How to look for a difficult to feel apical impulse?

Beginners in clinical medicine often have difficulty in localizing the apex beat, especially in slightly obese individuals. Initial check of apex beat can be with the subject reclining in a couch with back elevation at about 30 degrees. If the apex beat cannot be well localized in this position, a left lateral position with the left arm kept above the head can be tried. Try palpating at the end of expiration when the heart is closest to the chest wall. Alternate option is sitting and leaning forward position. Even with these techniques, apical impulse may not be palpable in those with significant obesity and highly muscular chest wall. Emphysema with a barrel shaped chest is another situation which makes palpation of apical impulse difficult as lung overlaps the apex beat. Normal apical impulse moves away from the palpating finger quickly, meaning that it is not sustained. A sustained apical impulse occurs in left ventricular hypertrophy as in severe aortic stenosis.