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The cardiac impulse during ventricular systole
Annotations
The cardiac
impulse
during
Cardiographic,
angiocardiographic,
Apex cardiography was one of the earliest methods of graphic recording of the heartbeat.’ With the advent of electrocardiography, phonocardiography, cardiac catheterization, and angiocardiography, interest in the apex cardiogram naturally waned, since more accurate and fuller information was supplied by those techniques. Nonetheless, palpation of the cardiac impulse remains an important part of clinical examination of the heart and yields information which, taken in conjunction with other physical signs, helps to mold our clinical diagnosis at the bedside. For this reason, there has recently been a revival of interest in the recording of the cardiac impulse. Methods of recording the impulse. The methods are divisible into two main types: the first records relative displacement of a localized area of the chest wall in relation to the surrounding chest wa11,2-4 and the second records absolute displacement in relation to a fixed point in space.6m7 The first method provides the traditional apex cardiogram. It is useful as a timer for mechanical events throughout the cardiac cycle, especially during the diastolic portion. The second method, that of recording absolute displacement, is known either as kinetocardiography or, as we prefer to call it, “impulse cardiography.” This method is of special value in providing an optical record of what the hand feels when placed on the chest wall. Relationship of areas on the chest wall to the yentricular cavities. Using the impulse cardiogram, Deliyannis and associates* have examined the impulses both at the apex and at the left sternal edge in health and disease. Angiocardiographic studies have shown that the apical impulse usually reflects movements of the left ventricle, whereas the left parasternal impulse reflects those of the right ventricle. In exceptional cases, however, with great hypertrophy of the right or the left ventricle, this law no longer holds, for either ventricle may enlarge to such a degree as to underlie both areas of the precordium.8 Types of impulse. Qualitatively, four main types of impulses during ventricular systole have been noted: the normal, the overacting, the sustained, and the retracting. 889 The normal impulse moves outward for a period at the beginning of ventricular systole, always returning again to the base line before the last third of systole. In some cases actual retraction of the impulse occurs during late systole. The pattern of normal impulse is similar at both 279
ventricular and
anatomic
systole studies
the apex and the left sternal edge. The overacting impulse is one of normal form but of abnormally large amplitude. It is typically seen in overacting hearts, as in the case of thyrotoxicosis or anxiety, but it is also related to the build of the chest, being often found in children and also in adults with a depressed sternum. Another example of an overacting impulse, confined to the left sternal edge, is that due to atria1 septal defect, wherein the output of the right ventricle may be double or treble that of the left. The third type of impulse is the sustained impulse seen in the presence of hypertrophy of either ventricle or in cardiac aneurysm. This is the type of impulse usually described as “heaving” or “lifting.” Although usually of greater excursion than normal, this need not necessarily be so; the basic abnormality, independent of chest build, is its sustained nature. In the impulse record the sustained outward movement continues into the last third of systole, often only returning to the base line in early diastole, at the completion of the period of isometric relaxation. The fourth type, the retracting impulse, is seen in constrictive pericarditis, tricuspid incompetence, or with extensive pleuropericardial adhesions. In defining these four types of impulse, it is important to emphasize that these criteria apply when the patient is examined lying straight back on a couch or bed at an angle of about 45 degrees. Assumption of the left lateral decubitus position deforms the pattern of the impulse because of diaphragmatic and mediastinal shift.9 Genesis of the apical impulse. ANGIOCARDIOGRAPHIC STUDIES. Timed angiocardiographic studies8 have shown that the basic difference between the normal impulse and the sustained impulse is mirrored in the movement of the portion of the heart underlying the apex beat. Thus, in health the anterior wall of the left ventricle near the apex of the heart moves initially outward in early systole and then retracts from the anterior chest wall, as the whole heart contracts concentrically during later systole. In left ventricular hypertrophy, however, the anterior wall of the left ventricle fails to retract normally from the anterior chest wall during the last third of systole, thus accounting for the prolonged sustained outward impulse. ANATOMIC STCTDIES. Studies of the different muscle layers of the heart (external spiral, middle circular, and internal spiral) suggested one explanation for failure of the apical portion of the heart to retract
280
Am. Heart 1. Aztgust, 1965
Annotations
in late systole in left ventricular hypertrophy.8 In health, external and internal spiral fibers retract the apex, whereas the basal portion is squeezed by middle circular fibers which do not extend to the apex. In left ventricular hypertrophy, however, the middle circular fibers were found to extend to the apex and must thus tend to oppose the retracting action of the external and internal spiral layers: hence, in systole the whole heart is squeezed and little retraction of the apex takes place. Other factors, however, probably also contribute to the genesis of the sustained impulse, including general increase in heart size and, in some cases, dilatation as well as hypertrophy. Impulse cardiography aims essentially at producing a graphic record of palpatory physical signs in the heart, and thus offers a more accurate and objective record of an important bedside physical sign. J. P. D. Mounsey,
MA.,
M.D. (Cantab.), F.R.C.P. Department of Medicine Postgraduate Medical School London, England
REFERENCES 1. Marey, sciences
E. J.: La methode graphique experimentales, Paris, 1878,
Cerebrovascular in women taking
dans les Masson.
2. Johnston, F. D., and Overy, D. C.: Vibrations of low frequency over the precordium, Circulation 3579, 1951. 3. Luisada, A. A., and Magri, G.: The lowfrequency tracings of the precordium and epigastrium in normal subjects and cardiac patients, AM. HEART J. 44545, 1952. 4. Benchimol, A., Dimond, E. G., and Carson, J. C.: The value of the apescardiogram as a reference tracing in phonocardiography, AM. HEART J. 61:485, 1961. 5. Dressier, W.: Pulsations of the wall of the chest, Arch. Int. Med. 60:225, 437, 441, 654, and 663, 1937. 6. EddIeman, E. E., Willis, k’., Reeves, T. J., and Harrison, ‘I‘. R.: The kinetocardiogram. I. Method of recording precordial movements, Circulation 8:269. 1953. 7. Beilin, L., and Mounsev, P.: The left ventricular impulse in hypeitensive heart disease, Brit. Heart T. 24:409. 1962. 8. Deliyannis, >. A., Giham, P. M. S., Mounsey, J. P. D., and Steiner, R. E.: The cardiac impuise and the motion of the heart, Brit. Heart J. 26:396, 1964. 9. Boicourt, 0. W., Nagle, R. E., and Mounsey, J. P. D.: Systolic retraction of the apical impulse, Brit. Heart J. In press.
accidents oral contraceptives
In 1961, Jordan6 was first to report a case of thromboembolism in association with the administration of norethynodrel. The patient, a 40-year-old woman, had a pulmonary embolus. At a subsequent conference held in Chicago in September, 1962, to discuss the incidence of thromboembolic phenomena in women taking Enovid (norethynodrel plus ethynylestradiol 3-methyl ether), 132 case histories were presented. Two of these related to cerebrovascular incidents. The first (Case No. 10) was that of a 33year-old woman who had been taking Enovid for 1 month, and who developed a right hemiparesis and hemianopia. She improved gradually but the right hemianopia persisted. The second patient (Case No. 20, age not given) had a normal delivery in October, 1961, and started on Enovid in December, 1961. In April, 1962, she suddenly developed a right hemiplegia and was aphasic. Carotid angiograms were normal. She had had rheumatic fever at the age of 10 years and had residual mitral insufficiency. She made a good recovery from her “stroke.” The generai conclusion of the conference was that there was no increase in the incidence of thromboembolic phenomena from the use of Enovid. However, reports of additional cases of thromboembolic episodes associated with norethynodrel continued to appear, including the report of a case
of nonfatal anterior cardiac infarction in a 32-yearold woman3 and a case of left popliteal artery thrombosis requiring amputation in a 39-year-old woman.s Zilkha12 reported two cases of cerebrovascular accidents in young women taking oral contraceptives. One was 23 years old and had a sudden onset of difficulty in speech and weakness of the right side of the face and right arm. Her blood pressure was 120/80 mm. Hg, and a left carotid arteriogram and an air encephalogram were both normal. An electroencephalogram confirmed the clinical impression of an acute lesion in the left frontotemporal region. She had been taking Enovid cyclically for 6 weeks. She gradually recovered over the succeeding months. The second case was that of a 26-yearold woman who complained of a disturbance of vision on waking one morning. Examination revealed a congruous left upper quadrantic field defect. There were no other abnormal physical signs. She had been taking norethisterone cyclically for 6 months. Similar reports followed. Stewart-Wallacelo described two cases of acute ischemic episodes in the brain stem. The first case was that of 32-year-old woman who had been taking oral contraceptives for 22 months, and who suddenly developed severe vertigo, vomiting, ataxia, diplopia, right Horner’s
The cardiac
impulse
during
Cardiographic,
angiocardiographic,
Apex cardiography was one of the earliest methods of graphic recording of the heartbeat.’ With the advent of electrocardiography, phonocardiography, cardiac catheterization, and angiocardiography, interest in the apex cardiogram naturally waned, since more accurate and fuller information was supplied by those techniques. Nonetheless, palpation of the cardiac impulse remains an important part of clinical examination of the heart and yields information which, taken in conjunction with other physical signs, helps to mold our clinical diagnosis at the bedside. For this reason, there has recently been a revival of interest in the recording of the cardiac impulse. Methods of recording the impulse. The methods are divisible into two main types: the first records relative displacement of a localized area of the chest wall in relation to the surrounding chest wa11,2-4 and the second records absolute displacement in relation to a fixed point in space.6m7 The first method provides the traditional apex cardiogram. It is useful as a timer for mechanical events throughout the cardiac cycle, especially during the diastolic portion. The second method, that of recording absolute displacement, is known either as kinetocardiography or, as we prefer to call it, “impulse cardiography.” This method is of special value in providing an optical record of what the hand feels when placed on the chest wall. Relationship of areas on the chest wall to the yentricular cavities. Using the impulse cardiogram, Deliyannis and associates* have examined the impulses both at the apex and at the left sternal edge in health and disease. Angiocardiographic studies have shown that the apical impulse usually reflects movements of the left ventricle, whereas the left parasternal impulse reflects those of the right ventricle. In exceptional cases, however, with great hypertrophy of the right or the left ventricle, this law no longer holds, for either ventricle may enlarge to such a degree as to underlie both areas of the precordium.8 Types of impulse. Qualitatively, four main types of impulses during ventricular systole have been noted: the normal, the overacting, the sustained, and the retracting. 889 The normal impulse moves outward for a period at the beginning of ventricular systole, always returning again to the base line before the last third of systole. In some cases actual retraction of the impulse occurs during late systole. The pattern of normal impulse is similar at both 279
ventricular and
anatomic
systole studies
the apex and the left sternal edge. The overacting impulse is one of normal form but of abnormally large amplitude. It is typically seen in overacting hearts, as in the case of thyrotoxicosis or anxiety, but it is also related to the build of the chest, being often found in children and also in adults with a depressed sternum. Another example of an overacting impulse, confined to the left sternal edge, is that due to atria1 septal defect, wherein the output of the right ventricle may be double or treble that of the left. The third type of impulse is the sustained impulse seen in the presence of hypertrophy of either ventricle or in cardiac aneurysm. This is the type of impulse usually described as “heaving” or “lifting.” Although usually of greater excursion than normal, this need not necessarily be so; the basic abnormality, independent of chest build, is its sustained nature. In the impulse record the sustained outward movement continues into the last third of systole, often only returning to the base line in early diastole, at the completion of the period of isometric relaxation. The fourth type, the retracting impulse, is seen in constrictive pericarditis, tricuspid incompetence, or with extensive pleuropericardial adhesions. In defining these four types of impulse, it is important to emphasize that these criteria apply when the patient is examined lying straight back on a couch or bed at an angle of about 45 degrees. Assumption of the left lateral decubitus position deforms the pattern of the impulse because of diaphragmatic and mediastinal shift.9 Genesis of the apical impulse. ANGIOCARDIOGRAPHIC STUDIES. Timed angiocardiographic studies8 have shown that the basic difference between the normal impulse and the sustained impulse is mirrored in the movement of the portion of the heart underlying the apex beat. Thus, in health the anterior wall of the left ventricle near the apex of the heart moves initially outward in early systole and then retracts from the anterior chest wall, as the whole heart contracts concentrically during later systole. In left ventricular hypertrophy, however, the anterior wall of the left ventricle fails to retract normally from the anterior chest wall during the last third of systole, thus accounting for the prolonged sustained outward impulse. ANATOMIC STCTDIES. Studies of the different muscle layers of the heart (external spiral, middle circular, and internal spiral) suggested one explanation for failure of the apical portion of the heart to retract
280
Am. Heart 1. Aztgust, 1965
Annotations
in late systole in left ventricular hypertrophy.8 In health, external and internal spiral fibers retract the apex, whereas the basal portion is squeezed by middle circular fibers which do not extend to the apex. In left ventricular hypertrophy, however, the middle circular fibers were found to extend to the apex and must thus tend to oppose the retracting action of the external and internal spiral layers: hence, in systole the whole heart is squeezed and little retraction of the apex takes place. Other factors, however, probably also contribute to the genesis of the sustained impulse, including general increase in heart size and, in some cases, dilatation as well as hypertrophy. Impulse cardiography aims essentially at producing a graphic record of palpatory physical signs in the heart, and thus offers a more accurate and objective record of an important bedside physical sign. J. P. D. Mounsey,
MA.,
M.D. (Cantab.), F.R.C.P. Department of Medicine Postgraduate Medical School London, England
REFERENCES 1. Marey, sciences
E. J.: La methode graphique experimentales, Paris, 1878,
Cerebrovascular in women taking
dans les Masson.
2. Johnston, F. D., and Overy, D. C.: Vibrations of low frequency over the precordium, Circulation 3579, 1951. 3. Luisada, A. A., and Magri, G.: The lowfrequency tracings of the precordium and epigastrium in normal subjects and cardiac patients, AM. HEART J. 44545, 1952. 4. Benchimol, A., Dimond, E. G., and Carson, J. C.: The value of the apescardiogram as a reference tracing in phonocardiography, AM. HEART J. 61:485, 1961. 5. Dressier, W.: Pulsations of the wall of the chest, Arch. Int. Med. 60:225, 437, 441, 654, and 663, 1937. 6. EddIeman, E. E., Willis, k’., Reeves, T. J., and Harrison, ‘I‘. R.: The kinetocardiogram. I. Method of recording precordial movements, Circulation 8:269. 1953. 7. Beilin, L., and Mounsev, P.: The left ventricular impulse in hypeitensive heart disease, Brit. Heart T. 24:409. 1962. 8. Deliyannis, >. A., Giham, P. M. S., Mounsey, J. P. D., and Steiner, R. E.: The cardiac impuise and the motion of the heart, Brit. Heart J. 26:396, 1964. 9. Boicourt, 0. W., Nagle, R. E., and Mounsey, J. P. D.: Systolic retraction of the apical impulse, Brit. Heart J. In press.
accidents oral contraceptives
In 1961, Jordan6 was first to report a case of thromboembolism in association with the administration of norethynodrel. The patient, a 40-year-old woman, had a pulmonary embolus. At a subsequent conference held in Chicago in September, 1962, to discuss the incidence of thromboembolic phenomena in women taking Enovid (norethynodrel plus ethynylestradiol 3-methyl ether), 132 case histories were presented. Two of these related to cerebrovascular incidents. The first (Case No. 10) was that of a 33year-old woman who had been taking Enovid for 1 month, and who developed a right hemiparesis and hemianopia. She improved gradually but the right hemianopia persisted. The second patient (Case No. 20, age not given) had a normal delivery in October, 1961, and started on Enovid in December, 1961. In April, 1962, she suddenly developed a right hemiplegia and was aphasic. Carotid angiograms were normal. She had had rheumatic fever at the age of 10 years and had residual mitral insufficiency. She made a good recovery from her “stroke.” The generai conclusion of the conference was that there was no increase in the incidence of thromboembolic phenomena from the use of Enovid. However, reports of additional cases of thromboembolic episodes associated with norethynodrel continued to appear, including the report of a case
of nonfatal anterior cardiac infarction in a 32-yearold woman3 and a case of left popliteal artery thrombosis requiring amputation in a 39-year-old woman.s Zilkha12 reported two cases of cerebrovascular accidents in young women taking oral contraceptives. One was 23 years old and had a sudden onset of difficulty in speech and weakness of the right side of the face and right arm. Her blood pressure was 120/80 mm. Hg, and a left carotid arteriogram and an air encephalogram were both normal. An electroencephalogram confirmed the clinical impression of an acute lesion in the left frontotemporal region. She had been taking Enovid cyclically for 6 weeks. She gradually recovered over the succeeding months. The second case was that of a 26-yearold woman who complained of a disturbance of vision on waking one morning. Examination revealed a congruous left upper quadrantic field defect. There were no other abnormal physical signs. She had been taking norethisterone cyclically for 6 months. Similar reports followed. Stewart-Wallacelo described two cases of acute ischemic episodes in the brain stem. The first case was that of 32-year-old woman who had been taking oral contraceptives for 22 months, and who suddenly developed severe vertigo, vomiting, ataxia, diplopia, right Horner’s