S4 Gallop

The S4 occurs in late diastole, just before S1, coinciding with atrial contraction (the a wave in the jugular venous waveform). It is generally present when the heart is so stiff that it is reliant upon a significant amount of filling via atrial contraction. Like the split S1, the S4 gallop is best heard over the apex of the heart. However, unlike the split S1, it is best heard with the bell of the stethoscope because of its low pitch.

 

Patient 1:

This patient has an S4 gallop.

S4 Gallop

Annotated

Patient 2:

This is a middle-aged man who was admitted to the hospital with a new diagnosis of non-ischemic cardiomyopathy, possibly related to chronic alcohol use. Note the low-frequency extra sound just before S1.

S4 Gallop

Annotated

Patient 3:

This is a middle-aged man with poorly-controlled diabetes mellitus who was admitted to the hospital with a necrotizing soft tissue infection involving the back of his neck. He was noted to be tachycardic with a right-sided S4 gallop. No definitive explanation for this finding was determined.

S4 Gallop

Annotated

S4 Gallop

Annotated

S4 Gallop

Annotated

Patient 4:

This is a young man with cocaine-induced cardiomyopathy. Sometimes it is difficult to distinguish an S3 gallop from an S4 gallop when the patient is tachycardic. In this case, notice the sinus pause halfway through the second recording, proving that the gallop is an S4 ( it is the first sound on the next beat).

 

Patient 5:

This is an older woman with metastatic carcinoid syndrome who developed infective endocarditis of the tricuspid and aortic valve and was admitted with decompensated heart failure. This patient also has a clearly visible arterial pulse in the neck.

Patient 6:

This is a middle aged man with poorly controlled diabetes mellitus who was admitted to hospital for a soft tissue infection. Cardiac exam revealed an S4 gallop of unknown clinical significance. Echocardiography was completely normal.

Patient 7:

This is a middle-aged woman who was admitted to the hospital with generalized weakness thought to be caused by a myopathy of unclear etiology. She was found to have an S4 gallop on exam of unclear significance. 

 

Patient 8:

This is an older man with methamphetamine-induced cardiomyopathy, admitted to the hospital with respiratory failure. He was incorrectly diagnosed with pneumonia. Physical examination demonstrated elevated jugular venous pulse and a gallop.

 

Patient 9:

This is a middle-aged man with drug-induced cardiomyopathy, admitted to the hospital with decompensated heart failure. This patient also has Kussmaul’s sign.

Patient 10:

This is a patient with heart failure and S4 gallop.