The apical impulse is the point of maximum impulse felt during cardiac examination. In normal systole, it feels like a gentle thrust followed by slight retraction. It is caused by rotation of the left ventricle during contraction and relaxation. Normally it is located on the left side of the chest, less than 10cm from the midline, and occupies less than one intercostal space. Abnormal locations or characteristics can indicate conditions like dilated cardiomyopathy, mitral stenosis, or aortic stenosis.

1. APICAL IMPULSE
Definition: It is the outermost and lowermost point of maximum impulse (PMI) in early
systole, which imparts a perpendicular gentle thrust to a palpating finger, followed by a slight
medial retraction in the late systole.
Cause of Normal Apical Impulse: Anterior and counter clock-wise rotation of LV due to
isovolumic contraction during early systole and medical retraction due to clock-wise rotation of
the LV during late systole.
Characteristics of Normal Apical Impulse: Location – Left 5th
ICS at or medial to mid-
clavicular line and <10cm from mid-sternal line. Extent - <3cm in diameter which is one ICS.
Duration - <50% of systole.
Abnormal Apical Impulse:
 ABSENT : Dilated cardiomyopathy, Pericardial effusion, Behind the rib, Dextrocardia,
Obesity, COPD, Left pleural effusion
 TAPPING : Mitral stenosis (palpable S1 - closing snap)
 HYPERDYNAMIC : Increased in amplitude, duration is >1/3 to <2/3 of systole, occupies
more than one intercostal space. Occurs in LV volume overload (AR, MR,VSD, PDA,
High output states)
 HEAVING : Increase in amplitude, duration is >2/3 of systole and occupies more than
one intercostal space. Occurs in LV pressure overload (AS, HTN, Coarctation of aorta)
 DIFFUSE : Occupying more than 1 ICS. Occurs in LV aneurysm, Eccentric LVH as in
AR
 DOUBLE : HOCM, AS with AR, Left dyssynergy, LV aneurysm
 TRIPLE OR QUADRUPLE : HOCM
 RETRACTILE : Severe TR
References: Clinical Examination in Cardiology - B.N.Vijay Raghawa Rao,
Bedside Cardiology - Jules Constant, Manual of Practical Medicine - R.Alagappan;
Prepared by Dr.Anvesh Karthik Yalavarthy

2. References: Clinical Examination in Cardiology - B.N.Vijay Raghawa Rao,
Bedside Cardiology - Jules Constant, Manual of Practical Medicine - R.Alagappan;
Prepared by Dr.Anvesh Karthik Yalavarthy