1. Normal landmark
2. Palpating deviation
3. Absent apex beat causes
4. Apex deviation causes
5. Abnormal apex beat types

Normal landmark

• Palpate sternal angle [angle of Louie], which is 2nd rib.
• Space below is 2nd intercostal space.
• Count down to 5th intercostal.
• 1cm medial to midclavicular line.
• Pediatric heart is different. See Pediatric Heart Reference.

Palpating deviation

• Dr makes a claw.
• Put middle finger in 5th intercostal space on lateral ribcage.
• Place rest of hands fingers in spaces above and below.
• Move claw around medially, finding the apex beat.

Absent apex beat causes

• DOPES:
• Death
• Obesity
• Pericarditis
• Emphysema, other COPD
• Sinus inversus

Apex deviation causes

With trachea shift also:

• Mediastinal shift

Without trachea shift:

• Cardiomegaly
• Scoliosis
• Pectus excavatum
• Sinus inversus

Abnormal apex beat types

• Double impulse:
  • What: systole has 2 impulses.
  • DDx: hypertrophic cardiomyopathy.
• Dyskinetic:
  • What: uncoordinated, easily palpable.
  • DDx: MI.
• Hyperdynamic:
  • What: forceful, sustained apex beat.
  • DDx: AS, HTN. 
• Hyperkinetic:
  • What: coordinated, palpated beat is distributed over greater area.
  • DDx: LV dilation. 
• Tapping apex:
  • What: S1 sound is palpable. See Heart Sounds Reference.
  • DDx: mitral stenosis.