Double apical impulse is seen in?

ANSWER: (A) HOCMREF: Harrison's 17th ed chapter 227"Most HOCM patients demonstrate a double or triple apical precordial impulse and a fourth heart sound. Those with intraventricular pressure gradients may have a rapidly rising arterial pulse. The hallmark of HOCM is a systolic murmur, which is typically harsh, diamond-shaped, and usually begins well after the first heart sound. The murmur is best heard at the lower left sternal border as well as at the apex, where it is often more holosystolic and blowing in quality, no doubt due to the mitral regurgitation that usually accompanies HOCM"Some important points about apical impulse:Normal: visible in the midclavicular line at the fifth intercostal spaceHypokinetic:Hypovolumic shockCalcified mitral stenosisSchemic heart disease with failureMyxedemaCardiomyopathiesEmphysemaHyperkinetic: (Duration of impulse is normal, increased amplitude)Aortic regurgitationMitral regurgitationASDPDAHyperdynamic circulatory states like anemia 8c thyrotoxicosisHeaving apical impulse: Duration of apical impulse is more than one third of systole. It is seen inAortic stenosisCoarctation of aortaSystemic hypertensionTapping apical impulse: only seen in uncomplicated mitral stenosis characterized by hypokinetic apical impulse with palpable loud SI