Current issues of ACP Journal Club are published in Annals of Internal Medicine


Diagnosis

Precordial examination was sensitive but not specific for detecting cardiomegaly

ACP J Club. 1994 Mar-April;120:42. doi:10.7326/ACPJC-1994-120-2-042


Source Citation

Heckerling PS, Wiener SL, Wolfkiel CJ, et al. Accuracy and reproducibility of precordial percussion and palpation for detecting increased left-ventricular end-diastolic volume and mass. JAMA. 1993 Oct 27;270:1943-8.


Abstract

Objective

To assess the accuracy of indirect definitive precordial percussion and palpation for detecting increased left ventricular end-diastolic volume (LVEDV), left ventricular mass (LVM), and left ventricular end-diastolic wall thickness (LVEDWT).

Design

Blinded comparison of precordial percussion, and palpation with ultra-fast computed tomography (CT).

Setting

A university medical center.

Patients

103 patients (mean age 59 y, 60% men) referred for CT scanning. Exclusion criteria were thoracic deformities or previous thoracic surgery.

Description of test and diagnostic standard

Indirect definitive percussion of the precordium was done in the left fourth through sixth intercostal spaces with the patient supine. Location of the border of cardiac dullness was measured in each intercostal space from the midsternal line to the tip of the pleximeter finger at the point where a dull percussion note or increased wall resistance was found. When an apical impulse was felt, the intercostal space in which its center was located and the distance of its center from the midsternal line were recorded. Then, with the patient placed in the left lateral decubitus position at 45 degrees, the maximum diameter of the apical impulse on the left lateral chest wall was measured. Contrast-enhanced CT was done to measure LVM, LVEDV, and LVEDWT.

Main outcome measures

Areas under the receiver operating characteristic (ROC) curves, sensitivities, and specificities.

Main results

Percussion of cardiac dullness in the left fifth intercostal space was the best predictor for increased LVEDV (ROC area 0.68, 95% CI 0.55 to 0.81); percussion of cardiac dullness in the left sixth intercostal space was the best predictor for increased LVM (ROC area 0.83, CI 0.67 to 0.99) and increased LVEDWT (ROC area 0.85, CI 0.65 to 0.99). The sensitivities, specificities, and likelihood ratios for dullness distance of > 10.5 cm in the fifth intercostal space for increased LVEDV, LVM, and LVEDWT are shown in the Table. 53% of patients had a discernible apical impulse. An apical impulse diameter of > 3.0 cm in the left lateral decubitus indicated an increased LVEDV and an increased LVM; sensitivities, specificities, and likelihood ratios are shown in the Table.

Conclusion

Indirect definitive percussion of the precordium was sensitive but not specific for detecting cardiomegaly.

Source of funding: Not stated.

For article reprint: Dr. P.S. Heckerling, Department of Medicine, University of Illinois, Box 6998 M/C 787, Chicago, IL 60680, USA. FAX 312-413-8283.


Table. Test characteristics of precordial percussion and palpation for detecting increased left ventricular end-diastolic volume (LVEDV), left ventricular mass (LVM), and left ventricular end-diastolic wall thickness (LVEDWT)*

Finding Outcomes Sensitivity (95% CI) Specificity (CI) +LR -LR
Dullness distance > 10.5 cm in the left fifth intercostal space LVEDV 94% (69 to 100) 32% (23 to 43) 1.4 0.2
LVM 88% (47 to 99) 27% (18 to 38) 1.2 0.4
LVEDWT 80% (30 to 99) 29% (20 to 39) 1.1 0.7
Apical impulse diameter > 3.0 cm LVEDV 100% (68 to 100) 41% (26 to 57) 1.7 0.0
LVM 100% (60 to 100) 30% (17 to 47) 1.4 0.0

*LRs defined in Glossary and calculated from data in article.


Commentary

The study by Heckerling and colleagues is valuable because it emphasizes the role of physical examination in the evaluation of a patient. Increasing use of technologic advances in medicine is occurring at considerable expense to the patient and society, and it is refreshing to read a well-designed study that emphasizes the usefulness of relatively simple techniques for diagnosis.

The evidence presented by the authors clearly shows the value of a careful examination in excluding cardiac enlargement caused by increased LVEDV or LVM. The study also indicated that the results of precordial percussion are moderately reproducible and should be included in the clinical examination of the heart. Limitations in the value of the apical impulse diameter are well known and emphasized in this article. The authors also showed the difference in the value of determining the percussion dullness distance between the left fifth intercostal space and the left sixth intercostal space and indicated that additional study is needed to confirm the value of percussion in the sixth intercostal space for detecting increased LVM.

Eugene L. Coodley, MD
University of CaliforniaIrvine, California, USA