Apex Beat - Wikipedia

Maximum pulse felt on the chest during heart beat

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The apex beat (lat. ictus cordis), also called the apical impulse,[1] is the pulse felt at the point of maximum impulse (PMI), which is the point on the precordium farthest outwards (laterally) and downwards (inferiorly) from the sternum at which the cardiac impulse can be felt. The cardiac impulse is the vibration resulting from the heart rotating, moving forward, and striking against the chest wall during systole. The PMI is not the apex of the heart but is on the precordium not far from it. Another theory for the occurrence of the PMI is the early systolic contraction of the longitudinal fibers of the left ventricle located on the endocardial surface of this chamber. This period of the cardiac cycle is called isovolumic contraction. Because the contraction starts near the base of the left ventricle and spreads toward the apex most of the longitudinal fibers of the left ventricle have shortened before the apex. The rapidly increasing pressure developed by the shortening of these fibers causes the aortic valve to open and the apex to move outward causing the PMI. Anatomical dissection of the musculature of the apex reveals that muscle fibers are no longer longitudinal oriented but form a spiral mass of muscular tissues which may also have an effect on the ability of the apex to contract longitudinally. After the longitudinal fibers contract, the ejection of blood out of the left ventricle is accomplished by the torsional (as one would wring out a face cloth) action of the circumferential muscle fibers of the left ventricle that are in the mid-portion of the ventricle and contract after the longitudinal fibers. During the longitudinal fiber contraction, the volume of the left ventricle has not changed keeping the apex in intimate contact with the chest wall allowing the ability to feel the apex move outward before the heart empties greater than 55% of its volume and the apex falling away from the chest wall. [2]

Identification

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The normal apex beat can be palpated in the precordium left 5th intercostal space, half-inch medial to the left midclavicular line and 3–4 inches left of left border of sternum.

In children the apex beat occurs in the fourth rib interspace medial to the nipple. The apex beat may also be found at abnormal locations; in many cases of dextrocardia, the apex beat may be felt on the right side.

Interpretation

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• Algorithm for classification of the apex beat characters

Lateral and/or inferior displacement of the apex beat usually indicates enlargement of the heart, called cardiomegaly. The apex beat may also be displaced by other conditions:

• Pleural or pulmonary diseases
• Deformities of the chest wall or the thoracic vertebrae

Sometimes, the apex beat may not be palpable, either due to a thick chest wall, or conditions where the stroke volume is reduced; such as during ventricular tachycardia or shock.

The character of the apex beat may provide vital diagnostic clues:

• A forceful impulse indicates volume overload in the heart (as might occur in aortic regurgitation)
• An uncoordinated (dyskinetic) apex beat involving a larger area than normal indicates ventricular dysfunction; such as an aneurysm following myocardial infarction
• A pulse deficit between the PMI and periphery may occur in some arrhythmias, such as premature ventricular contraction or atrial fibrillation.

Sustained apex beat, namely prolonged upward cardiac force during systole in a physical exam, can be seen in some chronic conditions such as hypertension and aortic stenosis, especially in elderly and females.[3]

An algorithm for the classification of some common apex beat characteristics is shown in the image

References

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1. ^ Lynn S. Bickley; Peter G. Szilagyi (1 December 2008). Bates' guide to physical examination and history taking. Lippincott Williams & Wilkins. pp. 357–. ISBN 978-0-7817-8058-2.
2. ^ Visualization of the point of maximal impulse and "S4" on echocardiogram: an observation. Conn Med. 2007 Feb;71(2):85–8.
3. ^ "webcampus.drexelmed.edu". Archived from the original on 18 October 2018. Retrieved 17 October 2018.

External links

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• Examination of Cardiac Apex Beat

v t e Medical examination and history taking
Medical history	Chief complaint History of the present illness Systems review Nursing assessment Allergies Medications Past medical history Family history Social history Psychiatric history Progress notes Mnemonics SAMPLE OPQRST SOAP COASTMAP
Physical examination	General/IPPA Inspection Auscultation Palpation Percussion Vital signs Temperature Heart rate Blood pressure Respiratory rate HEENT Eye examination Ophthalmoscopy Swinging light test Hearing Weber Rinne Respiratory Respiratory sounds Cardiovascular Cardiac examination Peripheral vascular examination Heart sounds Other Abdominojugular test Ankle–brachial pressure index Abdominal Liver span Rectal examination Bowel sounds Musculoskeletal Knee examination Hip examination Shoulder examination Elbow examination GALS screen Neurological Mental status Mini–mental state examination Cranial nerve examination Upper limb neurological examination Neonatal Apgar score Ballard Maturational Assessment Gynecological Well-woman examination Pap test Breast examination Sports Athletic heart syndrome Sudden cardiac death RED-S
Assessment and plan	Medical diagnosis Differential diagnosis

v t e Signs and symptoms relating to the circulatory system
Chest pain	Referred pain Angina Levine's sign
Auscultation	Heart sounds Split S2 S3 S4 Gallop rhythm Heart murmur Systolic Functional murmur Still's murmur Diastolic Pulmonary insufficiency Graham Steell murmur Continuous Carey Coombs murmur Mitral insufficiency Presystolic murmur Pericardial friction rub Heart click Bruit carotid
Pulse	Tachycardia Bradycardia Pulsus paradoxus doubled Pulsus bisferiens Pulsus bigeminus Pulsus alternans
Other	Palpitations Apex beat Cœur en sabot Jugular venous pressure Cannon A waves Hyperaemia
Shock	Cardiogenic Obstructive Hypovolemic Distributive See further Template:Shock
Cardiovascular disease	Aortic insufficiency Collapsing pulse De Musset's sign Duroziez's sign Müller's sign Austin Flint murmur Mayne's sign Other endocardium endocarditis: Roth's spot Janeway lesion/Osler's node Bracht–Wachter bodies Pericardium Cardiac tamponade/Pericardial effusion: Beck's triad Ewart's sign Other rheumatic fever: Anitschkow cell Aschoff body EKG J wave Gallavardin phenomenon
Vascular disease	Arterial aortic aneurysm Cardarelli's sign Oliver's sign pulmonary embolism Right heart strain radial artery sufficiency Allen's test pseudohypertension thrombus Lines of Zahn Adson's sign arteriovenous fistula Nicoladoni–Branham sign Venous Friedreich's sign Caput medusae Kussmaul's sign Trendelenburg test superior vena cava syndrome Pemberton's sign