Correlation Between the Apex Cardiogram

and Left Ventricular Pressure*

JORGE C. RIOS, U.D. AND RASHID A. MASS-WI, b1.n.t

Washington, D. C.

RECORDIALmovements reflecting mechanical Electronics for Medicine recorder at a paper speed

P action of the heart have been observed
with interest since the pioneer work of Mareyl
of 50 mm.,‘sec.
Subjects of this study were divided into four groups: Group
I consisted of 50 healthy subjects in whom apex
in 1863, and numerous recording systems have
cardiograms alone were recorded for the purpose of
been devised.‘+ Apex cardiography, which is
studying normal variations with particular attention
the recording of low frequency displacements of
given to the amplitude of diastolic events. Croup II
the apical region, is perhaps the most commonly was made up of 5 patients in whom simultaneous left
used current method of study. Its value in the ventricular pressures and apex cardiograms were re-
diagnosis of ventricular hypertrophy,” bundle corded on two separate catheterizations, once during
branch block,‘” valvular lesions,‘*J2 arterioscle- congestive failure and again after treatment. Group
rotic heart disease’“-1” and hypertensive heart III inciuded 7 patients, some still in failure. in whom
disease’” has been investigated. The potential left.uemx&&r .en&diitolic pressure was altered by
value of apex cardiogra.$y in the study of left various maneuvers, and the corresponding changes on
,trantricular dynamics has been recently demon- the apex cardiogram were studied during the same
catheterization. Of this group, 3 patients were exer-
strated by Dimond and Benchimol.lt
cised, 2 received inhalation of amyl nitrite and 2 were
The purpose of this study was to re-examine
given rapid infusions of 250 to 400 ml. of physiologic
the utility of the apex cardiogram in reflecting saline solution. Angina pectoris developed in 1
variations in left ventricular end-diastolic pres- patient undergoing right heart catheterization, and
sure and thus serving as a practical guide in the her apex cardiogram and pulmonarv artery “wedge”
study of left ventricular disease in a large group pressure (portraying left ventricle diastolic pressure)
of patients. before and during the attack were studied. Group IV
consisted of 8 patients with primary myocardial dis-
MATERIAL AND METHODS east in whom only a single pair of recordings of apex
Simultaneous records of apex cardiogram and left cardiogram and left ventricular pressure were ob-
ventricular pressure were obtained in 20 cardiac pa- tained during the failure of the left ventricle.
tients in the course of left heart catheterization. As a Measurements of the diastolicJiliing xave (DFW) from
control study apex cardiograms were recorded in a the 0 point to the peak of the a! and the u wave from
group of 50 healthy normotensive medical students its onset to its peak were made and expressed as per-
and physicians between the ages of 26 and 40 years. centages of the total amplitude of the apex cardiogram
Apex cardiopms were obtained using a crystal from 0 to E, according to the method of Dimond and
microphone (Electronics for Medicine, Model A-161) Eknchimol” (Fig. 1). At least three sets of values
with a frequency response set between 0.1 to 20 c.p.s. were measured and averaged. All tracings were ob-
The contact disc was placed at the point of maximal tained at the end of normal expiration.
impulse and secured with a rubber strap. All de- The data were analyzed statistically with the use of
terminations were performed with patients in supine the t test and the correlation coefficient.
position and, when necessary, in left lateral decubitus.
Left verkular catheterization was performed using RESULTS
the percutaneous transfemoral retrograde technic. Group I (:Yormal Subjects):
The atnplitude of
Pressures were obtained with Statham P23Db pres- the diastolic filling wave averaged 33yc f 4.3,
sure transducers. All records were made on a DR-8 and the a wave averaged 87c f 2.5 (Fig. 2).

l From the Cardiopulmonary Laboratory and the Geor,qr it’ashington University Division of Medicine, District of
Columbia General Hospital, Washington, D. C.
t For reprints address R. A. Massumi, M.D.

.VDLUME 15, -MAY1965 647

648 Rios and Massumi

ECG

FIG. 1. Recordiqs of apex cardiogram with other hemodynamic eaents for orientation and timiq. A, simultaneous re-
cording of, from top to bottom, electrocardiogram, heart sounds at the apex, indirect carotid pulse tracing and apex
cardiogram. B, simultaneous electrocardiogram, apex cardiogram and left ventricular pressure pulse. IC = onset
of isometric contraction; CE = onset of carotid ejection; IR = onset of isometric relaxation synchronous with the
second sound; the interval CE-IR = ejection period; 0 = opening of the mitral valve; a = atria1 contraction:
0-IC = diastolic filling wave (DFW) composed of an early steep portion representing the early rapid filling, a middle
slow segment of diastasis and the late rapid filling (a). Horizontal line 0 = lowest point of amplitude; E = highest
point; O-.4 = DFW amplitude; D-A = atria1 systolic amplitude; O-E = total amplitude.

‘I’ABLE I
Hemodynamic and Apex Cardiographic Data from ‘Two Separate Catheterizations in 5 Patients (Group II).

Left Ventricular
End-diastolic a/Total
Case 8: Pressure DFW/Total Ratio
Sex Age Diagnosis (mm. Hg) Ratio (<,;,) (%) Remarks

6-M 49 PMD 35 32 10 First cath.

12 16 11 Second cath.-after treatment

7-M 44 PMD 45 38 19 First cath.

30 26 16 Second cath.-after treatment
8-M 46 HCVD 40 42 23 First cath.
10 14 9 Second cath.-after treatment
9-F 35 PMD 37 25 14 First cath.
34 23 Second cath.-after treatment
11-M 48 PMD 52 50 14 First cath.
10 27 13 Second cath.-after treatment

DFW = diastolic filling wave; PMD = primary myocardial disease: and HCVD = hypertensive cardiovascular
disease.
Cases 6, 7, 8 and 11 responded to therapy, but Case 9 did not. Note that the values for DFW decrease commen-
surately with the fall in left ventricular pressure. Apex cardiographic a waves could not be measured with accuracy
in Case 9 during the stxond catheterization.

THE AMERICAN JOURNAL OF CARDIOLOGY

 Apex Cardiogram and Left Ventricular Pressure 649

00
000

>I 0

00

00
8
0

coo
0
000
oo”
00 0
008
GO
3 :: 00

Control Patients

A I
Control Patients
B

FIG. 2. Scattergrams of (A) diastolic filling wave/total and of(B) a/total ratios in the normal subject and in
patients with heart disease.

Group ZZ: Measurements made during failure maneuvers and in all cases proportional changes
(Table I) yielded an average of 37 per cent in the diastolic filling wave occurred (Fig. 4-6).
(range 25% to 50%) for the diastolic filling In 2 other cases (included in Table II) no change
wave and 16 per cent (range 10% to 23yc) for occurred in left ventricular end-diastolic pres-
the a wave. After treatment, satisfactory com- sure after exercise (Case 3) and infusion of saline
pensation was achieved in 4 of the 5 cases (Cases solution (Case 12), and their diastolic filling
6,7,8,11) with a commensurate decrease in both waves likewise remained constant. The a waves
the left ventricular end-diastolic pressure and varied in the same direction as the left ventricular
amplitude of the diastolic filling wave (Fig. 3). end-diastolic pressures.
The variations in the a waves, on the other hand, Group IV: Values obtained in patients of
exhibited a less convincing correlation with the this group, all of whom were in failure, were
end-diastolic pressures. One patient (Case 9) used only for calculations of the regression equa-
failed to respond to therapy and both his left tions.
ventricular end-diastolic pressure and diastolic Comparison of apex cardiographic measure-
filling wave remained unchanged. ments in the group of patients with heart disease
Group ZZZ: In patients of this group (Table with similar measurements in the group of 50
II, Cases 1, 2, 4, 5, 7, 8, 10) left ventricular end- normal controls showed statistically significant
diastolic pressures were modified by different differences in the diastolic filling and a waves.

VOLUME 15, MAY 1965

650 Rios and Massumi

Hemodynamic and Apex Cardiographic Data on Two or Threr Separate Occasions During Same Catheterization in
9 Cases (Group m).

Left
Ventricular DFW/
End-diastolic Total a/Total
Case & Pressure Ratio Ratio
Sex .+e Diagnosis Intervention (mm. Hg) (%-I (%I

1-M 35 HCVD Rest 21 24 13

Exercise 45 32 20
Inhalation amyl nitrite 18 21 12
2-M 48 PMD Control 15 24 12
Leg raising 27 34 24
Before infusion of salinr 23 31 15
After infusion of saline 25 31 23
3-M 42 CAD Rrst 20 20 11
After rxercisc 20 20 12
After inhalation amyl nitrite 8 14
After disappearance of amyl nitrite effect 20 19 1 (I
4-M 60 ASCVD Rest 25 21 6
After exercise 32 32
5-F 45 C.4D Before angina pectoria 17 26 11
During angina pectoris 29 37 16
7-M 44 PMD Rest 12 16 11
After rxercisc 35 36 25
8-M 46 HCWD Before infusion of saline 18 20 12
After infusion of salinr 18 20 12
1 O-F 46 Chagas Before amyl nitrite inhalation 27 26 18
After amyl nitrite inhalation 12 16 9
12-M 54 ASCVD Before infusion of saline 25 33 17
After infusion of saline 25 33 19

CAD = coronary artery disease with angina pectoris; C:ha#;ts = chronic Chagas’ myocardiopathy.
ASCVD = arteriosclerotic cardiovascular disease.
Note parallel changes between the Irft ventricular, end-diastolic pressures and apex cardiographic values for DF\\’
and u. The amplitude of thr n waves could not bc measured with accuracy on two occasions.

Corresponding values for the normal controls in firmness of the myocardium and also in the
already stated were considerably lower and the curvature of the apical region are all sensed by
statistical computations yielded t = 5.5 (/I = the recording assembly as displacement. Ill

0.001) for the diastolic filling wave and t = 9 fact, the first two phenomena, namely, changes
(p = 0.001) for the a wave. The correlation in ventricular volume and myocardial firmness
coefficient for left ventricular end-diastolic pres- (“endurcissement’)‘) were suggested as the
sure and diastolic filling wave was 0.83 (p = responsible mechanism by the earliest workers
O.Ol), the regression equation being? = 9.91 + whose chief interest lay in the systolic complex
0.67,~ (Fig. 7). of the apex cardiogram.‘,‘8
The configuration of the systolic complex is
DISCUSSION subject to great variations depending on the
The genesis of the apical displacement and its spatial relationship of the pickup to the apex.
graphic representation, the apex cardiogram, is The amplitude of the systolic complex depends,
obscure. It is clear, however, that outward among many factors, on the size of the stroke
movements of the apical region give rise to up- volume (Fig. 8).
ward deflections and inward movements to The diastolic components of the apex cardio-
downward deflections. In addition, it must be gram which constitute the subject of this study-
recognized that changes in ventricular volume, have been known to bear a temporal relation to

THt AMERICAPI’ JOURNAL Ok CARDIOLOGY

 Apex Cardiogram and Left Ventricular Pressure 651

IO 20 30 40 80

Left Ventricular End-diastolic Pressure (mm. Hg)

FIG. 3. Composite graph of left ventricular end-diastolic pressures on the abscissa plotted
against the amplitudes of diastolic filling waves on the ordinate. The graph represents 11 cases
with two to three sets of values at different levels connected by lines in each (Groups II and III).
Cases 6, 7, 9 and 11 had two catheterizations. In the remaining 6 cases, left ventricular end-
diastolic pressure was altered by various maneuvers: leg raising in Case 2 (see Fig. 4); exercise
in Cases 1 (Fig. 5), 3, 4 and 6; inhalation of amyl nitrite in Cases 1 (Fig. 5), 3, and 10 and spon-
taneous angina pectoris in Case 5.

the diastolic events within the left ventricle. displacement requires the consideration of yet
Changes occurring in left ventricular volume another important corollary of left ventricular
during diastole, as shown by Rushmerlg and disease, namely, the increased tension of the
Hawthorne,*0 are probably the major factor in ventricular wall secondary to anatomic or hemo-
producing the diastolic complex of the normal dynamic changes. The altered pressure-volume
apex cardiogram. The greater diastolic dis- relation (decreased compliance) in the
placement in the presence of raised left ventricu- diseased or failing left ventricle adequately ex-
lar diastolic pressure (left ventricular failure or plains the exaggerated tension or firmness of the
otherwise) as demonstrated in this study, on left ventricular wall for a given increment of
the other hand, requires special explanation. volume, and it is perhaps this “firming up”
In fact, it is quite probable that the diastolic or tensing of the left ventricular apex which is
forward displacement imparted to the chest sensed as displacement. It may be recalled, in
wall by the diseased left ventricle is of a less this connection, that the gentle and impalpable
than normal magnitude because of the’ dimin- diastolic filling of the left ventricle in health
ished stroke volume and the greater capacity of becomes palpable at the apex when this chamber
the dilated left ventricle to accommodate the fails or loses its compliance.
diastolic load. Therefore, the understanding Increased amplitude of the diastolic events in
of the seemingly paradoxic increase of diastolic the apex cardiogram in patients with heart fail-

VOLUME 15, MAY 1965

 Rios and Massumi

leg rmsq. There is concomitant

rise in left ventricular rnd-dia-
stolic pressure and thr diastolic
amplitude of the apex cardio-
qam. Note B was rerordrd at a
speed of 25. mm.,‘sec.

A B C

FIG. 5. &se 1. .%wkzn~ou~ h”.t of’ntrtcuhr.~‘JJUM,hd~cmd uf~x cardqram. A, control; B, after exercise; C, after
inhalation of amyl nitrit?. Note the parallelism betwwn left ventricular end-diastolic pressuw and apex cardiographic
diastolic amplitude.

THE AMERICAN JOURNA” OF CARDIOLOGY

 Apex Cardiogram and Left Ventricular Pressure 653

ure has been identified by a number of au-

thors17vz1 Our demonstration that these changes
are proportional to changes in left ventricular
end-diastolic pressure confirms previous observa-
tionsg that the apex cardiogram is a useful means
for detecting the presence of left ventricular dis-
ease or failure. It has been reassuring that the
diastolic filling wave amplitude returned to
normal after subsidence of clinical failure in
many of our cases not included in this study.
However, the a waves have generally remained
elevated even after normal left ventricular func-
tion has been restored. This finding is conso-
nant with the notion of decreased left ventricular
compliance, a phenomenon which may outlast
the period of failure if the anatomic alterations
of the ventricular wall should persist.r5J7J1
The technic requires practice and constant
vigilance against artifacts caused by improper
placement of the pickup, inadequate patient FIG. 6. Case 3. Simultaneous left ventricular pressure pulse
and apex cardiogram at the time of compensation. A, con-
instructions regarding breath-holding at the trol; B, after exercise. Note that following exercise
end of a normal expiration and many other fac- there are no changes either in the left ventricular end-
tors. Executed properly, the apex cardiogram diastolic pressure or in the diastolic wave of the apex
provides indirect information on two important cardiogram.
parameters of left heart hemodynamics. Thus,
the amplitude of the a wave representing the diastolic pressure and may disclose left ventricu-
vigor of left atria1 contraction reflects compliance lar failure when other studies remain equivocal.
of the left ventricle ; it is magnified in hyperten- Our preliminary studies in ischemic heart
sion, aortic stenosis, left ventricular hypertrophy disease have confirmed the presence of height-
and all types of left ventricular fibrosis. The ened amplitude of the diastolic filling and a
diastolic filling wave amplitude, on the other waves after exercise, as has been pointed out
hand, serves as a reflection of left ventricular previously.r3J5J7 We believe that the technic

.
.’
l 2 _.**
.’
.’

.
FIG. 7. Scattergram of left ventricular
end-diastolic pressure on the abscissa
and apex cardiographic diastolic am-
plitude in all cases of heart disease in-
cluded in the study. The solid line
is the line of ideal correlation. The
dotted is the regression line.

IO 20 30 40 NM Mo

Left Ventricular End-diastolic Pressure

VOLUME 15, MAY 1965

654 Rios and Massumi

FE. 8. fi&hm brtwr~m cmj~l~tud~o/ +rx Lard~ry U/~ILJYSILI~~~ COII$IPYand SI.Z of stroX~~r~olurrr~. .I. cast ol’ complete heart
block showing the highest systolic deHections in beats (2 and 4) preceded by hemodynamically fa\-orablc P-R intervals
between 0.20 and 0.26 sec. and hence possessing grratcr stroke volume. B, another case ofcomplete heart block showing,
from top to bottom, heart sounds, electrocardiogram, brachial pulse tracing and apex cardiogram. Note that, as in -1,
the highest systolic walw are found in beats 2 and 4, both of which are preceded by good P-K intervals. Brachial
arterial pressure tracing confirms the presence of greater stroke volumes in beats 2 and 4. C:, simultaneous recording
of the apex cardiogram with left ventricular prrssurc. pulse showing commensurately ymallrr apex cardiographic systolic
waves in premature ventricular brats possrssing smallr~ systolic praks.

may prove a valuable adjunct to electrocardiog- and vibrations. 1. Studies on the normal heart.
_.i~z. Heart .J., 20: 667. 1940.
raphy and other objective means in the detection ‘3. EDDLEMAN, E. E., WILLIS. Ii.. ~:LIRISI'IANSON, L..
of coronary disease. PIEKCCI, .J. K. and WALKER. Ii. P. ‘The kinetio-
cardiogram n. The normal conliguration and
SUMMARY amplitude. Circulation, 8: 370. 1953.
4. ROSA. I,. M., CONSTANTINO. .I. P.. REICH. K.,
Simultaneous apex cardiograms and left K.~RY.+K, N. and ZESWFR. H. The precordial
ventricular pressure pulses were recorded in 20 accelerogram in normal subjrcts and nonc;lrdiac
cardiac patients in various stages of compensa- patients. E,xper. iMrd. E ~S!(~,o..1’1: 207, 1961.
5. I,UISAD.~. A. A. ‘l‘he Heart. p. 95, Bnltirnorc, 1954.
tion in search of a clinically useful correlation
LVilliams & Wilkins Co.
between the external phenomena at the apex 6. ~IARTIAN, 1-I. El reqistro conjunto de1 fonorardio-
and the intracardiac diastolic pressure events. qrama, 10s pulses xnoso y artrrinl, cl cardiograma
For an understanding of the normal variations, ;tpexiano y el rlectrocnrdio~rama. . Irch. ITI.Tf.
apex cardiograms were recorded in SO healthy ctlrdiol. Ml.wo, 31 : 39> 1961.
7. SCHELI.ING, .J. I,., KEYMOND. .\. and KIVIER, .J, 1,.
subjects. A useful relation between the arn- Interet de l’enregistrement simultane du phono-
plitude of the diastolic components of the apes cardiogramme et du cerdioyram apexien. Ciudio-
cardiogram (0 wave and diastolic filling waL,e) lo,&. I%: 199, 1960.
and the height of left ventricular diastolic pres- 8. HENCHIMOL, A. and DI\WW. t;. G. ‘The \aluc of the-
apcxcardiogram as a reference tracing in phono-
sure has been found.
cardiography. .4m. Heart .I.. 61 : 485. 1961.
The genesis of apex cardiographic deflections 0. BENCHIMOL, A. and DIMOND. E. G. The normal and
and the possible explanations for the correlation abnormal apwcardiog-ram and its relation to
described have been discussed. intracardiac we&s. .+I/. ./. Curd&., 12: 368,
1963.
10. LEWIS. .T. K. Nature and siynificancc of htxrt
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THE AMERICAN JOURNAI. OF CARDIOLOGY

 Apex Cardiogram and Left Ventricular Pressure 655

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VOLUME 15, MAY 1965