S3 and S4

by Carlo Raj, MD

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    00:01 back and take a look at S1. You do that in order, you are being in great shape. Before we move on, let us take a look at some S3 and S4 issues. First and foremost what does S3 mean to you? S3 is always going to take place after S2 and that is nice because chronological order. So take a look at the picture down below. Then you will notice that there is a little red line with S3, you see there? And that S3 right there is following your S2. What is exactly happening here? How are you referring to S2 as? S2 is a diastolic heart sound because you just close your aortic and pulmonic valves during diastole. And in the mean time what happens afterward? The mitral valve opens and blood is gushing into left ventricle.

    00:46 Are you picturing this? You have to picture this in your head or otherwise it is just bunch of words that makes no sense. So all of this blood is rushing into the left ventricle during diastole, the mitral valve has opened and if the left ventricle is too large as it may occur with pathology such as congestive heart failure. Could occur physiologically? Sure. Really, what kind of patient? A patient that is a well-conditioned athelete. Isn't their heart a little bit more efficient in terms of increasing preload and having increased contraction? That is why they are athletes. They are able to properly have enough blood and oxygen being supplied to the skeletal muscle. "So Dr. Raj, you're telling me that S3 could be found in normal individuals?" That's exactly right. Who are these individuals? Athletes, may be pregnant ladies. What happens to plasm volume in a pregnant woman? It increases up to as much as 50 percent. That is a lot of volume in your plasm I am telling you. And what may then happen to left ventricle? Well that left ventricle might then become overwhelmed with fluid during diastole and you may create an S3. Hope that is clear? So it could be found normally in children for the same reason, athletes, reasons we just talked about and pregnant woman. An S3. However, in the United States a 35-year-old who is obese, hearing S3. That is pathology. You are thinking about left ventricular dysfunction, a systolic dysfunction. That is what happens with congestive heart failure? What is the most common cause of congestive heart failure? I am throwing a lot of information at you, but that's okay because this is how you are going to learn. You are going to feel overwhelmed. You are going to take what I am telling you and you are going to digest this and trust me anything that I have been talking to you about throughout this entire lecture series, it is not the first time that you are going to hear it nor is it the last. Guarantee you are going to hear these a hundred different times. So congestive heart failure, the most common cause would be a myocardial infaction, would be an ischemic event. Therefore, causing death of the myocardium resulting in perhaps congestive heart failure. Resulting in what kind of dysfunction? Sytolic dysfunction. Are you with me? Good. Now is it possible that you might then create an S3? Of course. Take a look at that chest X-ray in your hand with congestive heart failure.

    03:21 Tell me about that apex. Where is that apex? It is not where it should be. It is not at the midclavicular. It is laterally displaced. You feel good? I hope so. Is this information setting in? It will, have faith. Let's continue. There is athletes. S4 is a little bit of a different story.

    03:42 It is regrouped. So S3 could be found in normal individuals, yes. We are going to hear S3 after S2.

    03:47 What is an S2? An S2 is a diastolic heart sound. What happened at S2? Closure.

    03:52 Closure of whom? A2, P2, followed by mitral valve opening, left ventricle is too large. You create an S3. What about S4? Take a look at the bottom picture. You've an S4, where is it? It is before S1. Regroup, tell me about S1. S1 is a sytolic or diastolic heart sound? It is a systolic heart sound. How do you know, Dr. Raj? Because during systole, you have closure of the mitral followed by closure of the tricuspid. Welcome to S1.

    04:24 What happen right before S1? It is the fact that you are at late diastolic. Think about this.

    04:30 I am asking you what happened at the beginning or right before closure of that mtiral valve.

    04:37 Late diastole, what does that mean to you? Atrial kick, right. SA node depolarized the atria kicks. This is part of diastole. Is that clear? Atria is going to kick. It is acute part of late diastole and is kicking the blood into left ventricle. What if the left ventricle is thickened? What if it is stiff? Like what? There is something called hypertrophy. You've heard of that before. You have heard of hypertension. You've heard of that before. That's a lot of pressure on your left ventricle and at some point left ventricle is then going to respond physiologically. It is going to go through an adaptation process.

    05:16 What is that called? Hypertrophy. What kind? Concentric, we will talk about this. Not to worry. Over and over again, a concentric hypertrophy is when the sarcomeres are going to duplicate in parallel. Why? In this case, it is pressure overload. What caused that excess pressure? Hypertension being the most common. Later on, we will talk about aortic stenosis. But hold on, let me just give you what is happening with S4. So here is hypertension, huge problem in the US, metabolic syndrome. What is the cut off point for hypertension? 140/90. Our discussion earlier took place with the difference between urgency and emergency? Do you remember that? If you haven't, make sure once again you go back and review to see. It's not that information is difficult. It is the volume of information and so, therefore, it is important that you keep going back and review. Trust me. It will work out. Trust me, it will. Just stick with me. So with all that pressure taking place in left ventricle undergoing concentric hypertrophy, a thickened left ventricle wall. Tell me about the compliance of this left ventricle. Take your time. Tell me about the compliance. It is decreased, right? Decreased compliance, what does that mean? It has becomed stiffened. Now during that kick, the blood is having a hard time getting into left ventricle. What are you going to create? You are going to create an S4. Look at the term bolded here. Always abnormal S4, what does it mean? Indicates a stiff left ventricle. Example, hypertension. What's another one? A pressure type of overload on left ventricle, aotric stenosis. What kind of hypertrophy? Concentric. What does that mean to you? The sarcomeres are duplicating how? In parellel.

    06:55 Causing what? Narrowing of the left ventricle. I'm going to take you one step furthee, you ready? Of course, you are. You are born ready. So that left ventricle on thickening, this is a diastolic dysfunction. That chamber becomes very small and if that chamber becomes very small you can’t fill it up doing diastole, is that clear? That is the diastolic dysfunction.

    07:14 What then happens to left atrium, please? You see the last line right here. This is dilated what? Left atrium. How come? The left atrium is having a hard time kicking left ventricle. Therefore left atrium is going to do what? It is then going to get dilated. So what does S4 mean to you? Always pathologic. What does it mean to you? It means that you have a stiff left ventricle.

    07:35 Now is it possible for you to have congestive heart failure in which blood remains back in left ventricle? Think about what I am just saying. Congestive heart failure, you have a dying heart. Blood then remains back in the left ventricle. Are you with me? So you are creating what kind of issue? You are creating an issue where the blood is contributing to stiffnes. So could you have an S4 with congestive heart failure? Sure you can. That is not a good sign though.

    About the Lecture

    The lecture S3 and S4 by Carlo Raj, MD is from the course Heart Sounds.

    Included Quiz Questions

    1. S4
    2. S1
    3. S2
    4. S3
    5. S5
    1. 50-year-old postmenopausal woman with a laterally displaced apex
    2. 35-year-old male marathon runner right after exercising
    3. 25-year-old G1P0 woman at 20 weeks gestation
    4. 5-year-old child with asthma
    5. 20-year-old woman with an apex at the 5tᵗʰ intercostal space, mid-clavicular line
    1. Concentric hypertrophy due to parallel duplication of sarcomeres
    2. Eccentric hypertrophy due to duplication of sarcomeres in series
    3. Concentric hypertrophy due to duplication of sarcomeres in series
    4. Eccentric hypertrophy due to duplication of sarcomeres in parallel
    5. Congenital septal hypertrophy
    1. Vigorous relaxation
    2. Forceful contraction
    3. Ventricular dysfunction
    4. Left ventricular stiffness
    5. Left atrial dilation

    Author of lecture S3 and S4

     Carlo Raj, MD

    Carlo Raj, MD

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