Abstract
The S4 heart sound is a presystolic heart sound occurring immediately before S1 associated with reduced ventricular compliance. It is best heard with the bell of the stethoscope at the apex of the heart with the patient in the left lateral decubitus position. The characteristic sound of an S4 is created by the movement of blood during diastole from the atria flowing against a stiff ventricular wall caused by hypertension, pulmonary hypertension, ventricular outflow obstruction, or ischemic heart disease. An S4 can also be heard in athletes with physiologic hypertrophy of the ventricles. In patients with a pathologic S4, a longer interval between S4 and S1 represents a poorer prognosis. Detection of an S4 in a patient with risk factors for pathologic reduced ventricular compliance should trigger further cardiac work up and treatment of underlying pathology to decrease progression.
This is a preview of subscription content, log in via an institution to check access.
Access this chapter
Tax calculation will be finalised at checkout
Purchases are for personal use only
References
Vancheri F, Gibson D. Relation of third and fourth heart sounds to blood velocity during left ventricular filling. Br Heart J. 1989;61(2):144–8.
Erikssen J, Rasmussen K. Prevalence and significance of the fourth heart sound (S4) in presumably healthy middle-aged men, with particular relation to latent coronary heart disease. Eur J Cardiol. 1979;9(1):63–75.
Markus GM, Gerber IL, MeKeown BH, Vessey JC, Jordan MV, Huddleston M, McCulloch CE, Foster E, Chatterjee K, Michaels AD. Association between phonocardiographic third and fourth heart sounds and objective measures of left ventricular function. JAMA. 2005;293(18):2238–44.
Tabuchi H, Kawai N, Sawayama T. Mechanism and clinical usefulness of S4-S1 interval in heart failure associated with left ventricular inflow pattern. J Cardiol. 1998;31(5):273–9.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
1 Electronic Supplementary Material
Video 19.1
S4 gallop. Phonocardiogram is not ideal, but audio is excellent (Provided by Robin Winkler Doroshow, MD, Medstar Georgetown University Hospital, Washington, DC) (MP4 987 kb)
Video 19.2
Atrial (S4) gallop, as described by Dr. W. Proctor Harvey (File 085 from Clinical Cardiology by W. Proctor Harvey, MD, MACC, Jules Bedynek, MD, and David Canfield and published by Laennec Publishing Inc., Fairfield, NJ. Used with permission and copyrighted by Laennec Publishing, Inc. All rights reserved) (MP4 1322 kb)
Rights and permissions
Copyright information
© 2015 Springer-Verlag London
About this chapter
Cite this chapter
Yaeger, K., Norton, M., Jalaj, S. (2015). The S4 Gallop. In: Taylor, A. (eds) Learning Cardiac Auscultation. Springer, London. https://doi.org/10.1007/978-1-4471-6738-9_19
Download citation
DOI: https://doi.org/10.1007/978-1-4471-6738-9_19
Publisher Name: Springer, London
Print ISBN: 978-1-4471-6737-2
Online ISBN: 978-1-4471-6738-9
eBook Packages: MedicineMedicine (R0)