Physical examination maneuver

Physical Exam

Point of Maximal Impulse

also known as Apical impulse; apex beat
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Video coming September 2026

How to Perform

With the patient supine and the precordium exposed, palpate the left precordium with the finger pads to locate the apical impulse, which is typically in the fifth intercostal space near the midclavicular line. Once identified, define its borders and assess its location, diameter, amplitude, and duration. If the apical impulse is not readily palpable, ask the patient to roll into the left lateral decubitus position and repeat the examination.

How to Interpret

Showing 6 of 19 findings

Aortic Stenosis

Apical-carotid delay in a patient with known aortic stenosis
Rule in
Very helpfulDerived CI
Rule out
Very helpfulDerived CI
Evidence:Limited

Cardiomegaly

Laterally displaced PMI
Rule in
Somewhat helpfulDerived CI
Rule out
Minimally helpfulDerived CI
Evidence:Limited

Hypertrophic Cardiomyopathy

Double (bifid) apical impulse
Rule in
Very helpfulDerived CI
Rule out
Not helpfulDerived CI
Evidence:Limited

Left Ventricular Dilation

Diffuse PMI (apical diameter >3 cm in left lateral decubitus)
Rule in
Very helpfulDerived CI
Rule out
Very helpfulDerived CI
Evidence:Limited

Left Ventricular Hypertrophy

Sustained or double PMI
Rule in
HelpfulDerived CI
Rule out
Somewhat helpfulDerived CI
Evidence:Limited

Reduced Left Ventricular Ejection Fraction

Laterally displaced PMI, supine
Rule in
Very helpful
Rule out
Minimally helpfulNo CI
Evidence:Limited

References

  • Eilen SD, Crawford MH, O'Rourke RA. Accuracy of precordial palpation for detecting increased left ventricular volume. Ann Intern Med. 1983;99(5):628-630. doi:10.7326/0003-4819-99-5-628. PubMed: 6227265
  • O'Neill TW, Barry M, Smith M, Graham IM. Diagnostic value of the apex beat. Lancet. 1989;1(8635):410-411. doi:10.1016/s0140-6736(89)90004-4. PMID: 2563789.
  • Ehara S, Shirai N, Matsumoto K, Okuyama T, Matsumura Y, Yoshikawa J, Yoshiyama M. The clinical value of apex beat and electrocardiography for the detection of left ventricular hypertrophy from the standpoint of the distance factors from the heart to the chest wall: a multislice CT study. Hypertens Res. 2011;34(9):1004-1010. doi:10.1038/hr.2011.69. PMID: 21654756.
  • Madhok V, Falk G, Rogers A, Struthers AD, Sullivan FM, Fahey T. The accuracy of symptoms, signs and diagnostic tests in the diagnosis of left ventricular dysfunction in primary care: a diagnostic accuracy systematic review. BMC Fam Pract. 2008;9:56. PMID: 18842141.
  • Gadsboll N, Hoilund-Carlsen PF, Nielsen GG, Berning J, Brunn NE, Stage P, Hein E, Marving J, Longborg-Jensen H, Jensen BH. Symptoms and signs of heart failure in patients with myocardial infarction: reproducibility and relationship to chest X-ray, radionuclide ventriculography and right heart catheterization. Eur Heart J. 1989;10(11):1017-1028. PMID: 2591393. doi:10.1093/oxfordjournals.eurheartj.a059414.
  • Kawasaki T, Shiraishi H, Matoba S. Clinical significance of physical examination for hypertrophic cardiomyopathy. Circ J. 2023;87(8):1068-1074. doi:10.1253/circj.CJ-23-0131. PMID: 37286487.
  • Heckerling PS, Wiener SL, Wolfkiel CJ, et al. Accuracy and reproducibility of precordial percussion and palpation for detecting increased left ventricular end-diastolic volume and mass. JAMA. 1993;270(16):1943-1948. PMID: 8411551.
  • Chun PKC, Dunn BE. Clinical clue of severe aortic stenosis. Simultaneous palpation of the carotid and apical impulses. Arch Intern Med. 1982;142(13):2284-2288. PMID: 6216867.
  • Heckerling PS, Wiener SL, Wolfkiel CJ, et al. Accuracy and reproducibility of precordial percussion and palpation for detecting increased left ventricular end-diastolic volume and mass: a comparison of physical findings and ultrafast computed tomography of the heart. JAMA. 1993;270(16):1943-1948. PMID: 8411551.
  • McGee S. Evidence-Based Physical Diagnosis. 6th ed. Philadelphia, PA: Elsevier; 2025.

Research last updated September 9, 2026.

Related Systems / Regions

CardiovascularThorax

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Rule in:HAtrial Fibrillation, SHDecompensation, SHHypothyroidism +15 more
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Rule in:IEAortic Regurgitation, IEAortic Stenosis, IEReduced Left Ventricular Ejection Fraction
Rule out:IEAortic Regurgitation, IEAortic Stenosis, IEReduced Left Ventricular Ejection Fraction