Cardiomegaly: palpation could be quite useful in diagnosis.

Clinical bottom line (level 2b)

  1. A quarter of patients referred for PA chest x-ray had radiographic cardiomegaly (cardiothoracic diameter >0.5).
  2. A third of in-patients lying supine had a discernable apex pulse. The apex is harder to feel in large-framed patients. 53% of patients had a palpable apex impulse when lying in the left decubitus position.
  3. An apex palpable beyond the midclavicular line made cardiomegaly more likely (LR+2.5) , and slightly less likely if not (LR-0.53) .
  4. Clinicians agreed fairly well about position of an apex impulse.
O'Neil et al: Lancet 1989; 1: 410-411
Expires July 2003

The study

Setting: acute hospital, Ireland

100 patients (aged mean 63.8 years, 60% male) hospital patients referred for PA x-ray

Excluded if
  • too ill to be examined



    • Independent blinded reference standard, applied in all patients from a consecutive appropriate spectrum.
    Reference standard:
    • PA chest x-ray: positive if cardiothoracic ratio >0.5
    Diagnostic test: apex position. Apex considered impalpable if not felt in patient when lying at 45 degrees or sitting forward.

    The evidence

    pre-test probability of cardiomegaly: 25%, (95% CI: 17% to 34%)

    diagnostic test cardiomegaly no cardiomegaly LR+
    (95% CI)    		 post-test probability LR-
    (95% CI)    		 post-test probability
    apex palpable beyond midclavicular line 15 18 2.5
    (1.5 to 4.2)     		45% 0.53
    (0.32 to 0.86)     		15%
    apex palpable >10 cm from mid sternal line 20 54 1.1
    (0.87 to 1.4)     		27% 0.71
    (0.30 to 1.7)     		19%
    total 25 75

    palpability of apex=0.68
    position of apex=0.48
    • About 50% of apices were palpable. The patient's frame size affected apex palpability:
      • small frame: apex palpability 86%
      • medium frame: apex palpability 61%
      • large frame: apex palpability 36%
      p<0.05 for detecting apex in medium v. large framed patients

    Comments

    1. The most important caveat here is 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. Left ventricular mass, left ventricular end-diastolic volume and left-ventricular end-diastolic wall thickness said to be better predictors of mortality than radiographic cardiothoracic ratio.
    3. The trial has a relatively small number of patients. Uncertain whether clinicians can be accurate to 0.5 cm (especially with percussion) in non-trial conditions.

    Citation

    1. O'Neil TW, Barry M, Smith M, et al: Diagnostic value of the apex beat. Lancet 1989; 1: 410-411
    Contributor: Chris Ball and Musab Hayatli, July 2000
    Reviewer: Edward Havranek

    Clinical Question.
    Patient referred for PA x-ray
    Intervention or Exposure palpation
    Outcome diagnosis of cardiomegaly