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Comprehensive Evaluation of the Apex Beat Using 64-Slice Computed Tomography: Impact of Left Ventricular Mass and Distance to Chest Wall

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Comprehensive Evaluation of the Apex Beat Using 64-Slice Computed Tomography: Impact of Left Ventricular Mass and Distance to Chest Wall Journal of Cardiology (2010) 55, 256—265 View metadata, citation and similar papers at core.ac.uk brought to you by CORE available at www.sciencedirect.com provided by Elsevier - Publisher Connector journal homepage: www.elsevier.com/locate/jjcc Original article Comprehensive evaluation of the apex beat using 64-slice computed tomography: Impact of left ventricular mass and distance to chest wall Shoichi Ehara (MD, PhD) a,∗, Takuhiro Okuyama (MD, PhD) a, Nobuyuki Shirai (MD, PhD) a, Hiroki Oe (MD, PhD) a, Yoshiki Matsumura (MD, PhD) a, Kenichi Sugioka (MD, PhD) a, Toshihide Itoh b, Katharina Otani (PhD) b, Takeshi Hozumi (MD, PhD) a, Minoru Yoshiyama (MD, PhD, FJCC) a, Junichi Yoshikawa (MD, PhD, FJCC) c a Department of Internal Medicine and Cardiology, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka 545-8585, Japan b Siemens-Asahi Medical Technologies Ltd., Tokyo, Japan c Osaka Ekisaikai Hospital, Osaka, Japan Received 14 September 2009; received in revised form 9 November 2009; accepted 12 November 2009 Available online 14 January 2010 KEYWORDS Summary Apex beat; Objectives: Although physicians frequently perform palpation of the apex beat to evaluate left Apical impulse; ventricular (LV) size and hypertrophy, the clinical significance of apex beat palpation is still Computed unclear. The introduction of multislice computed tomography (MSCT) has enabled assessment tomography; not only of coronary stenoses but also LV volume, mass, and distance from heart to chest wall. Hypertrophy; The aim of this study was to evaluate the relationships among presence, location, and sustained Palpation or double apical impulse of apex beat and LV function, volume, mass, and distance from heart to chest wall determined by MSCT. Methods and results: The study population consisted of 200 consecutive patients clinically indi- cated for MSCT angiography for coronary artery evaluation. Apex palpation was performed with the patients in the supine and left lateral decubitus positions. Multivariate analysis revealed that LV mass index (p < 0.01), distance (p < 0.005), and being male (p < 0.005) remained inde- pendent factors associated with presence of apex beat in the supine position, and that LV mass index was also associated with location of apex beat. Furthermore, in patients with a palpa- ble apex beat, LV mass index was an independent factor associated with patterns of sustained or double apical impulse. In the group of all patients, patterns of sustained or double apical Abbreviations: LVH, left ventricular hypertrophy; LA, left atrial; LLD, left lateral decubitus; EDV, end-diastolic volume; BMI, body mass index; MSCT, multislice computed tomography; CAD, coronary artery disease; ESV, end-systolic volume; CI, confidence interval. ∗ Corresponding author. Tel.: +81 6 66453801; fax: +81 6 66466808. E-mail address: [email protected] (S. Ehara). 0914-5087/$ — see front matter © 2009 Japanese College of Cardiology. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.jjcc.2009.11.008 Comprehensive evaluation of apex beat using MSCT 257 impulse in the supine position had a sensitivity of 57%, specificity of 90%, positive predictive value of 68%, and negative predictive value of 85% as an indicator of LV hypertrophy. Conclusion: Palpation of the apex beat is a sensitive diagnostic maneuver for excluding patients with increased LV mass. We believe that our observations have important implications for bedside clinical examination. © 2009 Japanese College of Cardiology. Published by Elsevier Ireland Ltd. All rights reserved. apex beat diameter in the LLD position detected increased LV EDV or LV mass with a sensitivity of 100% and a speci- Introduction ficity of 40%, low rate of agreement between physicians may limit its clinical utility. Moreover, BMI and heart-to-chest dis- The importance of palpation of the apex beat on physical tance were not taken into account in their study, although examination has been emphasized to generations of medical it is known from findings of palpation that the apex beat is students. Many studies have obtained findings in the char- influenced by these factors. acteristics of the apex beat in relation to heart size and Recently, multislice computed tomography (MSCT) has function. A displaced apex beat is a clinical clue to cardiac reached a spatial and temporal resolution high enough for enlargement [1—3], and a sustained pattern has been con- assessment not only of coronary artery stenoses [10] and sidered a sensitive indicator of left ventricular hypertrophy plaques [11—13] but also LV function, volume, and mass, and (LVH) [4,5]. However, few clinicians consider the apex beat LA volume [14—16]. MSCT also enables precise measurement a good discriminator of cardiac enlargement and LVH, since of the distance from the heart to the chest wall. However, a number of factors, such as LV volume, LV mass, left atrial little objective evidence exists to validate palpation of the (LA) volume, and distance from the heart to the chest wall, apex beat as a means of diagnosis of increased LV mass. may affect palpation of the apex beat. We therefore examined how apex beat patterns obtained by The relationship between the apex beat and heart size palpation depend on patient position, as well as LV function, has previously been estimated using various modalities, such LV volume, LV mass, LA volume, and heart-to-chest distance as chest X-ray [6,7], transthoracic echocardiography [1,2,5], determined by MSCT, among other factors. and ultrafast computed tomography [3]. Mulkerrin et al. [7] compared the presence and location of the apex beat in Methods the left lateral decubitus (LLD) position with heart size cal- culated from chest X-ray, and reported that the apex beat Patients was not a useful clinical marker of heart size, being pal- pable in only 35% of subjects. Even when an impulse was The study population consisted of 200 consecutive patients palpable, displacement of the apex beat had a sensitivity (153 males, 47 females; mean age ± S.D., 64 ± 11 years) at of 69%, specificity of 74%, positive predictive value of 69%, Osaka City University clinically indicated for MSCT angiog- and negative predictive value of 69% as a marker of car- raphy for coronary artery evaluation between May 2007 diac enlargement. However, the reliability of radiographic and August 2008. Among these 200 patients, 60 had known cardiothoracic ratio as a surrogate for cardiac enlarge- coronary artery disease (CAD) (47 had undergone coronary ment is quite limited. A few echocardiographic studies have artery bypass surgery, while 13 had undergone percutaneous assessed the apex beat using quantitative LV data, but in coronary intervention); 114 were suspected to have CAD; 7 most of them apex palpation was performed with patients had valvular heart disease; and the remaining 19 had other in the LLD position to ensure adequate echocardiographic cardiac diseases (cardiomyopathy and aortic aneurysm). image quality [1,2,5,8]. Eilen et al. reported that location Patients with atrial fibrillation were excluded from the of the apex beat in relation to the mid-clavicular line is study. not a reliable indicator of increased LV end-diastolic vol- The following data parameters were determined: age, ume (EDV) [1]. However, they also palpated the apex beat sex, presence of risk factors (smoking, hypertension as only in the LLD position, and could not determine the clini- defined by the US Joint National Committee VII, diabetes cal significance of the apex beat in positions other than this. mellitus as defined by the World Health Organization Study Rotating the patient into the LLD position causes the heart to Group, or hypercholesterolemia as defined by the Japan move laterally. Furthermore, echocardiographic image qual- Atherosclerosis Society Guidelines), BMI, blood pressure ity depends on the skill of the operator and body mass index before image acquisition, and heart rates during scanning. (BMI) of the patient, and might be impaired by a poor acous- BMI was calculated by dividing body weight (kg) by the tic window or inadequate endocardial border discrimination square of height (m), with BMI ≥25.0 defined as obesity. in 5—10% of patients [9]. Thus, critical limitations remain The study was approved by the hospital Ethics Commit- associated with the use of echocardiography as a gold stan- tee, and informed consent was obtained from all patients dard for evaluation of the apex beat. Although examination before the study. of palpation was a secondary aim of their study and pat- terns of the apex beat were not assessed, Heckerling et Physical diagnostic maneuvers al., using ultrafast computed tomography [3], determined the sensitivity and specificity of apex beat distance from Immediately before image acquisition, apex palpation was the midsternal line and apex beat diameter in detecting performed with patients first in the supine and then in the increased LV EDV and LV mass. They concluded that although 45-deg LLD position. The point furthest down and outwards 258 S. Ehara et al. on the chest wall where the finger was lifted by a car- dual-head injector at a rate of 4.0 mL/s into a cubital vein, diac impulse was considered the apex beat. The location followed by 30 mL of saline solution chaser. The scan delay and pattern of each impulse that was felt were noted, and was determined using the bolus tracking technique. The CT the center of the apex beat was located in relation to the examination was performed with a tube voltage of 120 kV,an mid-clavicular line, defined as half the distance between effective tube current—time product of 770 effective mAs, a the sternal notch and the tip of the acromial process. When collimation of 64 mm × 0.6 mm, a pitch of 0.2, and a gantry no impulse was felt in the supine position, the patient was rotation time of 330 ms.
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