Gallops & Extra Heart Sounds

Cardiac auscultation should be performed in a systematic manner. Normal heart sounds (S₁, S₂) should be identified, and the precordium should be examined for gallops (S₃, S₄) and additional heart sounds.

Differential Diagnosis

• S₃ gallop
  –Low-frequency diastolic sound following S₂, best heard with bell
  –May be heard normally in healthy young adults
  –The presence of an S₃ in a patient over 40 suggests ventricular enlargement, often secondary to chronic mitral regurgitation, decreased left ventricular ejection fraction, elevated left atrial pressure, acute pulmonary edema, or high-output states (e.g., thyrotoxicosis, pregnancy)
  –Right ventricular infarct
  –Hypertrophic cardiomyopathy
• S₄ gallop
  –Low-frequency diastolic sound preceding S₁, best heard with bell
  –May be normally heard in healthy older adults
  –Occurs with hypertensive heart disease, aortic stenosis, hypertrophic cardiomyopathy, pulmonary hypertension, coronary artery disease

• Midsystolic click
  –Most commonly due to mitral valve prolapse

• Pericardial knock
  –Early diastolic sound
  –Common in constrictive pericarditis (with
  or without pericardial calcification)

• Opening snap
  –High-frequency, early diastolic sound
  –Most commonly due to mitral stenosis,
  tricuspid stenosis, ventricular septal defect, thyrotoxicosis

• Early systolic ejection sound (ejection click)
  –Associated with a bicuspid aortic valve, mitral or tricuspid prolapse, aortic stenosis, prosthetic valves

Workup and Diagnosis

• History and physical examination
• ECG is indicated in all patients
  –Atrial fibrillation is often seen in mitral stenosis
  –Left atrial enlargement is seen in mitral stenosis or mitral regurgitation
  –Left ventricular hypertrophy is seen in patients with hypertensive heart disease, hypertrophic cardiomyopathy, or bicuspid aortic valve
  • Chest X-ray may reveal valvular calcification, pulmonary edema, or left ventricular enlargement
  • Echocardiogram is used to assess chamber size, wall thickness, ventricular function, valvular abnormalities, and left ventricular outflow obstruction
  • Consider cardiology consult

  Treatment

  • Left ventricular hypertrophy: Blood pressure control
  • Mitral regurgitation: Endocarditis prophylaxis, afterload reduction with ACE inhibitors, and diuretics to control volume status, if needed; valve repair (preferred) or replacement may be indicated for severe disease
  • Aortic stenosis or bicuspid aortic valve: Valve replacement is often indicated for asymptomatic critical AS, symptomatic AS, and severe AS with LV dysfunction independent of symptoms
• Hypertrophic cardiomyopathy: High-dose β-blockers and calcium channel blockers are the mainstay of medical therapy; diuretics, if indicated, should be used cautiously; septal myomectomy or alcohol septal ablation for left ventricular outflow tract obstruction
• Mitral stenosis: Endocarditis prophylaxis; β-blockers, calcium channel blockers, or digitalis to slow ventricular rate and prolong diastolic filling; mitral valvulotomy or valve replacement for moderate-to-severe disease

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

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Copyright Details: In a Page: Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

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