Abnormal Apex Impulse

CLINICAL DIAGNOSTIC MANUAL

An abnormal apex impulse refers to a deviation in the location, intensity, or duration of the apical impulse of the heart, which is normally felt in the fifth left intercostal space at the midclavicular line.

This alteration can indicate various cardiac and extracardiac pathologies that affect the structure and function of the heart. Identifying and evaluating the apical impulse are crucial in the cardiovascular physical examination, providing valuable insights into the patient’s hemodynamic status.

Pathology	Suspected Diagnosis	Confirmatory Diagnosis
Interposition of fat, fluid, or air in the dermis	Displaced or non-palpable apical impulse, history of trauma or surgery.	Chest X-ray, echocardiogram, CT scan.
Dextrocardia	Apical impulse on the right side of the chest, thoracic asymmetry.	Chest X-ray, echocardiogram, CT scan.
Left ventricular hypertrophy	Displaced and sustained apical impulse, hypertension, dyspnoea.	Echocardiogram, ECG, blood tests.
Dilated left ventricle	Displaced and hyperdynamic apical impulse, dyspnoea, fatigue.	Echocardiogram, chest X-ray, CT scan.
Hypertrophic cardiomyopathy	Hyperdynamic and double apical impulse, dyspnoea, palpitations.	Echocardiogram, ECG, cardiac MRI (CMR).
Ventricular aneurysm	Hyperdynamic and sustained apical impulse, history of myocardial infarction.	Echocardiogram, CT scan, cardiac catheterisation.
Mitral stenosis	Hyperdynamic apical impulse, dyspnoea, diastolic murmur.	Echocardiogram, ECG, chest X-ray.
Right ventricular hypertrophy	Prominent left parasternal impulse, dyspnoea, cyanosis.	Echocardiogram, ECG, chest X-ray.