane of the adjoining ribs.
• Apex beat occur at the end of the isometric contraction phase of cardiac cycle.

Inspection of Apical impulse

Apical impulse is the outermost and the lowermost point over the precordium where a distinct impulse is seen or felt during each cardiac cycle. 
Apical impulse is formed due to the forward movement of the anatomical apex of leftventricle which produces an impulse on the precordium during each cardiac cycle. Normally apical impulse is visible in the 5th left intercostal space inside the mid clavicular line.
Causes of non visibility of apical impulse 

• Thick chest wall
• Apex beat behind the rib
• Pericardial effusion
• Left pleural effusion 

Displaced apex is observed in
Cardiomegaly
Rightventricular enlargement displaces the apex horizontally and outwards,
Leftventricular  enlargement shifts the apex downward and outward.
Displaced heart-is due to pleuropulmonary disease and gross kyphoscoliosis.
Diffuse apex 

• This is seen in ventricular aneurysm.