Palpable cardiac impulse predicts adequate acoustic windows

In this study, we sought to determine the usefulness of palpating an apical cardiac impulse on physical examination in predicting adequate echocardiographic images for stress echocardiography. A variety of stress tests using either echocardiographic imaging or nuclear imaging are available to referring physicians. Deciding which test is best for a given patient is often difficult. In the case of stress echocardiography, the most significant limitation is poor image quality in a small portion of patients. We enrolled 136 consecutive outpatients referred for echocardiography. The presence or absence of a palpable cardiac apex on physical examination was recorded by two independent and blinded examiners. Data, including age, sex, weight, prior chest surgery, and smoking, were also collected. Echocardiographic imaging of the left ventricle was scored according to the number of adequately visualized wall segments in a standard 16-segment model. One hundred eleven patients (82%) had adequate visualization of at least 14 of 16 wall segments. Ninety-eight patients (72%) had a palpable cardiac impulse, of whom 90 (92%) also had adequate acoustic image quality versus only 21 (55%) of the 38 patients in whom an apex was not palpable (P<0.0001). Other variables that were measured were not significantly related to image quality, with the exception of weight; patients with adequate images weighed a mean of 75 kg versus 91 kg in those with inadequate images (P<0.0006). However, multivariate analysis showed a palpable apex to be the only independent predictor after controlling for other variables. A physical examination assessment for a palpable apical impulse is useful to predict adequate echocardiographic image quality for stress echocardiography. When used in conjunction with other parameters, this may lead to more appropriate referral to augmented stress testing.