Summary:

This patient had a 2D echocardiogram which confirmed the presence of left ventricular hypertrophy.

Click to review auscultation.

Lessons:

1. Unlike the S₃, the apical S₄ is usually considered pathological and is often associated with an abnormal apex impulse.
   
   
2. It is often due to left ventricular hypertrophy, which is a common finding in patients with hypertension.
   
   
3. Hypertensive patients with significant left ventricular hypertrophy are at significantly higher risk for coronary artery disease (eg. myocardial infarction) than hypertensive patients with no evidence of left ventricular hypertrophy. Therefore this finding (the S₄) could have a bearing on your management strategy, e.g., lipids, diet, exercise, etc.

 

Note:
After age 75 many individuals have an audible S₄ at the apex, but these people will usually show LVH and impaired diastolic relaxation on their echocardiogram. Though common in the elderly, an S₄ is not necessarily "normal."

Case 4 is now finished.