The value and limitations of precordial palpation have been reviewed in the light of recent information. A markedly enlarged heart in the absence of significant increase in volume load signifies poor myocardial function. It is often difficult to differentiate a fourth heart sound from similar auscultatory phenomena, but a palpable presystolic kick is a reliable clinical clue to an elevated left ventricular end-diastolic presure. A hyperkinetic apical impulse is seen in slim, anxious patients, those with hyperkinetic states, and typically those with left ventricular volume overload. However, a sustained systolic apical impulse need not necessarily mean increased pressure load on the left ventricle, as it could be encountered with combined volume and pressure load and in patients with markedly dilated left ventricle. A bifid systolic apical impulse has little significance. A trifid impulse (one presystolic and double systolic waves) is most often seen in idiopathic hyperkinetic subaortic stenosis. The left parasternal impulse is normally characterized by a brief gentle early systolic lift followed by systolic retraction. A rocking movement with a lift starting in diastole and peaking in early systole is typical of right ventricular volume overload. A midsystolic gentle heave is seen in patients with decreased anteroposterior chest diameter, in those with right ventricular pressure overloaded, and occasionally in those with anterior wall dyskinesia. A late systolic lift is encountered typically in patients with mitral regurgitation, and also with myocardial aneurysm. An example of the value of careful precordial palpation is in differentiating mitral regurgitation from aortic stenosis when the auscultatory findings are often indistinguishable. Mitral regurgitation gives a hyperkinetic apical impulse and a late systolic left parasternal lift, whereas aortic stenosis gives a sustained apical impulse and a gentle systolic retraction in the left parasternal area. Also, precordial palpation helps to differentiate constrictive pericarditis from restrictive cardiomyopathy. The first leads to systolic precordial retraction while the latter produces a palpable systolic outward movement. © 1979.
