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Apical Pulse - Measuring Apical Pulse, Possible Variations, and Significance

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The apical pulse is a direct hearing of the heart functions from the heart apex and is usually felt with the help of a stethoscope.

Medically reviewed by

Dr. Prashant Valecha

Published At October 10, 2022
Reviewed AtOctober 10, 2022

Introduction:

The apical pulse is the best-heard heart sound in the chest, close to the apex of the heart. Therefore, these heart sounds help in assessing cardiac conditions directly. Heart disorders can be assessed clinically with the tendency and nature of apical pulse, which is further confirmed by running cardiac function tests. The earlier we diagnose the heart disorder, the earlier we treat it and reduce the risk for life.

What Is the Normal Apical Pulse Rate?

The rate is measured at rest while sitting or lying and varies with age, as in infants and adults.

  • Newborn - 100 to 170 beats/minute.

  • Six months to one year - 90 to 130 beats/minute.

  • Two to three years - 80 to 120 beats/minute.

  • Four to seven years - 70 to 100 beats/minute.

  • Older than ten years - 60 to 80 beats/minute.

Apical Pulse Rate

How to Measure Apical Pulse?

  • The apical pulse is best heard using a stethoscope or point of care ultrasonography (POCU).

  • It is recorded as ‘Lub-Dub’ as one pulse and calculated for pulse per minute.

  • The heart sounds ‘Lub-Dub’ are heard from the apex of the heart on the left side chest, midclavicular line, at fourth (in newborns) - fifth (in adults) intercostal spaces.

  • Using a stethoscope to auscultate apical pulse is calculated for 30 minutes and multiplied by two to calculate apical pulse/minute or for 15 seconds and multiplied by four to find out the pulse rate per minute. Also, it can be calculated for one minute for accuracy.

  • Also, the apical pulse is palpable on fingers, at the point of maximum pulsation, on the left side of the chest near the fifth rib, half an inch from the sternum.

What Are the Symptoms of High Apical Pulse?

Any disturbance or changes in the apical pulse rate can signify multiple systemic problems. An increase in apical pulse can present as,

  • A rise in temperature or fever.

  • Anxious.

  • Restlessness.

  • Short and shallow breathing.

  • Altered/ less conscious.

  • Confused orientation.

  • Excess blood loss (hemorrhage) leads to hypovolemic shock.

Increase in Apical Pulse:

Chest pain, increased physical activity, low blood pressure (hypotension), and excessive blood loss are definite signs seen among persons with increased apical pulse rates. Also, inadequate oxygen supply, reduced hemoglobin, and hyperthyroidism can increase the load of heart function. Hence, the apical pulse will be raised. Nevertheless, cardiac problems and heart failure directly affect the pulse.

When Does Low Apical Pulse Happen?

A decrease in apical pulse rate has been noted in cases of specific drugs such as beta-blockers and cardiac antidysrhythmic drugs. These drugs or medications act on the conduction of the heart and restore the heart rate to normal.

What Are the Variations in Apical Pulse?

  • An elongated apical pulse is interpreted as high blood pressure or atrial stenosis, which is a narrowed aortic valve. This means the heart is applying extra pressure to pump out blood to the body. The aortic valve may become narrow on the deposition of cholesterol or inflammation in the valve, or infection.

  • When a sluggish pulsation is heard during auscultation, it is a forced apical pulse. Such pulsation can occur due to aortic regurgitation or mitral regurgitation. This includes incomplete closure of the heart valves (aortic valve or mitral valve) and backflow of blood into the ventricles.

  • Irregular rhythmic pulsation is heard in cases of atrial fibrillation or arrhythmia. Cardiac arrhythmias are one of the most common disorders.

  • If two to three impulses are auscultated along with a single pulse, it can be cardiomyopathy. Hypertrophic inflammation of cardiac muscles causes diffuse impulses along with regular pulsation.

These variations will present as symptoms and signs such as pain, breathing difficulty, restlessness, weakness, light-headedness, and sweating. When a patient complains of such a situation, one must take him or her to the physician and seek immediate treatment.

What Are the Factors that Can Affect Apical Pulse?

  • Size of the heart.

  • Muscles of the heart.

  • Blood flows in and out of the heart.

  • Any resistance or pressure during cardiac output.

  • The function of the valve.

  • Conduction of heart.

Auscultating apical pulse may vary in certain conditions such as pregnancy, increased chest mass, any disease that pushes the heart to the right side, or dextrocardia. Dextrocardia is a rare condition where the heart is located on the right side of the chest. In addition, the presence of any tumor or any lung disorder (pulmonary pneumonia) may push the heart to the right side. Also, with congenital deformities in the shape of the heart or lowered position of the heart, the apical pulse location will vary.

When Do We Check Apical Pulse?

When peripheral pulses are feeble and unrecognizable, and in cases of emergency, where the apical pulse is measured along with breathing sounds, in some cases like cardiac arrhythmia, peripheral pulses are inappropriate, their apical pulse is measured.

Apical Pulse vs. Radial Pulse vs. Carotid Pulse:

  • Radial Pulse: It is peripheral pulsation measured on the wrist. It is measured against the radial artery. Radial pulse may get affected in case of injury to the hand or tight dressing, or heart dysfunction. Radial artery pulsation may also get affected by temperature or disease involving the radial vessel.

  • Carotid Pulse: It is a direct pulsation from the carotid artery. This artery comes directly from the aorta of the heart and hence, pulsates on cardiac output. Yet, a carotid pulse may get affected in case of tumors involving the carotid artery, vagus nerve stimulation, any compression on the vessel, or neck injury. However, if cardiac output is affected, the carotid pulse is inappropriate.

  • Apical Pulse: It is the heartbeat from the apex of the heart. It is measured on the fourth-fifth rib on the left side of the chest and is an accurate method to assess heart conditions during emergencies. The apical pulse projects the heart function directly. The apical pulse can be calculated and interpreted if it is unaffected by any existing or developing cardiac disorder. At the same time, radial pulse and carotid pulse will be affected and may get misinterpreted, as changes in cardiac output regulate the blood flow to the periphery. Hence, the apical pulse is considered to be more accurate.

How Is Apical Pulse Important for Physicians?

Sometimes, physicians may encounter irregular apical-radial pulse, called a pulse deficit condition. Pulse deficit is calculated as the difference between the apical and peripheral pulse rates. It requires two individuals to measure. One checks the radial pulse, while another simultaneously calculates the apical pulse for one minute and then compares. The apical pulse is normally the same as the peripheral pulse, yet any difference in the pulse rate gives a diagnosis of cardiac dysfunction. Under such a situation, an electrocardiogram (ECG) is used for diagnosis.

Conclusion:

The apical pulse is the most accurate and efficient way of measuring heart functions. One must check the apical pulse at regular intervals. For any changes felt or noted in apical pulse, one must do other heart function tests such as treadmill tests, ECG, echo-cardiogram tests, Holter monitors, and cardiac enzyme tests and must review with cardiologists. Hence, visit your physician for further evaluations.

Frequently Asked Questions

1.

Where Is the Apical Pulse Located?

The apical pulse is situated above the apex of the heart. The apex is the tip of the left ventricle that points downward on the left side of the chest. The heart's apex is on the right side in case of dextrocardia, a condition in which the heart is flipped from left to right.

2.

Why Is An Apical Pulse Necessary?

The apical pulse is the most audible heart sound in the chest, located near the apex of the heart. As a result, these heart sounds aid in directly assessing cardiac conditions. Clinical evaluation of heart conditions is possible using the pattern and characteristics of the apical pulse, which is then verified by performing cardiac function tests. The sooner a heart disorder is identified, the sooner it can be treated, and the lower the risk is for life.

3.

How Do Radial and Apical Pulses Differ From One Another?

The main distinction between apical and radial pulses is that radial pulses are felt at the wrist, whereas apical pulses are handled over the left of the chest over the heart. Apical pulse rate abnormalities may indicate heart disease, heart failure, or an overactive thyroid. Along with the conditions mentioned in the apical pulse, an abnormal radial pulse may signify an artery blockage.

4.

Which Among S1 and S2 Is the Apical Pulse?

The S1 sound, which has a slightly low pitch and is loudest at the apical region, results from the atrioventricular (mitral and tricuspid) valves closing as ventricular and atrial pressures diverge at the start of systole. S2 is a slightly high-pitched sound produced at the apical region due to the closure of the arterial valve. Clinically, S1 is equivalent to the apical pulse.

5.

What Is the Normal Apical Pulse?

Most adults should have an apical pulse between 60 and 100 beats per minute (bpm). This is an ideal at-rest range. It is typically considered abnormal when the adult apical pulse rate is greater than or equal to 100 beats per minute (bpm) or less than 60 bpm. Apical pulse rate abnormalities may indicate heart disease, heart failure, or an overactive thyroid.

6.

Are Apical Pulse and Heart Rate the Same?

The heart rate and pulse rate are related, but they are not the same. Your heart rate is the rate at which it beats at any given moment. The best place to measure your heart rate is your chest, where your apical pulse is. Blood is compressed and accelerated through your body's network of arteries every time your heart beats.

7.

How Do You Measure the Apical Pulse?

The best way to detect the apical pulse is with a stethoscope or point-of-care ultrasound (POCU). It is counted as one pulse, "Lub-Dub," and the pulse rate is calculated. When using a stethoscope to auscultate the apical pulse, the pulse rate per minute is determined by multiplying the apical pulse over 30 minutes by two or over 15 seconds by four. For accuracy, it can also be calculated for one minute.

8.

When Should the Apical Pulse Be Checked?

Apical pulse readings are typically performed while the subject sits or lies down. The doctor will place a stethoscope over the heart's apex on the left side of the breastbone. They can also detect the apical pulse at the maximum impulse point (PMI). Your doctor will locate the PMI and then listen to your pulse with the stethoscope for one minute to determine your apical pulse rate. When your heart beats with "lub-dub" sound, it equals one beat.
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Dr. Prashant Valecha
Dr. Prashant Valecha

Cardiology

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