Signs of Precordial heaves, thrills and pulsation

Precordial heaves, thrills and pulsation

A parasternal heave is a cardiac impulse palpated by placing the flat of the hand on the costal cartilages, to the left of the patient’s sternum. It may be due to right ventricular hypertrophy when the impulse is at the same time as the apex beat and carotid pulsation. Less commonly it is due to left atrial enlargement when the pulsation occurs before the apex beat or carotid pulsation.

A thrill is a palpable murmur and is due to turbulent blood flow. A thrill is indicative of a loud murmur. The flat of the hand should be placed at the base and apex of the heart. For example, a diastolic thrill at the apex is suggestive of severe mitral stenosis (aortic regurgitation rarely produces a thrill).

The apex beat is defined as the most inferior and lateral cardiac pulsation. It should be identified and its po-sition defined according the intercostal space (count down from the sternal angle which is at the second intercostal space) and the relationship to the chest (mid-clavicular line, anterior axillary line, etc). The normal position is the fourth or fifth intercostal space in the left midclavicular line. The character of the pulsation should also be palpated, but these may be subtle (see Table 2.1).