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308.e4
CHAPTER
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37
Percussion of the Heart
KEY TEACHING POINTS
• Although the clinical value of cardiac percussion is limited, the finding of cardiac dullness
extending less than 10.5 cm from the midsternal line greatly decreases the probability of
an enlarged heart on chest x-ray.
Introduction
I.
Percussion
enthusiastically introduced topographic percussion, a technique purportedly allowing clinicians to
precisely outline the borders of the underlying organs, including those of the heart.
many of Piorry’s claims seem extraordinary today (e.g., he declared that he could outline pulmonary cavities, the spleen, hydatid cysts, and even individual heart chambers), many of his innovations persist, including indirect percussion, the pleximeter (Piorry used an ivory plate, but most
clinicians now use the left middle finger), and the current practice of using percussion to locate the
border of the diaphragm on the posterior chest or the span of the liver on the anterior body wall.
In 1899, only 4 years after the discovery of roentgen rays, Williams challenged the accuracy
of cardiac percussion, showing that many patients with moderately large hearts (autopsy weight
of 350 to 500 grams) had normal findings during cardiac percussion.
fered another setback in 1907, when Moritz published the composite outlines of cardiac dullness
according to various authorities, showing that these authorities not only disagreed with each other
but also with the true roentgenographic outline.
regard percussion of the heart as unreliable and often inaccurate.
II.
Studies of cardiac percussion have several limitations, the most important of which is selectively
enrolling only healthy patients lacking chest deformities or emphysema. Nonetheless, even these
studies
cardiac border. Whether the patient is supine or upright, the average error in locating the cardiac
border is 1 to 2 cm (the standard deviation of this error is about 1 cm). e clinician usually overestimates the left border by placing it too far lateral and underestimates the right border by placing it too near the sternum (these errors tend to cancel each other if the study’s endpoint is total
transverse diameter of the heart).
e traditional sign of an enlarged heart by percussion is cardiac dullness that extends too far
laterally. e findings of either cardiac dullness extending beyond the midclavicular line or more
than 10.5 cm f rom the midsternal line modestly increase the probability of an enlarged cardiothoracic ratio (likelihood ratio [LR] = 2.4 to 2.5; EBM Box 37.1). If cardiac dullness does not
of the heart has its roots in the 1820s, when a student of Laennec, Pierre Piorry,
1–3
Although
5
Cardiac percussion suf-
4,6
By the 1930s, many leading clinicians began to
4,7
Clinical Significance
show that the percussed outline of the heart correlates only moderately with the true
8–11
In patients with emphysema, the errors are even greater.
12
4
309
310
PERCUSSION OF THE HEART
c
Cardiac dullness <10.5 cm from
against cardiothoracic ratio >0.5
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EBM BOX 37.1 Percussion of the Heart*
Likelihood Ratio†
Finding (Reference)
Dullness extends more than 10.5 cm from midsternal line, patient supine
Detecting cardiothoracic ratio >0.51397 61 2.5 0.05
Detecting increased left ventricular
end-diastolic volume
Dullness extends beyond midclavicular line, patient upright
Detecting cardiothoracic ratio >0.5897 60 2.4 0.1
*Diagnostic standard: for cardiothoracic ratio, maximal transverse diameter of heart on chest radiography
divided by maximal transverse diameter of thoracic cage; for increased left ventricular end-diastolic
volume, >186 mL by ultrafast computed tomography.
†
Likelihood ratio (LR) if finding present = positive LR; LR if finding absent = negative LR.
NS, Not significant.
14
Sensitivity
(%)
94 32 1.4 NS
Specificity
(%)
14
Probability
Decrease Increase
LRs
0.1 0.2 0.5 12510
if Finding Is
Present Absent
+45%+30%+15%–15%–30%–45%
LRs
8—THE HEART
midsternum, arguing against
cardiothoracic ratio >0.5
Cardiac dullness medial to
midclavicular line, arguing
extend beyond these points, the patient probably does not have an enlarged cardiothoracic ratio
(LRs = 0.05 to 0.1; EBM Box 37.1). Nonetheless, it is unlikely that this information is clinically
useful since the cardiothoracic ratio has uncertain clinical significance.
References may be accessed online at Elsevier eBooks for Practicing Clinicians.
Cardiac dullness >10.5 cm from
midsternum, detecting cardiothoraci
ratio >0.5
15
References
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1. Buzzi A. Piorry on percussion of the heart. Am J Cardiol. 1960;5:703–705.
2. Risse GB, Pierre A. Piorry (1794-1879), the French “master of percussion”. Chest. 1971;60(5):484–488.
3. Sakula AP. Adolphe Piorry (1794-1879): pioneer of percussion and pleximetry. orax. 1979;34(5):
575–581.
4. McGee S. Percussion and physical diagnosis: separating myth f rom science. Dis Mon. 1995;41(10):643–692.
5. Jarcho S. Percussion of the heart contrasted with roentgen examination (Williams, 1899). Am J Cardiol.
1969;23(6):845–849.
6. Moritz F. Einige Bemerkungen zur Frage der perkutorischen Darstellung der gesamten Vorderfläche
Des Herzens. Dtsch Arch Klin Med. 1907;88:276–285.
7. Parkinson J. Enlargement of the heart. Lancet. 1936;227(5885):1337–1391.
8. Kurtz CM, White PD. e percussion of the heart borders and the roentgen ray shadow of the heart.
Astudy of one hundred cases. Am J Med Sci. 1928;176:181–195.
9. Mainland D, Stewart CB. A comparison of percussion and radiography in locating the heart and superior
mediastinal vessels. Am Heart J. 1938;15(5):515–527.
10. Karnegis JN, Kadri N. Accuracy of percussion of the left cardiac border. Int J Cardiol. 1992;37(3):361–364.
11. Stroud WD, Stroud III MW, Marshall DS. Measurement of the total transverse diameter of the heart by
direct percussion. Am Heart J. 1948;35(5):780–786.
12. Dietlen H. Die Perkussion der Wahren Herzgrenzen. Dtsch Arch Klin Med. 1906-1907;88:286–301.
13. Heckerling PS, Wiener SL, Moses VK, Claudio J, Kushner MS, Hand R. Accuracy of precordial percus-
sion in detecting cardiomegaly. Am J Med. 1991;91(4):328–334.
14. Heckerling PS, Wiener SL, Wolfkiel CJ, etal. Accuracy and reproducibility of precordial percussion and
palpation for detecting increased left ventricular end-diastolic volume and mass. A comparison of physical findings and ultrafast computed tomography of the heart. JAMA. 1993;270(16):1943–1948.
15. Chana HS, Martin CA, Cakebread HE, Adjei FD, Gajendragadkar PR. Diagnostic accuracy of cardio-
thoracic ratio on admission chest radiography to detect left or right ventricular systolic dysfunction: a
retrospective study. J R Soc Med. 2015;108(8):317–324.
310.e1
CHAPTER
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38
Palpation of the Heart
KEY TEACHING POINTS
• A displaced supine apical impulse—defined as an impulse lateral to the midclavicular line
(MCL)—is an accurate sign of an enlarged heart, reduced ejection fraction, and increased
pulmonary capillary wedge pressure.
• Other measures of the displaced apical impulse (i.e., lateral to the nipple line or more than
10 cm from the midsternal line) are not as accurate as using the MCL for reference.
• In patients with mitral stenosis, the hyperkinetic apical movement indicates additional
valvular lesions.
• In patients with chest pain or dyspnea, the sustained or double apical movement
increases probability of left ventricular hypertrophy.
• Three different precordial movements increase probability of moderate-to-severe tricuspid
regurgitation: a lower sternal pulsation, a pulsatile liver, and the right ventricular rock.
I. Introduction
Much of the science of heart palpation is based on impulse cardiography and kinetocardiography,
research tools from the 1960s that precisely timed normal and abnormal precordial movements
and compared them with hemodynamic data and angiograms of the right ventricle and left ventricle. ese precise and sensitive instruments could detect very small movements of the body wall,
many of which are inconspicuous to the clinician’s hand. Although this chapter refers to these
studies to make certain points, only those movements easily palpable at the bedside are discussed.
Palpation of the heart is among the oldest physical examination technique, having been
recorded as early as 1550 BC by ancient Egyptian physicians (along with palpation of the peripheral pulses).1 In the early 19th century, Jean-Nicolas Corvisart, personal physician to Napoleon
and teacher of Laennec, was the rst to correlate cardiac palpation with postmortem ndings
and distinguish right ventricular enlargement from left ventricular enlargement.
experiments performed in 1830, James Hope proved that the cause of the apical impulse was
ventricular contraction, which threw the heart up against the chest wall.
II. Technique
When palpating the chest, the clinician should describe the location, size, timing, and type of
precordial movements.
6
2–4
During animal
5
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8—THE HEART
A. PATIENT POSITION
e clinician should rst palpate the heart when the patient is lying supine and again with the
patient lying on his or her left side. e supine position is used to locate all precordial movements
and to identify whether these movements are abnormally hyperkinetic, sustained, or retracting
(see later). e left lateral decubitus position is used to measure the diameter of the apical impulse
and to detect additional abnormal diastolic lling movements (i.e., palpable third or fourth heart
sounds).
7
Because the left lateral decubitus position distorts the systolic apical movement, including
those of healthy subjects (i.e., up to half of healthy patients have abnormally sustained movements
in the lateral decubitus position), only the supine position should be used to characterize the timing of the precordial movement.
8
B. LOCATION OF ABNORMAL MOVEMENTS
Complete palpation of the heart includes four areas on the chest wall (Fig. 38.1).
1,6,9–12
1. Apex Beat
e apex beat or apical impulse is the palpable cardiac impulse farthest away from the sternum
and farthest down on the chest wall, usually caused by the left ventricle and located near the
midclavicular line (MCL) in the fth intercostal space. e clinician should also palpate the areas
above and medial to the apex beat, where ventricular aneurysms sometimes become palpable.
2. Left Lower Sternal Area (Fourth Intercostal Space Near Left Edge of
Sternum)
Abnormal right ventricular and left atrial movements appear at this location.
3. Left Base (Second Intercostal Space Near the Left Sternum)
Abnormal pulmonary artery movements or a palpable P2 appear at this location.
Lower parasternal
Fig. 38.1 Locations of precordial movements. The principal areas of precordial pulsations are the api-
cal area, lower parasternal area, left base (i.e., second left intercostal parasternal space, “pulmonic area”),
right base (i.e., second right intercostal parasternal space, “aortic area”), and sternoclavicular areas. In some
patients, especially those with chronic lung disease, right ventricular movements may appear in the epigastric
area. The best external landmark is the sternal angle, which is where the second rib joins the sternum.
Sternoclavicular
Left base (“pulmonic”)Right base (“aortic”)
Apical
Epigastric
38—PALPATION OF THE HEART
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313
4. Right Base (Second Intercostal Space Near Right Edge of Sternum)
and Sternoclavicular Joint
Movements from an ascending aortic aneurysm may become palpable here.
C. MAKING PRECORDIAL MOVEMENTS MORE CONSPICUOUS
Two teaching techniques are often used to bring out precordial movements and make them easier
to time and characterize. In the rst technique, the clinician puts a dot of ink on the area of interest, whose direction and timing then become easy to see. In the second technique, the clinician
holds a cotton-tipped applicator stick (or wooden coee stirrer) against the chest wall, with the
end of the stick just o the center of the area of interest (the stick should be several inches long).
e stick becomes a lever and the pulsating chest wall a fulcrum, causing the free end of the stick
to trace in the air a magnied replica of the precordial movement.13 A folded paper stick-on note
may substitute for the applicator stick.
14
III. The Findings
Precordial movements are timed by simultaneously listening to the heart tones and noting the
relationship between outward movements on the chest wall and the rst and second heart sounds.
ere are four types of systolic movement: normal, hyperkinetic, sustained, and retracting.
A. NORMAL
e normal systolic movement is a small outward movement that begins with S1, ends by mid
systole, and then retracts inward, returning to its original position long before S2.
e normal apical impulse is caused by a brisk early systolic anterior motion of the anteroseptal
wall of the left ventricle against the ribs.15 Despite its name, the apex beat bears no consistent
relationship to the anatomic apex of the left ventricle.15 In the supine position, the apex beat is
palpable in only 25% to 40% of adults.
to 73% of adults.
16,20,21
e apex beat is more likely to be palpable in patients who have less body
fat and who weigh less.22 Some studies show that the apical impulse is more likely to be present
in women than men, but this dierence disappears after controlling for the participant’s weights.
16–19
In the lateral decubitus position, it is palpable in 50%
1,6,9–11
18
B. HYPERKINETIC
e hyperkinetic (or overacting) systolic movement is a movement identical in timing to the
normal movement, although its amplitude is exaggerated. Distinguishing normal from hyperkinetic amplitude is a subjective process, even on precise tracings from impulse cardiography. is
probably explains why the nding has minimal diagnostic value, appearing both in patients with
volume overload of the left ventricle (e.g., aortic regurgitation, ventricular septal defect) and in
some normal persons who have thin chests or increased cardiac output.
C. SUSTAINED
e sustained movement is an abnormal outward movement that begins at S1 but, unlike normal
and hyperkinetic movements, extends to S2 or even past it before beginning to descend to its original position. e amplitude of the sustained movement may be normal or increased. Sustained
apical movements are always abnormal, indicating either pressure overload of the left ventricle
(e.g., aortic stenosis, severe hypertension), volume overload (e.g., aortic regurgitation, ventricular
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8—THE HEART
septal defect), a combination of pressure and volume overload (combined aortic stenosis and
regurgitation), severe cardiomyopathy, or ventricular aneurysm.
D. RETRACTING
In the retracting movement, inward motion begins at S1 and outward motion does not start until
early diastole. Because retracting movements are sometimes identical to normal movements in
every characteristic except for timing, they are easily overlooked unless the clinician listens to the
heart tones when palpating the chest. Only two diagnoses cause the retracting impulse, constrictive pericarditis and severe tricuspid regurgitation.
1,8,11
E. HEAVES, LIFTS, AND THRUSTS
e words heave and lift sometimes refer to sustained movements, and thrust to hyperkinetic ones,
but these terms, often used imprecisely, are best avoided.
1,9–11
IV. Clinical Significance
A. APEX BEAT
1. Location
A traditional sign of an enlarged heart is an abnormally displaced apical impulse, which means it
is located lateral to some external reference point. e three traditional reference points are (1) the
MCL, (2) a set distance from the midsternal line (the traditional upper limit of normal is 10 cm),
and (3) the nipple line.
Of these three landmarks, the MCL is the best, as long as the clinician locates it precisely by
palpating the acromioclavicular and sternoclavicular joints and marking the midpoint between
them with a ruler.
line increases the probability that the heart is enlarged on the chest radiograph (likelihood ratio
[LR] = 3.4; see EBM Box 38.1), the ejection fraction is reduced (LR = 10.3), the left ventricular
end-diastolic volume is increased (LR = 5.1), and the pulmonary capillary wedge pressure is
increased (LR = 5.8). Other studies conrm the relationship between the displaced apical impulse
and depressed ejection fraction.
Using a point 10 cm from the midsternal line to dene the displaced impulse is not a useful
predictor of the enlarged heart (positive LR not signicant, negative LR = 0.5; see EBM Box
38.1), probably because the 10 cm threshold is set too low (the MCL usually lies 10.5 to 11.5 cm
from the midsternal line).23 Finally, the nipple line is the least reliable of the three landmarks,
bearing no consistent relationship to the apical impulse or to the size of the chest, even in men.
e distance of the nipple line from the midsternum or midclavicular line varies greatly
23,24
In the supine patient, an apical impulse located outside the midclavicular
32
33
2. Diameter of the Apical Impulse
As measured in the left lateral decubitus position at 45 degrees, an apical impulse with a diameter of 4 cm or more increases the probability that the patient has a dilated heart (LR = 4.7 for
increased left ventricular end-diastolic volume; see EBM Box 38.1). Smaller thresholds (e.g., 3 cm)
discriminate between dilated and normal hearts in some studies, but not in others.
3. Abnormal Movements
a. Hyperkinetic Apical Movements
e hyperkinetic apical movement is an important nding in one setting. In patients with mitral
stenosis, left ventricular lling is impaired, causing the apical impulse to be normal or even
20,31
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