What did we learn together from evaluating our patient’s precordial movement? Well, the location of that movement is normal. Fifth interspace, midclavicular line. The size… well, the size is normal too, about the size of a dime (1.8 cm), but the contour of that movement, that is not normal and it is telling us something. We’ll again use the cotton swab, so we can together analyze the timing, or, contour of the movement. We’ll place one not only on the carotid for timing, but at the apex, and we can see we have two movements at the apex. Let’s all watch together. [cut-away] Now those two movements at the apex, the first occurs just prior to systole, just prior to the carotid impulse, and the second occurs in very early systole and is brief. Now, that second impulse is a normal apical impulse, but the first impulse, the presystolic impulse, is not normal, and it is due in our patient to some decrease in compliance of the ventricle, because in presystole, the atrium contracts, pushing blood into the ventricle. As it decelerates, it finds a greater stiffness of that ischemic, less compliant, myocardium, blood decelerates more rapidly than normal, and that results in the movement you can feel on the chest wall – a presystolic movement at the apex followed by an essentially normal systolic impulse. It tells us something about ventricular compliance.