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Download Normal Heart Sounds
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Abnormal S3 and S4 heart sounds S3 Sound: Cause: Affected mechanism: Clinical significance: Ventricular gallop: dull, faint thud heard after S2. Rapid refilling or overfilling of the ventricles Possibly caused by stiff valve leaflets and/or ventricular walls vibrating as diastolic filling abruptly slows down, but may be the sound of the ventricle hitting the inner chest wall or the apex suddenly reaching the limit of its ability to expand lengthwise. May indicate: 1. Most commonly due to increased resistance as blood is forced into a stiff (usually left) ventricle. Although it is called atrial gallop, the sound originates in the ventricles during diastolic filling, which has two phases. The first is rapid and passive, and occurs when the atrioventricular valves open. S4 is associated with the second phase, which occurs in late ventricular diastole when the atria contract, actively forcing blood into the ventricles. The sound is thought to be that of the ventricular wall vibrating as a result of a sudden decrease in the rapid flow of blood into the ventricles. 1. Usually indicates increased resistance to blood flowing into the ventricles, which is known as reduced compliance, commonly as a result of ventricular hypertrophy (eg. systemic hypertension, aortic stenosis, hypertrophic cardiomyopathy) or coronary heart disease (previous myocardial infarction or acute ischaemia). Right ventricular S4 is typical of pulmonic valve stenosis and pulmonary artery hypertension. Cycle sound: lub-DUP-da or lub-DU-bub S4 Atrial gallop: low-pitched dull or thudding sound heard shortly before S1 Cycle sound: bla-lub-DUP or belub-DUP 2. Increased atrial pressure (atrioventricula r valves may also vibrate). S3 & S4 Quadruple gallop Cycle sound: bla-lub-DUP-da Ventricular dysfunction (eg. ischaemic heart disease, dilated or hypertrophic cardiomyopathy, myocarditis); Heart failure; Too much blood or fluid in the ventricles – eg. high cardiac output (anaemia, pregnancy or thyrotoxicosis), valve regurgitation or intracardiac shunt, heart block, renal failure, or excess transfused fluid or blood. Note: Important indicator of relatively advanced heart disease and almost always abnormal over the age of 40. May not appear so the absence of S3 does not rule out the above conditions. 2. Overfilling of a normal ventricle (eg. anaemia, thyrotoxicosis or acute mitral regurgitation) Note: Almost always abnormal if clearly heard and palpable, but may be heard in healthy people aged over 50 – possibly reflecting a normal decrease in ventricular compliance with ageing. The creation of this sound depends upon effective atrial contraction and blood flow through the atrioventricular valves, so S4 does not occur in patients with atrial fibrillation, or advanced mitral (no S4 sound on left) or tricuspid (no S4 sound on right) stenosis. Note: In patients with a rapid heart rate it may be difficult to distinguish S3 from S4, and in patients with tachycardia S3 and S4 may occur at almost the same time and be heard as a loud three-beat gallop.