Chapter two S3 &S4 gallop* - Medical Education Online

S3&S4-mdm 

Chapter two 

S3 &S4 gallop* 

1-A 65year old man is hospitalized in CCU with the diagnosis of MI. The second day of 

his stay in CCU he develops dyspnea. 

HR=100 bpm 

BP=125/70 mmHg 

JVP= raised 

S1 and S2 are attenuated and an S3 is heard in the apex of the heart. 

Rales are heard in auscultations. 

Which prescription is the least effective? 

a- Morphine 

b- NTG 

c- Digoxin 

d- Dobutamine 

2- A 55 year old woman comes to ED with exertional dyspnea, a raised JVP and 

prominent X and Y waves. Kussmaul sign is positive. S1 and S2 plus another high 

pitched extra sound can be heard on the apex. Pulsus Paradox is not detected. Which is 

the best diagnosis? 

a- Tamponade 

b- Constrictive pericarditis 

c- Restrictive cardiomyopathy 

d- Right ventricle infarct 

________________________________________________________________________ 

* Sounds generated by rapid ventricular filling are often called “gallop rhythms” or third/fourth heart sound; S3 and 

S4. Both sounds are of low frequency, S3 occurring in early diastole, S4 in late diastole. S3 can occur in healthy 

children and young adults and is then not considered pathological. In patients above the age of 40 the presence of S3 is 

recognized as an early indicator of heart disease. S4 is not a common finding in the young and healthy and is 

considered a sign of heart disease. 

Gallop rhythms are signs of early stage heart failure. S4 is less specific than S3 and can often be confused with a 

split first heart sound or first heart sound followed by an opening snap. S3 is considered one of the best predictors of 

early heart disease. 

S3 can be confused with the opening snap of mitral valve in mitral stenosis. The opening snap is higher in pitch and is 

usually occurring earlier in diastole. 

S4 can be confused with a split S1 or a S1 followed by an ejection sound. S4 is of lower pitch than the other sounds, 

and an established timing by EKG or by palpation should be enough to distinguish these sounds. 

In the middle aged and older age, the third heart sound is usually a sign of increased thickness in the ventricular 

wall. 

In mitral regurgitation, the subsequent increased flow into the ventricle will contribute to an audible S3. 

In constrictive pericarditis, the S3 is called a pericardial knock, as it occurs slightly earlier and is of higher pitch. 

The fourth heart sound is usually seen in context with significant aortic stenosis, Dialted and Hypertrophic 

Cardiomyophaty (HCM), systemic hypertension and in coronary artery diseases. .


3- What sign is the least prevalent for constrictive pericarditis? 

a- Kussmaul sign 

b- prominent Y wave 

c- prominent X wave 

4- pulsus paradox 

4- A 60 year old man with a history of chest pain on exertion has a BP of 140/90mmHg 

and a heart rate of 85. He has a positive stress test and an ejection fraction of 40% in 

echocardigraphy. What combination is good for his BP? 

a- betablocker+isosorbide 

b- betablocker+diltiazem 

c- betablocker+verapamil 

d- isosorbide+nifedipine 

5- What is among the signs of Temponade? 

a- Kussmaul 

b- prominent X 

c- pericardial knock 

d- 4 th heart sound 

6: For what type of heart failure Carvodilol is a betablocker of choice? 

a- Class IV heart failure 

b- Failure with a normal Ejection Fraction 

c- Previous pulmonary edema stable at present 

d- Within a short interval of MI 

7- All of the following can be used for cases of pulmonary edema with systolic left 

ventricular dysfunction except: 

a- IV Digoxin 

b- Loop diuretic is the diuretic of choice 

c- Aminophillyne to enhance heart contractility 

d- ACE inhibitors to lower afterload 

8- A 50 year old man has the chief complaint of dyspnea and exertional chest pain. 

BP=160/100 mmHg / PR=90 bpm 

Heart rhythm= irregular 

JVP= raised 

Pitting edema =2+ 

Rales are present. Liver is palpable and tender. No pericardial effusion is detected. No 

stenosis or regurgitations of valves can be detected. What should not be prescribed for 

this case? 

a- Digoxin 

b- Nitrates 

c- Betablockers 

d- Diuretic


S3 & S4 

Diastolic Dysfunction Systolic 

Examine JVP 

Not raised Raised 

HCMP Check for Pulsus Paradox 

Negative= 

Constrictive pericarditis 

Positive= check for Kussmaul 

sign 

Positive= RCMP Negative= Tamponade 

Algorithm 2-1: Differential Diagnosis of S3 and S4. 

(DCMP=Dilated cardiomyopathy/ JVP= Jugular vein pressure/ 

HCMP=Hypertrophic cardiomyopathy/ RCMP=Restrictive cardiomyopathy)


ED observation or 

short stay 

Assess BP, 

volume 

Status and 

perfusion 

Algorithm 2-2: Acute Pulmonary Edema Management 

Consider 

consultation 

and referral 

ED 

observation or 

short stay


Different causes of S3 & S4 gallop Treatment 

HCMP Defibrillator 

Amiodarone for AF rhythm 

Endocarditis prophylaxis 

Anticoagulant 

Constrictive Pericarditis Salt restriction 

Diuretic 

pericardiotomy 

RCMP Anticoagulant 

Diuretic 

Tamponade Thoracotomy (in an ordinary tamponade 

NS or Blood or vasopressor may be 

indicated) 

Acute pulmonary edema Furosemide IV 0.5 to 1 mg/kg 

Morphine IV 2 to 4 mg 

NTG SL 

Oxygen/intubation as needed 

Low output cardiogenic shock SBP100 

NTG=10-20 mcg/min IV 

Consider SNP: 0.1-5 mcg/kg/min IV 

ACEinh. if SBP is not


Drugs of importance: 

drug contraindications dosage explanation price 

SNP 

Hypersensitivity 

Reduced cerebral - 

perfusion 

AVF 

Coarctation of aorta 

(2cc/50 mg) 

0.3-0.5 

mcg/kg/min 

It should be 

diluted in 250- 

1000 cc DW5% or 

NS. It should be 

50100 Rls. 

AF or flutter with rapid 

ventricular rate 

covered to light by 

aluminum foils. 

TNG 

Dopamine* 

Dobutamine 

Norepinephrine 

Frusemide 

Warfarin 

Carvolilol 


Low blood pressure 

Anemia 

Shock 

Head trauma 

Closed Angle Glucoma 

Cerebral hemorrhage 


Pheochromocytoma 

VF 

OHCM 


IHSS 

AF 

flutter 


OHCM 

Vascular thrombosis 


Hepatic coma 

Anuria 

Electrolyte depletion 


Bleeding 

Peptic ulcer 

Open wound 

Liver and kidney- 

disease 


Cardiogenic shock 

Pulmonary edema 

Bradycardia 

AV block 

Uncompensated - 

HF 

Digoxin Hypersensitivity 

IHSS 

Beriberi 

Diastolic heartdysfunction 

Carotid sinussyndrome 

(1cc/5mg) 

0.2-10 

mcg/kg/min 

(Amp 200mg/5cc) 

5 mcg/min/kg IV 

(Vial 250 mg) 

0.5 mcg/min/kg IV 

(Vial 10mg) 

0.5-1 mcg/min 

IV inf. 

(Amp 20 mg) 

20-80 mg/day 

(Tab 5mg) 

5 mg/d 

(Tab 6.25 mg) 

3.125-0.375 mg po 

qd 

(Tab 0.25 mg) 

0.125-0.375 mg po 

qd 

It should be 

diluted in 50cc 

DW5% or NS. 

Not to exceed 20 

mcg/kg/min 

(See dopamine 

chart in table2-3) 

Titrate to desired 

effect 

Titrate not to 

exceed 30 

mcg/min 

Titrate up to 600 

mg/d for severe 

edema 

for 2-4 days 

subsequent doses 

determined by INR 

4765 Rls. 

2000 Rls 

6500 Rls 

33890 Rls. 

800 Rls 

370 Rls 

220 Rls 

236 Rls 

Table2-2: Drugs mentioned in this chapter. (An important note to remember: qd means per day and 

qid means 4 times a day.)


Answers: 

1-c 

2-b 

3-d 

4-a 

5-b 

6-c 

7-d 

8-a 

Dopamine Chart (gtts/min) 

(400mg/250cc Normal Saline) 

KGS 40 50 60 70 80 90 100 

MCG/MIN 

5 8 10 12 13 15 17 19 

10 15 19 22 26 30 33 37 

15 22 28 33 39 44 50 56 

20 30 37 44 52 59 67 74 

25 37 46 56 65 74 82 93 

Table2-3: Dopamine Chart 

References: 

1- auscultation.com/Human/Heart/.../ DiastolicGallopRhythm.htm 

2- Braunwald Eugene, et al. Harrison's Principles of Internal Medicine. 16th Edition. 

McGrawHill; 2005 

3-Institute for clinical systems improvement (ICSI). Diagnosis and treatment of chest 

pain and acute coronary syndrome (ACS).Bloomington (MN);2005 oct.77p 

4- Iranian Council for Graduate Medical Education. Exam questions. 

5-Katzung Bertram G. Pharmacology: Examination & Board Review.7th edition 

Mcgrawhill. 2005 

6-www.emedicine.com/med/topic3552.htm.2006

S3&S4-mdm

Chapter two S3 &S4 gallop* - Medical Education Online

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