EpistemisFourth heart sound (R4 / Atrial gallop)
Specialty: Cardiovascular.
Why it occurs
- Hypertensive heart disease with left ventricular hypertrophy and decreased compliance
- Ischemic heart disease (acute or chronic phase with myocardial stiffness)
- Aortic valve stenosis with severe concentric hypertrophy
- Obstructive or non-obstructive hypertrophic cardiomyopathy
- Diastolic dysfunction of the left ventricle associated with physiological or pathological aging
Initial workup
12-lead electrocardiogram to identify signs of left ventricular hypertrophy (Sokolow-Lyon or Cornell criteria), left ventricular overload, or ischemic changes of the ST segment or T waves; Transthoracic echocardiogram with Doppler to evaluate the thickness of the ventricular walls, rule out dynamic obstruction of the left ventricular outflow tract, and measure the parameters of diastolic function (E, A, e' waves and the volume of the right and left atrium); Graded stress test or coronary angiography if myocardial ischemia is suspected.
red flags
Presence of a fourth low-pitched sound audible immediately before the first heart sound (R1), associated with typical oppressive chest pain of anginal nature radiating to the jaw or left upper limb, dyspnea at rest or progressive exertion, exertional syncope, or severely elevated blood pressure levels (hypertensive crisis with SBP >180 mmHg or DBP >120 mmHg with suspected target organ damage). Requires urgent cardiological evaluation to rule out active myocardial ischemia or severe aortic stenosis.
Standard management
- Metoprolol succinate — beta blocker indicated to reduce heart rate, prolong diastole and promote ventricular filling in rigid ventricles; 25 to 100 mg once daily orally
- Amlodipine — dihydropyridine calcium antagonist indicated if R4 is associated with uncontrolled hypertensive heart disease; 5 to 10 mg once daily orally, monitoring for the development of malleolar edema
- Losartan — angiotensin II receptor antagonist to promote regression of left ventricular hypertrophy in hypertensive patients; 50 to 100 mg once daily orally
- Verapamil (non-dihydropyridine calcium antagonist, useful in hypertrophic cardiomyopathy to improve ventricular relaxation; 120 to 240 mg per day divided into two doses, contraindicated if there is systolic dysfunction or conduction blocks).
Educational guidance for study. It is NOT a prescription recommendation. The actual choice depends on the cause, the patient, and current guidelines.
- Area
- Cardiovascular
- Listed causes
- 5
- Treatment options
- 4