The S3 Gallop

Abstract

The third heart sound (S3) most commonly appears in individuals under the age of forty. A pathologic presentation occurs more often in older individuals in volume-overloaded states, such as heart failure. This diastolic gallop is produced by rapid deceleration of transmitral blood flow as it strikes a noncompliant left ventricle. The change in velocity causes reverberations that produce the sound. An S3 is best detected in a quiet room with the bell of the stethoscope placed at the apex while the patient is in the left lateral decubitus position. A positive finding may have several implications depending on the clinical context. Most often an S3 is a sign of reduced left ventricular ejection fraction and therefore left ventricular dysfunction. In aortic stenosis, tricuspid regurgitation and mitral regurgitation the presence of a third heart sound is a sign of severe disease. Similarly, the prognosis for a heart failure patient with an S3 is worse. Treatment is aimed at alleviating the underlying disease process through medical or surgical intervention.

Keywords

S3 Gallop Third Heart Sound Left Ventricular Dysfunction Heart Failure Diastolic Sounds 

Abbreviations

ACC/AHA

American College of Cardiology/American Heart Association

ACE

Angiotensin-converting enzyme

AV valves

Atrioventricular valves

BMI

Body mass index

CHF

Congestive heart failure

EDV

End-diastolic volume

EF

Ejection fraction

HF

Heart failure

LV

Left ventricular

LVEDP

Left ventricular end diastolic pressure

LVEF

Left ventricular ejection fraction

LVH

Left ventricular hypertrophy

NSAID

Non-steroidal anti-inflammatory drug

PMI

Point of maximum impulse

PW Doppler

Pulsed and continuous wave Doppler

S1

First heart sound

S2

Second heart sound

S3

Third heart sound

S4

Fourth heart sound

SOB

Shortness of breath

Supplementary material

310603_1_En_18_MOESM1_ESM.mp4 (1.1 mb)
Video 18.1 S3 murmur. Also soft Still’s murmur; Echo is WNL (Provided by Robin Winkler Doroshow, MD, Medstar Georgetown University Hospital, Washington, DC) (MP4 1150 kb)
310603_1_En_18_MOESM2_ESM.mp4 (2.9 mb)
Video 18.2 Several patients with an S3 gallop, including a 60 year old woman with ventricular gallop, as described by Dr. W. Proctor Harvey (File 082 from Clinical Cardiology by W. Proctor Harvey, MD, MACC, Jules Bedynek, MD, and David Canfield and published by Laennec Publishing Inc., Fairfield, NJ. Used with permission and copyrighted by Laennec Publishing, Inc. All rights reserved) (MP4 2927 kb)

References

  1. 1.
    Bonow RO, Mann DL, Zipes DP, Libby P. Braunwald’s heart disease: a textbook of cardiovascular medicine. 9th ed. Philadelphia: Elsevier Saunders; 2012.Google Scholar
  2. 2.
    Manson A, Nudelman S, Haglet M, et al. Relationship of the third heart sound to transmitral flow velocity deceleration. Circulation. 1995;92:388–94.CrossRefPubMedGoogle Scholar
  3. 3.
    Tribouilloy CM, Enriquez-Sarano M, Mohty D, Horn RA, Bailey KR, Seward JB, Weissler AM, Tajik AJ. Pathophysiologic determinants of third heart sounds: a prospective clinical and doppler echocardiographic study. Am J Med. 2001;111:96–102.CrossRefPubMedGoogle Scholar
  4. 4.
    Drazner MH, Rame JE, Stevenson LW, Dries DL. Prognostic importance of elevated jugular venous pressure and a third heart sound in patients with heart failure. N Engl J Med. 2001;345(8):574–81.CrossRefPubMedGoogle Scholar
  5. 5.
    Silverman M. The third heart sound. Clinical methods: the history, physical, and laboratory examinations [Internet]. 1990. Available from: http://www.ncbi.nlm.nih.gov.
  6. 6.
    Collins SP, Arand P, Lindsell CJ, Peacock WF, Storrow AB. Prevalence of the third and fourth heart sound in asymptomatic adults. Congest Heart Fail. 2005;11:242–7.CrossRefPubMedGoogle Scholar
  7. 7.
    Marcus GM, Gerber IL, McKeown BH, Vessey JC, Jordan MV, Huddleston M, McCulloch CE, Foster E, Chatterjee K, Michaels AD. Association between phonocardiographic third and fourth heart sounds and objective measures of left ventricular function. JAMA. 2005;293(18):2238–44.CrossRefPubMedGoogle Scholar
  8. 8.
    Marcus GM, Michaels AD, De Marco T, McCulloch CE, Chatterjee K. Usefulness of the third heart sound in predicting an elevated level of b-type natriuretic peptide. Am J Cardiol. 2004;93:1312–3.CrossRefPubMedGoogle Scholar
  9. 9.
    Folland ED, Kriegel BJ, Henderson WG, Hammermeister KE, Sethi GK. Implications of third heart sound in patients with valvular heart disease. N Engl J Med. 1992;327(7):458–62.CrossRefPubMedGoogle Scholar
  10. 10.
    Fuster V, Walsh RA, Harrington RA, editors. Hurst’s the heart. 13th ed. New York: McGraw-Hill Professional; 2011.Google Scholar
  11. 11.
    Alpert M. Systolic murmurs. In: Walker HK, Hall WD, Hurst JW, editors. Clinical methods: the history, physical, and laboratory examinations. 3rd ed. Boston: Butterworths; 1990.Google Scholar
  12. 12.
    Horn RA, Sarano ME, Seward JB. The significance of an audible s3 is different in aortic regurgitation, mitral regurgitation and LV dysfunction: a quantitative Doppler echocardiographic study. J Am Coll Cardiol. 1996;27(2s1):115–6.CrossRefGoogle Scholar
  13. 13.
    Topol EJ, Califf RM, Prystowsky EN, Thomas JD, Thompson PD, editors. Textbook of cardiovascular medicine. 3rd ed. Philadelphia: Lippincott Williams, & Wilkins; 2007.Google Scholar
  14. 14.
    Dayem MKA, Wasfi FM, Bentall HH, Goodwin JF, Cleland WP. Investigation and treatment of constrictive pericarditis. Thorax. 1967;22:242–52.PubMedCentralCrossRefPubMedGoogle Scholar
  15. 15.
    Hunt SA, ACC/AHA 2005 Guideline update for the diagnosis and management of chronic heart failure in the adult – summary article. J Am Coll Cardiol. 2005;46:e1-e82.Google Scholar
  16. 16.
    ACC/AHA 2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease. J Am Coll Cardiol. 2008;52(13):e1–142. Pubmed 18848134.Google Scholar

Copyright information

© Springer-Verlag London 2015

Authors and Affiliations

  1. 1.Georgetown University Hospital, Georgetown University School of MedicineWashingtonUSA

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