A sustained apical impulse with a presystolic and an early diastolic component may be felt in a patient with a stiff, poorly compliant ventricle with hypertrophy that is volume overloaded or failing. A presystolic component is the palpable equivalent of an audible fourth heart sound, while the early diastolic component is the palpable equivalent of an audible third heart sound. In the video, note the presystolic component occurs just before the carotid pulse, the sustained systolic impulse occurs with the carotid pulse and the early diastolic component occurs just after the carotid pulse.