praecordial pulsations in health and disease · postgrad. med.j. (february 1958) 44, 134-139....

Postgrad. med. J. (February 1958) 44, 134-139.

Praecordial pulsations in health and disease

PATRICK MOUNSEYM.D., F.R.C.P.

Royal Postgraduate Medical School, London, W.12

SummaryIn a previous paper (Mounsey, 1966) the

genesis of praecordial pulsations in health anddisease was examined. The normal, short, out-ward impulse at the apex reflected underlyingearly systolic outward movement of the under-lying ventricle as visualized in the lateral angio-cardiogram. The sustained impulse of left ventri-cular hypertrophy was seen in the angiocardio-gram to be due to failure of retraction of theantero-apical portion of the left ventricle in latesystole. In cardiac aneurysm where a sustainedimpulse is also met, paradoxical pulsation of theaneurysm with failure of late systolic retractionaccounted for the abnormal impulse.Marked systolic retraction of the cardiac im-

pulse was met in two important conditions, tri-cuspid incompetence and constrictive pericarditis.The high stroke-output of the dilated right ven-tricle in tricuspid incompetence with both for-ward and backward ejection of blood accountedfor systolic retraction at the apex in this con-dition. In constrictive pericarditis, on the otherhand, in cases where the process involves pre-dominantly the atrioventricular groove and out-flow tract regions, the relatively free surface ofthe anterior wall of the right ventricle may showcompensatory increased movement with markedsystolic retraction and diastolic expansion, them-selves in turn transmitted to the praecordium.The giant atrial beat of hypertrophic obstruc-

tive cardiomyopathy reflected increased atrio-ventricular transport function as was shown inthe timed cineangiocardiogram.

In the present paper, details of the form ofthe cardiac impulse in health and disease aredescribed. These have been recorded with aninstrument measuring absolute displacement, theimpulse cardiograph (Beilin & Mounsey, 1962).The impulse cardiogram aims at being a graphicrecord of what the physician's hand and fingersfeel.

The form of the ventricular systolic impulseIn the same way that phonocardiography has

emphasized the importance of accurate timingof sounds and murmurs, so impulse cardiographyhas shown the diagnostic value of careful timingof the impulse. Too much importance shouldnot be attached to the amplitude of the cardiacimpulse. This may be exaggerated in the pres-ence of a normal heart in thin and anxious sub-jects or be diminished with a hypertrophiedheart in a fat placid patient with a barrel chest.Timing of the ventricular systolic impulse, how-ever, is not affected by either the patient's buildor his basal state, but is closely related to thepresence of heart disease.There are four main types of ventricular sys-

tolic impulse, each of which can be readilydistinguished at the bedside (Mounsey, 1966).Timing of the impulse is achieved by listeningwith the stethoscope and simultaneously palpat-ing and observing praecordial movements. Thenormal cardiac impulse is a relatively short out-ward movement, starting at the time of the firstheart sound (Fig. la). Its peak is reached dur-ing the first third of systole, after which it fallsinwards again, usually showing some retractionin late systole. A characteristic of the normalcardiac impulse is that it always returns to thebaseline by the time of the second heart sound.The second type of ventricular systolic impulseis the overacting impulse* which is one of nor-mal form but of abnormally large amplitude(Fig. lb). It is seen in any high-output state suchas thyrotoxicosis, or in simple anxiety, but it isalso related to the build of the chest, beingcommon in children and also in adults with adepressed sternum. Another condition that givesrise to an overacting impulse at the left sternaledge is an atrial septal defect, where the outputof the right ventricle is greatly increased fromthe left to right intra-atrial shunt. The third typeof ventricular systolic impulse is the sustained

*Although the so-called 'tapping impulse' of mitralstenosis may sometimes have some features of an overactingimpulse, the tapping quality arises more from palpablevibrations of the loud first heart sound than from displace-ment of the praecordium.

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Praecordial pulsations in health and disease 135

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FIG. 1. (a) The apical impulse cardiogram (apex) in health. Pre-EB: pre-ejection beat. Phonocardiograms:PA, HF: pulmonary area, high frequency. LSE, LF: left sternal edge, low frequency. 1 and 2: first and secondheart sounds. Electrocardiogram lead II. The ejection beat returns to the baseline before the last third ofsystole, when slight systolic retraction is seen in this subject. (The pre-ejection and ejection beats togethercompose the ventricular systolic impulse.)

(b) Apical impulse cardiogram (apex) of the overacting type, in thyrotoxicosis. Increased amplitudeof ejection beat. Pre-EB: pre-ejection beat. Phonocardiogram: SA, LF: supramammary area, low frequency.AS: atrial sound, coinciding with the central portion of the atrial beat. SM: systolic murmur. Electrocardiogramlead II.

(c) Apical impulse cardiogram (apex) of the sustained type, in hypertensive heart disease. Outwardejection beat sustained up to time of second heart sound (2). Pre-EB: pre-ejection beat. Phonocardiogram: PA,HF: pulmonary area, high frequency. SA, LF: supramammary area, low frequency. AS: atrial sound coincid-ing with peak of outward movement of atrial beat.

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FIG. 2. (a) Annular constrictive pericarditis as seen at operation. Pericardial constriction, (1) in A-V groove,and (2) around base of aorta and pulmonary artery.

(b) Impulse cardiogram in annular constrictive pericarditis. Marked systolic retraction at apex andlesser amount at left sternal edge. Systolic outward beat is present over the right chest. Steep diastolic rapid inflowbeat at apex.



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136 Patrick Mounsey

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FIG. 3. Impulse cardiogram, chest X-ray, cineradiogram left cardiac border, and cross-section of heart atautopsy in patient with cardiac aneurysm. Paradoxical systolic pulsation shown in cineradiogram tracings,accounting for overlying sustained cardiac impulse. Bulging of left cardiac border in chest X-ray. Extensiveinfarct involving whole of lateral wall of left ventricle at autopsy. ECG showing ST elevation and tall T wavesin anterior chest leads.

impulse (Fig. Ic). This is seen in the presence ofhypertrophy of either ventricle, and also in car-diac aneurysm. The impulse starts at the time ofthe first heart sound as in health, but is sus-tained right up to and even beyond the time ofthe second heart sound. It is what is usuallyreferred to as a 'heaving' or 'lifting' type of im-pulse, but is more aptly described by the Frenchas the 'choc en d6me'. A sustained cardiac im-

pulse is never met in health if the subject isexamined lying back, propped up at 45°*. Itspresence always indicates the presence of heartdisease. The fourth type of cardiac impulse isthe retracting impulse, in which marked, latesystolic retraction occurs, followed by an equally

*Assumption of the left lateral decubitus position deformsthe pattern of the impulse because of diaphragmatic andmediastinal shift (Boicourt, Nagle & Mounsey, 1965).



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abnormal, outward movement in early diastole(Fig. 2). Accurate timing is necessary to analysethis impulse, for on superficial examination sys-tole may be easily confused with diastole. Thistype of impulse is met in constrictive pericarditis,tricuspid incompetence, when it is localized tothe apex, or with extensive pleuropericardial ad-hesions (Boicourt et al., 1965).The sustained ventricular systolic impulse is

one of the most useful palpatory physical signsindicating heart disease. By far its commonestcause is hypertrophy of either left or right ven-tricle, when it is usually most marked at the apexand left parasternal areas respectively. Whenit is due to a cardiac aneurysm, the sustainedcardiac impulse is of greatest amplitude in thepraecordial area overlying the aneurysm, whichis seen to show paradoxical pulsation on screen-ing (Fig. 3) (Mourdjinis et al., 1968). Carefulpalpation of the praecordium combined with de-tailed screening of the heart will reveal an oftenunsuspected ventricular aneurysm in as many as15% of patients who have had a cardiac infarct.

Severe mitral incompetence may sometimesmimic right ventricular hypertrophy (Fig. 4).Here, left atrial systolic expansion gives rise toa sustained left parasternal impulse, even with-out associated right ventricular hypertrophy.The use of the sustained and overacting type

of impulse to differentiate between systolic anddiastolic overload has proved helpful with lesionsof the right heart, but less so with those affect-ing the left heart. In atrial septal defect the

relationship seems to hold, an overacting im-pulse being seen with a left-to-right shunt withlittle or no rise in pulmonary artery pressure,but a sustained impulse appearing with asso-ciated pulmonary hypertension (Fig. 5) (Gillam,Deliyannis & Mounsey, 1964). In aortic or mitralincompetence, on the other hand, where diastolicoverload is present, either an overacting impulseor a sustained impulse or a mixture of the twomay be met (Fig. 6).

The atrial beatAlthough Mackenzie (1908) drew attention to

the atrial beat in the apex cardiogram, palpationof the atrial beat has only recently been ac-corded importance in clinical diagnosis. A smalloutward movement accompanying mechanicalatrial systole is always recorded in the impulsecardiogram in health, but is rarely palpable. Inthe presence of ventricular hypertrophy, how-ever, an augmented and palpable atrial beat isthe rule. The hand appreciates this as an initialoutward movement preceding the first heartsound and the ventricular systolic impulse.Looked at in the impulse cardiogram it mayform a staircase effect, the first or smaller stepbeing the atrial beat followed by the larger ven-tricular systolic beat (Fig. Ic). In others, it mayform two distinct separate outward movements.Sometimes it is of such large amplitude as tobe mistaken for the ventricular systolic beat, asin hypertrophic obstructive cardiomyopathy.Here, the atrial beat may dwarf the ventricular

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FIG. 4. Sustained left parasternal impulse (LPI) with simultaneous late systolic retraction in apical impulse(apex) in patient with gross mitral incompetence and normal right heart pressures. Phonocardiogram: AA,MF: aortic area, medium frequency.

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138 Patrick Mounsey

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FIG. 5. Diagram of cardiograms of left parasternalimpulse of atrial septal defect in relation to pulmonarysystemic flow ratios and right ventricular pressures.Overacting impulses in five out of seven patients withlittle pulmonary hypertension (Cases 1, 2, 4, 5 and 7),with outward impulse virtually complete by first two-thirds systole (shaded area). Sustained impulse in pul-imonary hypertensive patient (Case 8), with outwardimpulse continued into last third systole (shaded area).

systolic beat, a physical sign which at once sug-gests the possibility of this diagnosis (Fig. 7)(Nagle et al., 1966). An atrial beat of increasedamplitude is also often met in ischaemic heartdisease and is especially large in the presence ofventricular aneurysm (Fig. 3). An augmentedatrial beat is always accompanied by an atrialsound (Fig. 1). To the trained observer feelingthe atrial beat is often easier than hearing theatrial so-und.

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FIG. 6. Apical impulse cardiogram (apex): mixed, sus-tained and overacting type in aortic incompetence. Thediastolic rapid inflow beat (DRIB) is immediatelyfollowed by the atrial beat (AB), which are thus sum-mated. The third heart sound (3) coincides with the peakof the diastolic rapid inflow beat. The atrial sound (AS)follows closely the peak of the atrial beat. Phonocardio-gram: MA, LF: mitral area, low frequency. AA, HF:aortic area, high frequency. 1 and 2: first and secondheart sounds. SM: systolic murmur. EDM: earlydiastolic murmur.

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FIG. 7. Giant atrial beat (AB) in cardiomyopathy, exceeding in amplitude the ventricular systolic impulse.Phonocardiogram: LSE, MF: left sternal edge, medium frequency. ASM: atrial systolic murmur. 1 and 2: firstand second heart sounds. SM: systolic murmur. Electrocardiogram lead II.



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The diastolic rapid inflow beatDuring the period of rapid ventricular filling

and coincidental with the third heart sound, anoutward movement is recorded in the impulsecardiogram, which we have named the diastolicrapid inflow beat. In contradistinction to theatrial sound it is usually easier to hear the thirdheart sound than to feel the diastolic rapid in-flow beat, so that this palpatory physical sign isless common than the atrial beat. There are twoconditions, however, in which the diastolic rapidinflow beat becomes easily recognizable clinic-ally. These are constrictive pericarditis, when itssteep upstroke is accompanied by an early dia-stolic sound (Fig. 2) (Mounsey, 1959), and intricuspid and sometimes mitral incompetence.The force of the diastolic rapid inflow beat inthese diseases is sometimes so great as to causeconfusion with the ventricular systolic impulse.

AcknowledgmentFigs. 1 and 6 are reproduced by kind permission of S.

Karger, Basel and New York, the publishers of Cardiologia

(from Cardiologia, 48, 203: 1966). Figs. 3, 5 and 7 are re-produced by kind permission of the Editor of the BritishHeart Journal, 21, 325 (1959), 26, 726 (1964), 28, 419 (1966).

ReferencesBEILIN, L. & MOUNSEY, P. (1962) The left ventricular impulse

in hypertensive heart disease. Brit. Heart J. 24, 409.

BoIcOURT, O.W., NAGLE, R.E. & MOUNSEY, J.P.D. (1965)The clinical significance of systolic retraction of the apicalimpulse. Brit. Heart J. 27, 379.

GILLAM, P.M.S., DELIYANNIS, A.A. & MOUNSEY, J.P.D.(1964) The left parasternal impulse. Brit. Heart J. 26, 726.

MACKENZIE, J. (1908) Diseases of the Heart. Oxford Univer-sity Press.

MOUNSEY, P. (1959) Annular constrictive pericarditis. Brit.Heart J. 21, 325.

MOUNSEY, J.P.D. (1966) The impulse cardiogram and thephonocardiogram. Cardiologia, 48, 203.

MOURDJINIS, A., MOUNSEY, J.P.D., OLSEN, E.G.J. &RAPHAEL, M.J. (1968) Brit. Heart J. (In press).

NAGLE, R.E., BOICOURT, O.W., GILLAM, P.M.S. & MOUNSEY,J.P.D. (1966) Cardiac impulse in hypertrophic obstructivecardiomyopathy. Brit. Heart J. 28, 419.



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