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Communications to the Editor |

The Fourth Heart Sound FREE TO VIEW

Robert J. Adolph, MD
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Professor Emeritus of Medicine University of Cincinnati Cincinnati, OH



Chest. 1999;115(5):1480-1481. doi:10.1378/chest.115.5.1480-a
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To the Editor:

As always, I enjoyed Dr. Spodick’s recent comments.1It has been 25 years since we thrust and parried in the literature over the audibility of the fourth heart sound. It remains my contention that differentiation of a split S1 from an S4-S1 is difficult unless the S4 is palpated as a presystolic outward movement of the chest wall on the upstroke of a left ventricular heave. A split S1 is common at any age and an S4 in an older person usually indicates disease, eg, left ventricular hypertrophy or fibrosis. As stated in my editorial,2 a recorded S4 does not necessarily equate with an audible S4. Dr. Spodick seems to agree. Indeed, that is the main thesis of my editorial.

In an era when only dinosaurs like Dr. Spodick and I care enough about an S4 to belabor its recognition, it is heartening that we now seem to agree on the following: (1) a recorded S4 does not necessarily equate with audibility; (2) an S4 virtually always indicates heart disease; (3) most filters used in recording systems pass inaudible low-frequency vibrations; (4) an audible S4 is loud and palpable; and (5) I concur that blinded auscultators provide the best chance for objectivity, but clearly their accuracy depends on their bedside experience.

Now as for the S3 gallop…

Correspondence to: Robert J. Adolph, MD, Room 3468, Medical Science Building, University of Cincinnati, Cincinnati, OH 45267

References

Spodick, DH (1999) Audibility of fourth heart sound.Chest115,1218-1219
 
Adolph, RJ In defense of the stethoscope [editorial].Chest1998;114,1235-1236. [CrossRef]
 

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References

Spodick, DH (1999) Audibility of fourth heart sound.Chest115,1218-1219
 
Adolph, RJ In defense of the stethoscope [editorial].Chest1998;114,1235-1236. [CrossRef]
 
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