Cardiac apical impulse is normally localized at the fifth intercostal space, midclavicular line. Abnormalities include:

• Forceful apical thrust: Left ventricular hypertrophy
• Lateral and downward displacement of apex impulse: Left ventricular dilatation
• Prominent presystolic impulse: Hypertension, AS, hypertrophic cardiomyopathy
• Double systolic apical impulse: Hypertrophic cardiomyopathy
• Sustained “lift” at lower left sternal border: Right ventricular hypertrophy
• Dyskinetic (outward bulge) impulse: Ventricular aneurysm, large dyskinetic area post MI, cardiomyopathy