The Physiology of 3rd & 4th Heart Sound

Saptanshu Das, 1st Semester

Preceptor - Dr Archana Mishra (Associate
Professor, Dept. of Physiology,SCB MCH)
Genesis of 3rd Heart Sound or S3
• During Rapid Inflow, walls of ventricles
become distended.

• At end of Rapid inflow, ventricular walls

become taut.

• As the ventricle rapidly expands from the

early filling, there is tensing in the
CardioHemic system causing vibrations
in the heart muscle.

• This gives rise to 3rd Heart Sound (S3)

Third Heart Sound

• 3rd heart sound is low pitched, soft

sound.
• It appears 100 - 150 ms after S2, in the
early ventricular diastolic phase.
s1 s2 s3 s1 s2 s3
• In normal patients late 1/3rd of ventricular diastole is
generally silent.
• In early phase of Diastolic dysfunction, abnormal(prolonged)
ventricular relaxation impairs early diastolic filling.
• This decreases the filling in the early diastolic phase giving
rise to a compensatory enhanced atrial contribution to
diastolic filling
• An audible heart sound (S4) represents this forceful, atrial
contraction into the non-compliant ventricle.
• S3 + S4 + Tachycardia
• At a heart rate of greater than 100 beats per
second or Tachycardiac situations, the diastolic
period is shortened.
• This causes the S3 and S4 sounds to get
superimposed, creating a single loud sound.
 Auscultation of S3/S4
- LEFT
VENTRICLE
-
• Left Lateral Decubitus*
• Apex/Mitral Area
• Bell lightly placed on
the skin*
• During auscultation,
patient asked to hold
breath after expiration.
• Location - Right Ventricle
• Maneuver -
• Left Lateral Decubitus Position

• Bell placed lightly over the skin

• Lower left Parasternal Border

• Auscultated during inspiration

• While auscultating with Bell, when 2
continuous sounds are heard in the early
Ventricular Diastolic phase, it might get
difficult to distinguish S2 splitting and S3.
• S2 sounds are best observed in the
Pulmonary area of auscultation, where S3
will not be appreciable.
• Also S2 splitting in inspiration is widened.
• A similar situation may happen for S4 and
S1 splitting.
• S1 is best appreciated in Mitral region, and
it is also readily heard even if the patient is
not in left lateral decubitus position. This
can be used advantageously to
differentiate between S4 and S1 splitting.
• Young People/Children

• Athletes

• Pregnancy(3rd trimester)
• In Left Ventrical - • Non Compliant -
• Compliant - • Dilated
• Mitral valve Cardiomyopathy
regurgitation
• Heart /failure
(Congestive
Cardiac Failure)*
• S3 sound can be an important sign
of systolic heart failure because, in
this setting, the myocardium is
usually overly compliant, resulting in
a dilated LV.
• In Left Ventricle - • In Right Ventricle
• Systemic • Pulmonary Artery
Hypertension Stenosis
• Hypertrophic • Pulmonary
Cardiomyopathy hypertension
• Ongoing • Early Restrictive
Myocardial Cardiomyopathy
Ischemia
• S4 is Physiological in old and pathological
for young while S3 is pathological for old
and physiological for young.
THANK YOU