In this study, we sought to determine the usefulness of palpating an apical
cardiac impulse on physical examination in predicting adequate echocardiog
raphic images for stress echocardiography. A variety of stress tests using
either echocardiographic imaging or nuclear imaging are available to referr
ing physicians. Deciding which test is best for a given patient is often di
fficult. In the case of stress echocardiography, the most significant limit
ation is poor image quality in a small portion of patients. We enrolled 136
consecutive outpatients referred for echocardiography. The presence or abs
ence of a palpable cardiac apex on physical examination was recorded by two
independent and blinded examiners. Data, including age, sex, weight, prior
chest surgery, and smoking, were also collected. Echocardiographic imaging
of the left ventricle was scored according to the number of adequately vis
ualized wall segments in a standard 16-segment model. One hundred eleven pa
tients (82%) had adequate visualization of at least 14 of 16 wall segments.
Ninety-eight patients (72%) had a palpable cardiac impulse, of whom 90 (92
%) also had adequate acoustic image quality versus only 21 (55%) of the 38
patients in whom an apex was not palpable (P <0.0001). Other variables that
were measured were not significantly related to image quality, with the ex
ception of weight; patients with adequate images weighed a mean of 75 kg ve
rsus 91 kg in those with inadequate images (P <0. 0006). However multivaria
te analysis showed a palpable apex to be the only independent predictor aft
er controlling for other variables. A physical examination assessment for a
palpable apical impulse is useful to predict adequate echocardiographic im
age quality for stress echocardiography. When used in conjunction with othe
r parameters, this may lead to more appropriate referral to augmented stres
s testing.