EpistemisThird heart sound (R3 / Ventricular gallop)
Specialty: Cardiovascular.
Why it occurs
- Systolic heart failure with ventricular volume overload
- Dilated cardiomyopathy with altered elasticity of the ventricular wall
- Severe mitral or aortic regurgitation with exaggerated rapid ventricular filling
- Chronic ischemic heart disease with left ventricular dysfunction
- Left-to-right shunt (significant atrial or ventricular septal defect)
Initial workup
Complete transthoracic echocardiogram with tissue Doppler to quantify ejection fraction, measure left ventricular end-diastolic volume, evaluate ventricular geometry, and identify significant valvular regurgitation; Serum determination of natriuretic peptides (NT-proBNP); Chest x-ray to evaluate cardiomegaly and pulmonary hyperflow or congestion; Electrocardiogram to document ventricular hypertrophy, pathological Q waves from previous infarction or left bundle branch block.
red flags
Appearance of a third low-frequency heart sound (detected with the bell of the stethoscope in the left ventricular apex in the left lateral decubitus position) associated with paroxysmal nocturnal dyspnea, progressive orthopnea, bibasal pulmonary crackles, symmetrical edema of the lower extremities with pitting, or anginal chest pain on exertion. It suggests decompensated congestive heart failure with critical elevation of left ventricular filling pressures, requiring immediate therapeutic adjustment to prevent frank pulmonary edema.
Standard management
- Furosemide — loop diuretic to reduce left ventricular filling pressure and preload; 40 mg orally or intravenously, adjusting dose according to daily water balance
- Lisinopril — ACE inhibitor to reduce afterload and attenuate eccentric ventricular remodeling; 2.5 to 10 mg once daily orally, monitoring renal function and serum potassium
- Bisoprolol — selective beta-1 beta blocker indicated for optimization of chronic treatment once euvolemic stability has been achieved; start with 1.25 to 2.5 mg once daily orally
- Sacubitril/Valsartan (replacing ACEIs/ARBs if symptomatic systolic dysfunction persists; starting dose of 49/51 mg twice daily).
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