Visualization of the Double Apical Impulse * Galloping Heart *
A 62-year-old man with a long-standing history of uncontrolled hypertension presented to the emergency department with chest pain. His blood pressure was 168/103 mm Hg. The left ventricular point of maximal impulse (PMI) was visible and prominent at the midclavicular line in the fifth intercostal space. On palpation, the PMI was found to be diffuse and laterally displaced, with presystolic outward movement of the cardiac apex and a double apical impulse. A prominent S4 sound was heard on cardiac auscultation. A wooden stick (coffee stirrer) taped to the chest wall over the PMI allowed for clear visualization of the double apical impulse (Video). The S4 sound is created by the vibrations of the left ventricle during atrial contraction as blood is ejected into a stiff, noncompliant ventricle and is best heard over the apex, with the bell of the stethoscope, owing to the low frequency of the sound. When the first and second heart sounds are normal, the S4 sound resembles that of the fast gait of a horse and so is often called a gallop. Diseases that lead to a noncompliant ventricle and a loud S4 sound include hypertension, aortic stenosis, and hypertrophic cardiomyopathy. An echocardiogram showed concentric left ventricular hypertrophy. The patient’s chest pain was attributed to symptomatic hypertension. The pain abated after treatment with antihypertensive medication.
