ACCURACY AND REPRODUCIBILITY OF PRECORDIAL PERCUSSION AND PALPATION FOR DETECTING INCREASED LEFT-VENTRICULAR END-DIASTOLIC VOLUME AND MASS - A COMPARISON OF PHYSICAL FINDINGS AND ULTRAFAST COMPUTED-TOMOGRAPHY OF THE HEART

Objective.-To assess the accuracy and reproducibility of indirect defi nitive precordial percussion in detecting increased left ventricular e nd-diastolic volume (LVEDV), left ventricular mass (LVM), and left ven tricular end-diastolic wall thickness ( LVEDWT), and to compare it wit h palpation of the apical impulse. Design.-Descriptive study. Setting. -Hospitals and clinics of a university medical center. Patients.-Conve nience sample of 103 patients (62 men and 41 women) referred for ultra fast computed tomography (CT) of the heart. Interventions.-Percussion dullness distance from the midsternal line in the left fourth through sixth intercostal spaces, distance of the apical impulse from the mid- sternal line, and apical impulse diameter in the left lateral decubitu s position were measured on all patients. Measurements of LVEDV, LVM, and LVEDWT were taken using ultrafast CT of the heart. Investigators p erforming the physical diagnostic maneuvers were blinded to the clinic al history and CT results, and investigators performing the CT scans w ere blinded to physical findings. Results.-Percussion dullness distanc e in the left fifth intercostal space was the best discriminator of LV EDV (receiver operating characteristic [ROC] area, 0.680; 95% confiden ce interval [CI], 0.547 to 0.813), and dullness distance in the left s ixth intercostal space was the best discriminator of LVM and LVEDWT (R OC areas, 0.831, 95% CI, 0.674 to 0.988; and 0.849, 95% CI, 0.651 to 0 .999, respectively). A percussion dullness distance of greater than 10 .5 cm in the left fifth intercostal space detected increased LVEDV or LVM with a sensitivity of 91.3% (95% CI, 70.5% to 98.5%) and a specifi city of 30.3% (95% CI, 19.9% to 43.0%). There was moderate concordance between investigators for percussion dullness distance (kappa, 0.57; 95% CI, 0.18 to 0.96). In patients in whom an impulse was palpated, an apical impulse diameter of greater than 3.0 cm in the left lateral de cubitus detected increased LVEDV or LVM with a sensitivity of 100% (95 % CI, 77.1% to 100%) and a specificity of 40% (95% CI, 23.2% to 59.3%) . However, an impulse was palpable in only 53% of cases and showed onl y slight interobserver reproducibility (kappa, 0.18; 95% CI, 0.0 to 0. 58). Conclusion.-Indirect definitive percussion of the precordium is a sensitive and moderately reproducible maneuver for excluding cardiome galy due to increased LVEDV or LVM. Although measurement of apical imp ulse diameter was also sensitive in excluding cardiomegaly, lack of a palpable impulse in many patients and low precision between physicians may limit its utility in clinical practice.