The LV Impulse in Left Ventricular Hypertrophy LVH

1. How can you establish by palpation that an LV apex beat is normal, i.e., that there is no hypertrophy, dilatation, or loss of compliance?

ANS: In the supine and left lateral decubitus positions the normal apex beat rises in systole and falls away rapidly to reach the S2 at the bottom of the fall or even before the last one-third of systole. This is not a visual phenomenon, so only compare what you hear with what you feel.

This depicts a normal apex impulse (apex cardiogram, or ACG) recorded over the apex beat with the subject in the left lateral decubitus position. The fingers feel the E-O slope as a purely systolic retraction. The S2-O portion of the slope is so short and rapid that the O nadir is perceived as ending at the S2. The end-systolic hump of the ACG is not perceived by palpation as interrupting the E-O slope.

2. What characteristics are imparted to an apex beat by a hypertrophied LV?

ANS: a. It will be sustained.

b. It may have a presystolic A wave or atrial hump.

c. It may have a midsystolic dip.

3. What is meant by a sustained apex beat?

ANS: It is one that remains outward throughout systole and begins to go away only with the second heart sound. This is usually detected with the patient in the left lateral decubitus position.

This depicts a normal apex impulse (apex cardiogram, or ACG) recorded over the apex beat with the subject in the left lateral decubitus position. The fingers feel the E-O slope as a purely systolic retraction. The S2-O portion of the slope is so short and rapid that the O nadir is perceived as ending at the S2. The end-systolic hump of the ACG is not perceived by palpation as interrupting the E-O slope.

If you imagine a sound shortly after the S2, the sustained apex beat will seem fall onto it rather than onto the S2.

Note: The term heave is often used to describe a large area and amplitude of sustained movement.

4. What is the most common mimic of the sustained apical impulse of LV dilatation?

ANS: A ventricular aneurysm involving the apex.

Note: a. In the absence of LVH or an aneurysm, a sustained apex beat suggests a depressed ejection fraction. b. Complete absence of the pericardium can also not only produce a sustained apical impulse but can displace it into the axilla.

5. How can the degree of aortic regurgitation (AR) be judged by the degree of sustaining?

ANS: With mild to moderate AR, the impulse may be overactive but will fall to its lowest level before the S2. When the AR is moderately severe or severe, proportionate hypertrophy will cause the apex beat to be sustained.

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Responses

  • awate
    What type of apex beat would you feel in left ventricular hypertrophy?
    1 year ago

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