A 52-year-old female with a history of diabetes, asthma, and uncontrolled hypertension presents to her primary care physician for a routine appointment. She reports that she feels well although she does admit that she has been poorly compliant with the diet and exercise changes her physician prescribed on her prior visit. On exam, the physician hears an extra heart sound in late diastole that immediately precedes S1. This heart sound is most associated with which of the following?
1.Mitral stenosis
2.Ventricular dilation
3.Mitral reguraitation
4.Increased filling pressures
5.High atrial pressure
Summary
An S4 heart sound occurs in late diastole and is associated with high atrial pressure.
The S4 heart sound, also referred to as an “atrial kick,” is heard in late diastole and immediately precedes S1 (Illustration A). This produces a “TEN-e-see” cadence on auscultation. A S4 is produced by high atrial pressures leading to rapid flow of blood against stiff ventricular walls. This occurs in conditions such as severe, uncontrolled hypertension, which can cause left ventricular hypertrophy.
Kessler and Joudeh review the evaluation and treatment of severe hypertension, which can cause left ventricular hypertrophy. They state that poorly controlled hypertension is a common finding in the outpatient setting. When patients present with severely elevated blood pressure (>180 mmHg), physicians need to differentiate hypertensive emergency from severely elevated blood pressure without signs or symptoms of end-organ damage (severe asymptomatic hypertension).
Palmiero et al. review left ventricular diastolic function and hypertrophy in hypertension. They state that Doppler echocardiography is the best tool for diagnosis of early left ventricular diastolic dysfunction. Hypertension affects LV relaxation and, when left ventricular hypertrophy occurs, it decreases compliance. Therefore, it is important to evaluate diastolic function by echo in all hypertensive patients.
Illustration A is a graphic representation of the timing of the S4 heart sound.