A large ventricular aneurysm may yield a palpable and visible ectopic impulse discrete from the apex beat. A prominent, rapid early filling wave in patients with advanced systolic heart failure may result in a palpable third sound (S 3), which may be present when the gallop itself is not audible ( Video 10.3 ). A palpable, presystolic impulse corresponds to a fourth heart sound (S 4) and reflects the atrial contribution to ventricular diastolic filling of a noncompliant left ventricle. A sustained apex beat is a sign of LV pressure overload (as in aortic stenosis or hypertension). LV cavity enlargement displaces the apex beat leftward and downward. The normal impulse may not be palpable in obese or muscular patients or in those with thoracic cage deformities. It is best appreciated at end-expiration, when the heart is closest to the chest wall. It is smaller than 2 cm (0.8 inch) in diameter and moves quickly away from the fingers. The point of maximal impulse normally is over the left ventricular (LV) apex beat and should be located in the midclavicular line at the fifth intercostal space. If the heart is not palpable in this position, the patient should be examined either in the left lateral decubitus position with the left arm above the head or in the seated position, leaning forward. Palpation of the heart should begin with the patient in the supine position inclined at 30 degrees. In very thin, tall patients, or in patients with emphysema and flattened diaphragm, the RV impulse may be visible in the epigastrium and should be distinguished from a pulsatile liver edge. A pulsation in the third intercostal space to the left of the sternum can indicate PA hypertension. A left parasternal lift indicates RV pressure or volume overload. Right upper parasternal and sternoclavicular pulsations suggest ascending AAA disease. The left anterior chest wall may heave in patients with enlarged and hyperdynamic left ventricles. The apical heartbeat may be visible in thin-chested adults. Zipes MD, in Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 2019 Inspection and Palpation of the Heart
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