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.