Cardiomegaly: precordial percussion was quite useful in diagnosis.

Clinical bottom line (level 1b)

  1. About a third of patients with dyspnoea or oedema had radiographic cardiomegaly.
  2. Percussion was useful in ruling in and ruling out radiographic cardiomegaly (distance >11 cm from mid-sternum (LR+8.1) (LR-0.12) .
  3. Percussion did not clearly help diagnose left ventricular end diastolic volume.
  4. A percussed cardiac diameter >11 cm in the left sixth intercostal space made an increased left ventricular mass more likely (LR+2.9) , but further testing was required.
  5. Clinicians only agreed reasonably well about radiographic cardiomegaly, left ventricular end-diastolic volume and mass using percussion.
Heckerling et al: American Journal of Medicine 1991; 91: 328-334
Expires July 2003

The study

Setting: medical wards and outpatient clinics, university hospital, USA

100 patients (aged mean 52 years, 53% male) complaining of exertional dyspnoea (49%), oedema (29%), orthopnoea (25%), angina (16%), resting dyspnoea (14%)

Excluded if
  • signs of chronic obstructive pulmonary disease
  • thoracic deformities
  • previous thoracic surgery
  • x-ray showed inadequate inspiration



    • Independent blinded reference standard, applied in all patients from a consecutive appropriate spectrum.
    Reference standard:
    • cardiothoracic ratio on PA chest x-ray performed as part of routine admission or screening procedures (cardiothoracic ratio (CTR): ratio of the maximum diameter of the cardiac silhouette to the maximum inner diameter of the thorax. Cut point for cardiomegaly: CTR>0.5)
    Diagnostic test: cardiac diameter by precordial percussion and palpitation. Supine patients were percussed and palpated. Examiners used light, indirect percussion to define heart borders in second-fifth (right) and sixth (left) intercostal spaces. Dullness was distinguished by changes in sound and vibration. Distances measured from the mid sternal line.

    The evidence

    pre-test probability of cardiomegaly: 36%, (95% CI: 27% to 45%)

    diagnostic test cardiomegaly no cardiomegaly LR+
    (95% CI)    		 post-test probability LR-
    (95% CI)    		 post-test probability
    percussion distance >10.5 cm 34 21 2.9
    (2.0 to 4.1)     		62% 0.083
    (0.021 to 0.32)     		4%
    percussion distance >11.0 cm 32 7 8.1
    (4.0 to 17)     		82% 0.12
    (0.049 to 0.32)     		7%
    total 36 64

    0.57
    • Apex beat only detectable in 40% of patients.

    Comments

    1. It is important to note that the gold standard for the study, cardio-thoracic ratio by chest radiograph, has limited usefulness for the diagnosis of the clinically more relevant conditions of left ventricular hypertrophy or systolic dysfunction.
    2. Despite adjustment for blood pressure and clinical symptoms, percussion distance remained significantly correlated with CTR (r=0.68).

    Citation

    1. Heckerling PS, Wiener SL, Moses VK, et al: Accuracy of precordial percussion in detecting cardiomegaly. American Journal of Medicine 1991; 91: 328-334
    Contributor: Chris Ball and Musab Hayatli, July 2000
    Reviewer: Edward Havranek

    Clinical Question.
    Patient dyspnoea or oedema
    Intervention or Exposure precordial percussion
    Outcome diagnosis of cardiomegaly