Inspection of the Precordium and Apical Impulse

Normal Findings

• The American Heart Association recommends that a normal precordial examination reveals a symmetric chest with a single outward apical impulse located at the 5th intercostal space inside the mid-clavicular line 1, 2
• Normal inspection reveals a symmetric thorax without visible malformations, asymmetry, or surgical scars 1
• The chest wall should be free from any infection or other forms of disease 1
• In normal adults, the precordium should not demonstrate any visible pulsations except for the apical impulse 3, 2
• Normally, the apical impulse appears as a single outward impulse, usually located at the 5th intercostal space inside the mid-clavicular line 1, 2

Abnormal Findings

• Lateral displacement of the apical impulse beyond the mid-clavicular line suggests left ventricular enlargement, according to the American College of Cardiology 3, 2
• Displacement of the apical impulse may occur in conditions such as left ventricular hypertrophy, as stated by the American Heart Association 4
• Dilated cardiomyopathy may cause displacement of the apical impulse, as reported by the European Society of Cardiology 5
• A hyperactive apical impulse may be seen in hyperdynamic states such as anemia, thyrotoxicosis, and aortic regurgitation, as described by the American College of Cardiology 1, 2, 3
• A sustained apical impulse may indicate pressure overload conditions such as aortic stenosis, according to the American Heart Association 3, 4
• Parasternal heave/lift suggests right ventricular hypertrophy or enlargement, as stated by the American College of Cardiology 4
• Visible pulsations in the epigastric area may indicate right ventricular enlargement or abdominal aortic pulsations, as reported by the European Society of Cardiology 3
• Systolic retraction may indicate severe left ventricular dysfunction or aneurysm, according to the European Heart Journal 6
• In Takotsubo cardiomyopathy, apical ballooning may be detected as an abnormal apical impulse with hypokinesis of mid and apical segments, as described by the European Society of Cardiology 7
• In acute severe mitral regurgitation, the precordial impulse may be misleading as a normal-sized left ventricle does not produce a hyperdynamic apical impulse despite the severity of the condition, as stated by the American College of Cardiology 3
• In hypertrophic cardiomyopathy, a double or bifid apical impulse may be appreciated, as reported by the American Heart Association 4
• Obesity, emphysema, or thick chest walls may obscure the apical impulse even when cardiac enlargement is present, according to the American College of Cardiology 2

Point of Maximal Impulse Displacement Conditions

Normal PMI Location and Variation

• The normal PMI location is at the 5th intercostal space inside the mid-clavicular line, but this is subject to great individual variation, and the American College of Emergency Physicians notes that the location varies considerably between individuals 8
• When performing echocardiography, the probe should be placed at the PMI as determined by physical exam to obtain the apical four-chamber view, according to the American College of Emergency Physicians 8