Epical impulse
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apical impulse clinical examination location normal characteristics guideline
Apical impulse is the outward systolic movement felt over the cardiac apex, produced mainly by the left ventricle contacting the chest wall. It is also called the apex beat.
How to examine: Palpate with finger pads while the patient is supine or in the left lateral position, preferably at end-expiration. Assess location, size, amplitude, and duration.
Normal
- Location: usually left 5th intercostal space, at or just medial to the midclavicular line
- Diameter: focal, usually no more than 2-3 cm
- Character: brief, gentle systolic impulse
Abnormal patterns
- Laterally and inferiorly displaced, diffuse: left ventricular dilatation, such as dilated cardiomyopathy or significant mitral/aortic regurgitation.
- Sustained/heaving: pressure overload with left ventricular hypertrophy, for example hypertension or aortic stenosis.
- Hyperdynamic: increased stroke volume, for example anemia, thyrotoxicosis, or aortic regurgitation.
- Double impulse: may occur in hypertrophic cardiomyopathy.
- Tapping impulse: classically associated with mitral stenosis.
A sustained impulse may reflect increased ventricular mass or obstruction to LV ejection, while an enlarged area suggests LV enlargement, as described in Fuster and Hurst's The Heart, 15th ed., section “Palpation.” The MSD cardiovascular examination reference similarly describes a normal impulse as being near the 4th-5th intercostal space, medial to the midclavicular line, and under 2-3 cm wide.
Ewing pulse
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"Ewing pulse"
There is no standard clinical pulse called “Ewing pulse.”
You may mean one of these:
- Ewing’s tests: bedside autonomic-function tests, commonly used to assess diabetic autonomic neuropathy. They examine heart-rate and blood-pressure responses to deep breathing, standing, Valsalva manoeuvre, and sustained handgrip.
- Ewing sign: a named clinical sign, but not a routinely described arterial pulse character.
- A commonly examined pulse may have been intended, such as water-hammer (Collapsing) pulse, pulsus paradoxus, pulsus alternans, or bisferiens pulse.
If you can share the spelling or the context from your notes, I can identify the exact term.
Compare Ewing’s tests with common pulse abnormalities
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Ewing cardiovascular autonomic reflex tests deep breathing Valsalva standing pulse abnormalities clinical examination
Ewing’s tests vs common pulse abnormalities
They are not the same category.
- Ewing’s tests are a battery of provocation tests that measure autonomic cardiovascular reflexes, mainly for cardiac autonomic neuropathy.
- Pulse abnormalities are physical findings on palpating an artery. They often reflect stroke volume, rhythm, arterial compliance, respiratory variation, or cardiac disease.
| Feature | Ewing’s cardiovascular reflex tests | Common pulse abnormalities |
|---|---|---|
| What it assesses | Integrity of parasympathetic and sympathetic autonomic control | Character of the arterial pulse |
| Method | ECG and/or BP responses during standard manoeuvres | Palpation of radial, carotid, or other artery; sometimes sphygmomanometry |
| Main clinical use | Detecting cardiac autonomic neuropathy, particularly in diabetes | Identifying haemodynamic, valvular, rhythm, or pericardial disease |
| Result | Abnormal heart-rate variability, abnormal reflex tachycardia/bradycardia, or abnormal BP response | A characteristic pulse contour, volume, rhythm, or respiratory variation |
| Interpretation | Suggests autonomic dysfunction | Suggests a particular cardiovascular mechanism or diagnosis |
Ewing’s five standard tests
| Test | Main autonomic component | What is measured |
|---|---|---|
| Heart-rate response to deep breathing | Parasympathetic (cardiovagal) | Reduced inspiratory-expiratory heart-rate variation |
| Valsalva manoeuvre | Mainly parasympathetic, with baroreflex contribution | Valsalva ratio: longest RR interval after strain / shortest RR interval during strain |
| Heart-rate response to standing | Parasympathetic | 30:15 ratio after standing |
| BP response to standing | Sympathetic adrenergic | Excess fall in systolic BP, indicating orthostatic hypotension |
| BP response to sustained handgrip | Sympathetic adrenergic | Inadequate rise in diastolic BP |
Thus, Ewing's tests provoke a controlled physiologic challenge and quantify the response. Diminished heart-rate variability with deep breathing, Valsalva, or postural change can indicate cardiovagal dysfunction. The Ewing battery review describes these five tests and their role in staging cardiac autonomic neuropathy. Bradley and Daroff's Neurology in Clinical Practice notes that autonomic dysfunction can be demonstrated by abnormal heart-rate responses to deep breathing, Valsalva, and postural change.
Common pulse abnormalities
| Pulse abnormality | Palpation finding | Typical associations | Difference from Ewing’s tests |
|---|---|---|---|
| Tachycardia | Rate >100/min | Fever, pain, hypovolaemia, anxiety, arrhythmia | A resting finding. Ewing tests assess whether rate changes appropriately with autonomic manoeuvres. |
| Bradycardia | Rate <60/min | Athletic conditioning, drugs, sinus-node disease, heart block | A resting rate finding, not a reflex-test result. |
| Irregularly irregular pulse | Completely irregular rhythm | Atrial fibrillation | Reflects rhythm disorder. |
| Pulsus alternans | Regular alternation of strong and weak beats | Severe LV systolic dysfunction | Reflects alternating stroke volume, not autonomic reflex failure. |
| Pulsus paradoxus | Inspiratory fall in systolic BP >10 mmHg, with diminished pulse during inspiration | Cardiac tamponade, severe asthma/COPD, massive PE, tension pneumothorax | A respiratory haemodynamic phenomenon, measured by BP, not an Ewing test. |
| Bisferiens pulse | Two systolic peaks per beat | Severe aortic regurgitation with aortic stenosis; hypertrophic obstructive cardiomyopathy | Due to abnormal LV ejection waveform. |
| Collapsing/water-hammer pulse | Rapid upstroke and rapid collapse | Aortic regurgitation, high-output states | Due to wide pulse pressure and rapid diastolic runoff. |
| Slow-rising pulse | Delayed, low-amplitude carotid upstroke | Severe aortic stenosis | Due to fixed LV outflow obstruction. |
| Small-volume/thready pulse | Weak, narrow pulse | Shock, low cardiac output, severe aortic stenosis | Reflects low stroke volume or poor perfusion. |
| Bounding pulse | Forceful, large-amplitude pulse | Fever, anemia, thyrotoxicosis, aortic regurgitation | Reflects high stroke volume or reduced vascular resistance. |
Key examination distinction
- A patient with autonomic neuropathy may have resting tachycardia, reduced HR variability, exercise intolerance, or postural hypotension. Ewing's tests help demonstrate the underlying impaired reflex control.
- A patient with pulsus alternans, water-hammer pulse, or slow-rising pulse has a palpable arterial waveform suggesting a cardiac mechanical or valvular abnormality. This is assessed during routine cardiovascular examination.
For example, pulsus alternans suggests severe LV systolic dysfunction, while pulsus paradoxus is an exaggerated inspiratory systolic BP drop and is classically associated with tamponade. Fuster and Hurst's The Heart, 15th ed., sections “Abnormalities of Arterial Pulse” and “Blood Pressure Abnormalities”; Harrison’s Principles of Internal Medicine, 22nd ed., “Cardiovascular Examination.”
Murmer
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heart murmurs clinical examination timing grading innocent pathological Merck Manual
Murmur is an abnormal, prolonged heart sound caused by turbulent blood flow through the heart or great vessels. It may be systolic, diastolic, or continuous.
Describe a murmur by
- Timing: systolic, diastolic, continuous
- Site of maximum intensity: aortic, pulmonary, tricuspid, or mitral area
- Radiation: to carotids, axilla, back, etc.
- Character/shape: blowing, harsh, rumbling; crescendo-decrescendo, pansystolic, decrescendo
- Intensity: grade 1 to 6
- Response to manoeuvres: inspiration, Valsalva, handgrip, squatting
Common murmurs
| Timing | Murmur | Typical finding |
|---|---|---|
| Ejection systolic | Aortic stenosis | Harsh crescendo-decrescendo at right 2nd intercostal space, radiates to carotids |
| Ejection systolic | Pulmonary stenosis | Left upper sternal border, may radiate to left shoulder |
| Pansystolic | Mitral regurgitation | Blowing at apex, radiates to axilla |
| Pansystolic | Tricuspid regurgitation | Left lower sternal border, louder on inspiration |
| Pansystolic | Ventricular septal defect | Harsh lower left sternal border |
| Mid-diastolic | Mitral stenosis | Low-pitched rumble at apex, best in left lateral position, often with opening snap |
| Early diastolic | Aortic regurgitation | High-pitched blowing decrescendo along left sternal border, louder sitting forward in expiration |
| Continuous | Patent ductus arteriosus | “Machinery” murmur below left clavicle |
Murmur grading
- Grade 1/6: very faint
- Grade 2/6: soft but readily heard
- Grade 3/6: moderately loud
- Grade 4/6: loud with palpable thrill
- Grade 5/6: heard with stethoscope partly off chest
- Grade 6/6: heard with stethoscope completely off chest
Important: A diastolic murmur is pathological until proven otherwise. A systolic murmur may be innocent, especially if soft, short, and without symptoms or abnormal examination findings. MSD’s auscultation guide outlines classification by timing, location, intensity, and response to manoeuvres.
Stenosis
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valvular stenosis definition aortic mitral clinical signs Merck Manual
Stenosis means narrowing of an opening or passage. In cardiology, it usually means narrowing of a heart valve, which obstructs forward blood flow.
Stenosis versus regurgitation
- Stenosis: valve does not open fully, causing obstruction to forward flow.
- Regurgitation (incompetence): valve does not close fully, causing backward leakage.
Main valve stenoses
| Condition | Obstructed flow | Typical murmur | Key features |
|---|---|---|---|
| Aortic stenosis (AS) | LV → aorta during systole | Harsh ejection systolic, crescendo-decrescendo murmur at right 2nd intercostal space, radiating to carotids | Slow-rising, low-volume pulse (pulsus parvus et tardus), sustained/heaving apex beat, possible syncope, angina, dyspnoea |
| Mitral stenosis (MS) | Left atrium → LV during diastole | Low-pitched mid-diastolic rumble at apex, often preceded by an opening snap | Dyspnoea, atrial fibrillation, pulmonary hypertension, embolic stroke risk |
| Pulmonary stenosis | RV → pulmonary artery during systole | Ejection systolic murmur at left upper sternal border | May cause a right ventricular heave; often congenital |
| Tricuspid stenosis | Right atrium → RV during diastole | Mid-diastolic murmur at lower left sternal border, louder with inspiration | Raised JVP with prominent a waves, peripheral oedema, hepatomegaly |
Aortic stenosis
Aortic stenosis is restricted opening of the aortic valve, creating obstruction to LV outflow during systole. Common causes include degenerative calcification in older adults, bicuspid aortic valve, and rheumatic heart disease. Severe disease produces the classic symptom triad:
- Exertional syncope
- Angina
- Exertional dyspnoea/heart failure
The MSD summary of aortic stenosis describes the typical slow-rising, low-amplitude pulse and sustained apical impulse. Diagnosis is confirmed and severity measured with Doppler echocardiography.
Mitral stenosis
Mitral stenosis is usually rheumatic in origin. Narrowing raises left atrial pressure, which can lead to left atrial enlargement, pulmonary congestion, atrial fibrillation, pulmonary hypertension, and thromboembolism. The typical auscultatory finding is an opening snap followed by a low-pitched diastolic rumble at the apex, best heard with the bell in the left lateral position. The MSD mitral stenosis reference outlines these features and the role of echocardiography.
Exam rule:
- Stenosis of the semilunar valves (aortic, pulmonary) causes a systolic ejection murmur.
- Stenosis of the atrioventricular valves (mitral, tricuspid) causes a diastolic murmur.
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