Key Takeaways
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The apical pulse is located at the left fifth intercostal space at the midclavicular line in most adults. It is assessed by auscultating the apex of the heart with a stethoscope.
Accurate identification of this location is essential for reliable heart rate measurement, rhythm assessment, and safe medication administration. Keep in mind that this is different than the arterial pulse because it allows the provider to listen to the heart as it contracts and pumps out blood.
This guide explains exactly where the apical pulse is found, how to locate it step by step, and what factors can change its position.
Finding the apical pulse
In adults, the apical pulse is found:
- On the left side of the chest
- At the fifth intercostal space
- At or slightly medial to the midclavicular line
In children younger than seven years, it is usually located at the fourth intercostal space at the midclavicular line.
What is the apical pulse?
The apical pulse is the heart rate obtained by listening directly to the apex of the heart using a stethoscope. It reflects actual ventricular contractions rather than peripheral perfusion. We go further in-depth about the specifics of the apical pulse here.
Healthcare professionals use apical pulse assessment when:
- A peripheral pulse is irregular
- Administering medications such as digoxin or beta blockers
- Assessing infants and young children
- Monitoring suspected arrhythmias
Because it measures heart activity directly, it is considered more accurate than peripheral pulse palpation when precision is required.
Step-by-step: How to locate the apical pulse
1. Position the patient
Place the patient in one of the following positions:
- Supine with the head of the bed elevated 30 to 45 degrees
- Sitting upright
- Left lateral recumbent position for improved detection
The left lateral position may make the point of maximal impulse easier to hear.
2. Identify the sternal angle
Palpate down the sternum until you feel a ridge. This is the sternal angle. It aligns with the second rib.
3. Find the second intercostal space
Move just below the second rib to locate the second intercostal space. From there, count down to the fifth intercostal space.
Accurate rib counting is essential. Do not estimate visually.
4. Locate the midclavicular line
Imagine a vertical line drawn downward from the midpoint of the clavicle. This is the midclavicular line.
Do not use the nipple as a landmark, as it varies by age, anatomy, and sex. In patients with dextrocardia, the heart’s apex is on the right side.
5. Place the stethoscope
At the intersection of the fifth intercostal space and the midclavicular line, place the diaphragm of the stethoscope directly on the skin.
Listen for a full 60 seconds, especially if rhythm irregularity is suspected.
What is the point of maximal impulse?
The point of maximal impulse, or PMI, is the area where the left ventricle contacts the chest wall during systole. In healthy adults, this typically corresponds with the apical pulse location.
You may sometimes palpate a gentle impulse before auscultating, but auscultation remains the primary method for assessing the apical pulse.
Does apical pulse location change?
Yes. Several factors can shift the location of the apical pulse. Below are several instances in which the apical pulse location can change.
In infants and children
- Located at the fourth intercostal space
- The heart sits more horizontally in early life
In left ventricular enlargement
Conditions such as hypertension or cardiomyopathy may cause the PMI to shift laterally or downward.
In pregnancy
The diaphragm rises during later pregnancy, which may slightly elevate heart position.
In chronic lung disease
Hyperinflated lungs can displace the heart and make the PMI harder to detect.
In chest wall abnormalities
Scoliosis or prior thoracic surgery may alter surface landmarks.
Any displacement from the expected location should be documented and evaluated in a clinical context.
Common mistakes when locating the apical pulse
- Using the nipple line as a guide
- Guessing the fifth intercostal space
- Placing the stethoscope too close to the sternum
- Listening over the clothing
A consistent landmarking method improves accuracy and interprofessional consistency.
Why accurate apical pulse location matters
Precise location ensures:
- Accurate heart rate measurement
- Proper rhythm assessment
- Safe administration of cardiac medications
- Correct identification of pulse deficits
- Early detection of cardiac enlargement
Inaccurate placement may lead to incorrect documentation or missed abnormalities.
