Displaced point of maximal impulse

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Overview

During a cardiac examination, the normal point of maximal impulse (PMI) should be routinely palpated in the left midclavicular line between the fourth and fifth ribs (normally 2-3 cm in diameter). The normal PMI represents the apical impulse of the left ventricle. A displaced PMI sheds light on abnormalities of the heart, and therefore allows for a correct diagnosis

Differential Diagnosis of a Displaced PMI

In alphabetical order

• Aortic aneurysm
• Dilated pulmonary artery
• Left ventricular aneurysm
• Left ventricular enlargement
• Left ventricular hypertrophy
• Massive pleural effusion
• Right-sided tension pneumothorax
• Right ventricular dilation
• Right ventricular hypertrophy

Chest X Ray

• Chest X-ray is useful for the diagnosis of congestive heart failure, pneumothorax and pleural effusions

MRI and CT

• MRI and CT scan for patients with aortic dissections or aortic aneurysms

Echocardiography or Ultrasound

• Echocardiogram assesses the presence/absence of apical aneurysm, wall thickness, ventricular function, chamber size, measurement of pulmonary artery (PA) pressure (indirectly)
• Transesophageal echocardiogram (aortic dissections or aortic aneurysms)

Treatment

• Blood pressure control (left ventricular hypertrophy)
• Observation and diuretics (tension pneumothorax)
• Treatment of underlying etiology and diuretics (right heart failure)

Surgery and Device Based Therapy

• Needle decompression and chest tube (pleural effusions)
• Surgical correction (aortic aneurysm)

References

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