Fourth heart sound

Fourth heart sound


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The fourth heart sound or S4 is a rare extra heart sound that occurs immediately before the normal two "lub-dub" heart sounds (S1 and S2). It occurs just after atrial contraction and immediately before the systolic S1. This produces a rhythm classically compared to the cadence of the word "Tennessee" with the first syllable ("Ten-") representing S4.

S4 is sometimes audible in healthy children and trained athletes, but is always abnormal in adults. It is a sign of a pathologic state, usually a failing left ventricle. If the problem lies with the left ventricle, the gallop rhythm will be heard best at the cardiac apex. It will become more apparent with exercise, with the patient lying on their left-hand side, or with the patient holding expiration. If the culprit is the right ventricle, the abnormal rhythm will be most evident on the lower left hand side of the sternum and will get louder with exercise and quick, deep inspiration Tavel ME. "The appearance of gallop rhythm after exercise stress testing." "Clin Cardiol". 1996 Nov;19(11):887-91] .

S4 has also been termed an atrial gallop or a presystolic gallop because of its occurrence late in the heart cycle. It is a type of gallop rhythm by virtue of having an extra sound; the other gallop rhythm is called S3. The two are quite different, but they may sometimes occur together forming a quadruple gallop. If the heart rate is also very fast (tachycardia), it can become difficult to distinguish between S3 and S4 thus producing a single sound called a summation gallop.


S4 is caused by the atria contracting forcefully in an effort to overcome an abnormally stiff or hypertrophic ventricle. This causes abnormal turbulence in the flow of blood that can be detected by a stethoscope.


The S4 rhythm is associated with anything that increases the stiffness of the ventricle, including:
*hypertrophy of the ventricle
*long-standing hypertension (causes ventricular hypertrophy)
*aortic stenosis (causes ventricular hypertrophy)
*overloading of the ventricle (causes ventricular hypertrophy)
*fibrosis of the ventricle (eg. post-MI)


The rhythm itself does not require treatment; rather plans should be laid to stop the progression of whatever causes the underlying ventricular dysfunction.


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