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Home , Apex beat, Auscultation, Heart sounds

Postgrad Med J: first published as 10.1136/pgmj.44.507.81 on 1 January 1968. Downloaded from Festschrift for Sir John McMichael 81

References KOPELMAN, H., ROBERTSON, M.H., SANDERS, P.G. & ASH, I. ANON. (1966) Editorial: Toxic bread. J. Amer. med. Ass. 196, (1966a) The Epping Jaundice. Brit. med. J. i, 514. 1150. KOPELMAN, H., SCHEUER, P.J. & WILLIAMS, R. (1966b) The CHUTTARI, H.K., SIDHU, WIG, K.L., GUPTA, D.N., RAMA- liver lesion of the Epping LINGASWAMI, V. (1966) Follow-up study of cases from the Jaundice. Quart. J. Med. 25, 553. Delhi epidemic of infectious hepatitis, 1955-56. Brit. med. SHERLOCK, S. & WALSHE, V.M. (1946) The post-hepatitis J. ii, 676. syndrome. Lancet, ii, 482.

The value of praecordial pulsations in the diagnosis of disease

PATRICK MOUNSEY Royal Postgraduate Medical School, London

PALPATION of the praecordium is as indispensable relation to a fixed point in space. Various as of the heart in clinical examina- methods have been used for making this mea- tion of the cardiac patient. Indeed, the two surement, by Dressler in 1937, Eddleman et al. should be practised simultaneously, checking the in 1953 and by Beilin & Mounsey in 1962. We timing of and praecordial move- have called our instrument the impulse cardio- ments in relation to one another. To some ex- gram and it aims at being a graphic record of tent the introduction of the modern binaural what the physician's hand and fingers feel. with its flexible rubber tubes has by copyright. been a retrograde step, since this instrument is less suited to simultaneous analysis of praecordial The technique of palpating the praecordium pulsations and heart sounds than was the original It is often a good practice when examining the solid tubular stethoscope invented by Laennec. praecordium to place the whole palm of the In the Traite de l'Auscultation Mediate, Laennec hand over the area of the chest that underlies (1819) emphasized that his instrument could be the heart. In this way, one can imagine that one used not only to auscultate the heart but also is holding the anterior surface of the heart in to appreciate accurately the cardiac impulse. He the cup of one's hand, thus appreciating both includes in his book a chapter on the cardiac right and left heart events simultaneously. Care impulse and states that a forcible impulse should should be taken, however, not to assume that http://pmj.bmj.com/ be regarded as the principle sign of cardiac pulsations at the apex are always due to the left hypertrophy. , while those in the left parasternal area Improved methods of recording the cardiac are due to the right. Although this state- impulse have been slower to develop than has ment is true probably in about 90% of patients, phonocardiography, although apex cardiography in the other 10% it is misleading. With great was one of the earliest methods introduced for enlargement of either left or right ventricle the recording the heart beat (Marey, 1878). Apex of relationship underlying chambers of the heart on October 2, 2021 by guest. Protected cardiography suffers from the disadvantage that to the praecordium are altered (Fig. 1). Thus, it is only a record of the relative displacement with marked left ventricular hypertrophy this of a point in an intercostal space in relation to chamber may underlie the whole area of prae- the immediately surrounding area of chest wall. cordium from the to the left sternal In cardiac diagnosis it is often the displacement edge, the right ventricle being pushed over to of a large area of the thoracic cage by the the right. Similarly, with great right ventricular movements of the underlying heart that is im- enlargement this chamber forms the apex of the portant diagnostically, (as in the left parasternal heart, the left ventricle being rotated posteriorly lift of right ventricular hypertrophy), and not (Deliyannis et al., 1964). It is more accurate, the relative movement of a small area in an therefore, when describing praecordial pulsations intercostal space. To record this, an instrument to relate these to the areas on the chest wall is required that measures absolute displacement, where they are felt, rather than to term them that is the total movement of the chest wall in 'right or left ventricular types' of impulse. F Postgrad Med J: first published as 10.1136/pgmj.44.507.81 on 1 January 1968. Downloaded from 82 Postgraduate Medical Journal

(a) (b) (c) FIG. 1. Superimposed tracings of right (dotted line) and left (solid line) ventricular angiocardiograms of (a) normal subject with functional systolic murmur. The apex beat (black dot) lies 2 cm lateral to the right ven- tricular cavity and overlies the antero-septal ventricular wall. (b) Patient with left ventricular hypertrophy from mitral incompetence. The apex beat (black dot) overlies the antero-lateral wall of the left ventricle; the left para- sternal area overlies its antero-septal ventricular wall. (c) Patient with right ventricular hypertrophy from pulmonary and ventricular septal defect. The apex beat (black dot) in the fourth intercostal space, 7 cm to the left of the mid line, overlies the anterior wall of the right ventricle. The left parasternal area overlies the more medial portion of the anterior wall of the right ventricle. The lies in the coronal plane, with the left ventricle rotated posteriorly. (Antero-posterior views.)

The genesis of the cardiac impulse in health and 1. The apical impulse in ventricular disease The first part of the apical impulse, both in Angiocardiographic and cinefluoroscopic health and disease, is probably caused by similar by copyright. studies have shown close correlation between the mechanisms. In William Harvey's words (1628), movements of the heart and the form of the 'the heart erects and raises itself into a point, cardiac impulse. so that at this moment it strikes the chest wall http://pmj.bmj.com/ EJECT%ION

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FIG. 2. Left ventricular angiocardiograms (lateral view) of patient with small ventricular septal defect; in (left) and in late systole (right). In line diagram, interrupted lines indicate diastolic, and solid line indicates late systolic cavity-wall positions. Apical retraction demonstrated in late systole coinciding with retraction in impulse cardiogram. Postgrad Med J: first published as 10.1136/pgmj.44.507.81 on 1 January 1968. Downloaded from Festschrift for Sir John McMichael 83

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FIG. 3. Left ventricular angiocardiograms (lateral view) of patient with aortic and mitral incompetence; in diastole (left) and in late systole (right). In line diagram, interrupted lines indicate diastolic, and solid line indicates late systolic cavity-wall positions. Apical portion of heart fails to retract in late systole, thus accounting for sustained, thrusting apical impulse. and externally a pulsation can be felt'. It is dur- trophy, thus tending to inhibit the apical re- ing the latter part of systole that the heart be- tracting action of the spiral fibres (Fig. 4) haves abnormally in the presence of hypertrophy. (Deliyannis et al., 1964). Other factors, however, Whereas in health the anterior wall of the heart probably also contribute to the genesis of the retracts from the thoracic cage as the heart sustained impulse including general increase in by copyright. empties in late systole (Fig. 2), in left ventricular heart size and sometimes dilatation as well as hypertrophy the antero-apical portion of the hypertrophy. heart fails to retract in late systole (Fig. 3), thus The cause of the sustained impulse in ventri- giving rise to the sustained cardiac impulse felt cular aneurysm is not far to seek. The aneurys- over the praecordium. Studies of the different mal wall which is composed entirely of fibrous muscle layers of the heart have suggested that tissue without any living myocardium, is unable the cause of this phenomenon is extension of the to take part in concentric contraction of the middle circular layer of muscle fibres toward heart and herniates outwards during ventricular the apex of the heart in the presence of hyper- systole (Fig. 5). The marked systolic retraction and diastolic

Normal heort Hypertrophied heart expansion seen in some cases of constrictive http://pmj.bmj.com/ is probably related to tethering of ~ Aota ~tro tra the inflow and outflow tracts of the ventricles, rinA in annular constrictive pericarditis (Fig. 6). In this condition, the anterior wall of the ventricles is often relatively free from constriction and Circular hence shows exaggerated contraction during w 7~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~n ventricular systole and expansion during dia-

4 ~~~~~~~~Circular ~ stole. Ventricular filling is abnormally abrupt on October 2, 2021 by guest. Protected and forceful due to the high venous filling pres- LV LV sure. The marked systolic retraction and large Apex Apex diastolic rapid inflow beat seen in the impulse cardiogram closely reflect the underlying heart FIG. 4. Schema of forces resulting from contraction of middle circular and of spiral fasciculi of left ventricle. wall movements (Mounsey, 1959). In health, the middle circular fasciculus constricts the Apical retraction seen in tricuspid incompet- upper portion ofthe heart, while the relatively unopposed ence is due to a different mechanism, reflecting spiral fibres retract the apex. In left ventricular hyper- the increased stroke output of the dilated right trophy the widened middle circular fasciculus extends further toward the apex, thus tending to inhibit the ventricle which is both ejecting blood into the apical retracting action of the spiral fasciculus. pulmonary and regurgitating it through Postgrad Med J: first published as 10.1136/pgmj.44.507.81 on 1 January 1968. Downloaded from 84 Postgraduate Medical Journal the incompetent into the right 2. The atrial beat . Cineradiological studies show a marked Increased atrial transport function with de- seesaw motion of the heart, with inward move- creased ventricular compliance is probably the ment of the left cardiac border during systole basic abnormality responsible for an augmented and simultaneous outward movement of the right atrial beat associated with ventricular hyper- atrial border. This seesaw cardiac motion is trophy. In hypertrophic obstructive cardiomyo- clearly reflected in the movements imparted to pathy, where great ventricular hypertrophy is the whole praecordium (Boicourt, Nagle & seen, the major portion of ventricular filling has Mounsey, 1965). been shown to take place during atrial systole by copyright. http://pmj.bmj.com/ on October 2, 2021 by guest. Protected

FIG. 5. Impulse cardiogram, chest X-ray, cineradiogram left cardiac border, and cross-section of heart at autopsy in patient with cardiac aneurysm. Paradoxical systolic pulsation shown in cineradiogram tracings, accounting for overlying sustained cardiac impulse. Bulging of left cardiac border in chest X-ray. Extensive infarct involving whole of lateral wall of left ventricle at autopsy. ECG showing ST elevation and tall T waves in anterior chest leads. Postgrad Med J: first published as 10.1136/pgmj.44.507.81 on 1 January 1968. Downloaded from Festschrift for Sir John McMichael 85

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FIG. 6. (a) Annular constrictive pericarditis as seen at operation. Pericardial constriction, (1) in A-V groove, and (2) around base of aorta and . (b) Praecordial impulse cardiogram (MID P) showing systolic retraction in constrictive pericarditis. The outward diastolic pulsation is the diastolic rapid inflow beat (DRI beat). The early diastolic sound (EDS) coincides with the steep portion of the upstroke of the DRI beat. : PA, MF: pulmonary area, medium frequency. 2' and 2": split second heart sound. LSE, MF: left sternal edge, medium frequency. Electrocardiogram lead 1I. by copyright. the thin tambour-like quality of the aneurysmal wall. V 4 Acknowledgments ORS The illustrations are reproduced by kind permission of the Editor of the British Heart Journal, 21, 325 (1959), 24, 409 oL (1962), 26, 396 (1964), 27, 379 (1965), 28, 419 (1966). References BEILIN, L. & MOUNSEY, J.P.D. (1962) The left ventricular impulse in hypertensive heart disease. Brit. Heart J. 24, 409. BoICOURT, O.W., NAGLE, R.E. & MOUNSEY, J.P.D. (1965) http://pmj.bmj.com/ The clinical significance of systolic retraction of the apical impulse. Brit. Heart J. 27, 379. DELIYANNIS, A.A., GILLAM, P.M.S., MOUNSEY, J.P.D. & STEINER, R.E. (1964) The cardiac impulse and the motion of the heart. Brit. Heart J. 26, 396. DRESSLER, W. (1937) Pulsations of the wall of the chest. FIG. 7. Superimposed tracings of cineangiocardio- Arch. intern. Med. 60, 662. grams of right ventricle in left lateral view, at three EDDLEMAN, E.E., WILLIS, K., REEVES, T.J. & HARRISON, T.R. points during , indicated in simultaneous (1953) The kinetocardiogram. I. Method of recording

electrocardiogram. Note major increase of ventricular praecordial movements. Circulation, 8, 269. on October 2, 2021 by guest. Protected cavity area during downstroke of P wave (-- - line) HARVEY, W. (1628) Exercitatio anatomica de Motu Cordis and beginning of QRS (- - - line), i.e. in atrial et Sanguinis in Animalibus. Frankfurt. systole and end-diastole. LAENNEC (1819) De l'Auscultation Mediate, pp. 206-210. J. A. Brosson, Paris. MACKENZIE, J. (1908) Diseases of the Heart. Oxford Uni- in cineangiocardiographic studies. This is asso- versity Press. ciated with a large outward movement of the MAREY, E.J. (1878) La Methode graphique dans les Sciences anterior ventricular wall which in turn causes experimentales. Masson, Paris. the giant atrial beat in the cardiac impulse (Fig. MOUNSEY, J.P.D. (1959) Annular constrictive pericarditis. Brit. Heart J. 21, 325. 7) (Nagle et al., 1966). In ventricular aneurysm, NAGLE, R.E., BoICOURT, O.W., GILLAM, P.M.S. & MOUNSEY, however, another factor is probably contributing J.P.D. (1966) Cardiac impulse in hypertrophic obstructive to the large amplitude of the atrial beat, namely cardiomyopathy. Brit. Heart J. 28, 419.