Evidence, trainers and tools for doctors and medical students
← TrainersAuscultation TrainerAuscultationFor Doctors
Auscultation Trainer · Learn

S4 (fourth heart sound)

← All sounds

Listen for: A low extra sound just before S1, at the very end of diastole: "da-lub-dub", the rhythm of "Ten-nes-see".

Usually means: The atrium pushing blood into a stiff ventricle, as in hypertension, left ventricular hypertrophy or ischaemia. It cannot occur in atrial fibrillation.

10 recordings of this finding. Compare with normal heart sounds to hear the difference.

References2
  1. Bickley LS, Szilagyi PG, Hoffman RM, Soriano RP. Bates' Guide to Physical Examination and History Taking. 13th ed. Philadelphia: Wolters Kluwer; 2021. Cardiovascular system chapter.
  2. Marcus GM, Gerber IL, McKeown BH, et al. Association between phonocardiographic third and fourth heart sounds and objective measures of left ventricular function. JAMA. 2005;293(18):2238-44.