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Causes of Fourth heartsound

Left ventricular S4 (LVS4)
  • Systemic hypertension
  • AS (left ventricular hypertrophy)
  • LV myocardial infarction
Right ventricularS4 (RVS4)
  • Pulmonary hypertension
  • Pulmonary stenosis (Right Ventricular hypertrophy)
  • RV myocardial infarction.
Features of Right ventricularS4(RVS4)
  • Heard at LLSB
  • Inspiratory augmentation^
  • Associated with  a wave in JVP
  • Seen in PAH and pulmonary stenosis
Triple rhythm-S1+S2+S3/S4
Quadruple rhythm-S1, S2 + S3 + S4.
Seen In:
  • Cardiomyopathy
  • Coronary artery disease
Causes of pathological S4
  • Hypertrophic cardiomyopathy
  • Systemic hypertension
  • Coronary artery disease
  • Myocardial infarction
  • Ventricular aneurysm.
  • S3 Ventricular distension sound
  • S4 Atrial contraction sound.