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Home , Fourth heart sound, Gallop rhythm, Heart sounds

Abnormal sounds (Ss and S•) with acute Myocardial infarct myocardial infarction: Prognostic significance of changes detected by phonocardiography and

LAWRENCE U. HASPEL, D.O. Chicago, Ill.

Ventricular and atrial gallops should Although in most cases the diagnosis of acute be looked for in any myocardial infarction can be based on history, patient suspected of having myocardial the electrocardiogram, and serum enzyme levels, the finding of abnormal by infarction. They help to auscultation and phonocardiography helps to confirm the diagnosis, along with the confirm the diagnosis. history, electrocardiograms, The purpose of this paper is to review the and serum enzyme values. Ventricular significance of these abnormal sounds (S 3 and and atrial gallops are S4 ) in terms of frequency of appearance, pathologic third and fourth heart genesis, characteristics, and effect on prog- nosis. sounds which occur in . The abnormal sounds to be discussed are Ventricular gallop is referred to as gallops (ventricular and atrial) . an accentuation of the third Both the ventricular and the atrial gallop oc- heart sound. It is a common finding that cur in diastole and represent pathologic third may be present in a great and fourth heart sounds. The term gallop variety of heart diseases. Although it rhythms refers to the auscultatory finding of an audible three-sound sequence to each heart does not always appear beat, instead of the normal two-sound (lub- with myocardial infarction, it may be dub) pattern of the first and second heart one of the first detectable sounds. signs of a failing myocardium. When The abnormal extra sound never occurs in this gallop persists, it , but is always a diastolic event. It is indicates a poor prognosis. It is a sign brief and of low frequency. In general, gallop rhythms produced by the left side of the heart of cardiac decompensation. are heard best at the cardiac apex; those pro- Atrial gallop is an accentuation of the duced in the right side of the heart, along the in late lower • left sternal border. The three-sound diastole. It represents a decrease in sequence to each heart beat at rates above 100 left ventricular compliance. per minute sounds on auscultation like a This sign occurs in nearly all instances horses gallop. of acute myocardial infarction. Ventricular gallop Some illustrative phonocardiograms of The ventricular gallop is an accentuation of patients suffering from acute the third heart sound and resembles the sound myocardial infarction demonstrate the of the word "Kentucky." Harvey made this presence of pathologic comment: ventricular and atrial gallops. The ventricular diastolic gallop often has clinical con- notations different from those of the atrial gallop. It is frequently one of the first signs that one can de- tect, indicating serious heart disease and/or cardiac decompensation. This gallop appears in the early part of diastole, later in timing than the opening snap but

Journal AOA/vol. 71, May 1972 771/49 Abnormal heart sounds with acute myocardial infarction

at the same time as the normal physiologic third heart sound found in youth. If searched for, the ventricular Disease diastolic gallop is a common finding and can appear in a great variety of diseased states of the heart, includ- LV hypertrophy LV dilation ing coronary hypertensive, primary myocardial (car- diomyopathies), rheumatic, congenital, and syphilitic Compliance disorders. The common denominator when a ventric- ular diastolic gallop is present, regardless of the I Early filling Filling pressure cause of the heart disease, is cardiac decompensation. The ventricular gallop is the pathologic t Atrial boost Early filling counterpart of the physiologic third heart S S3 (Ventricular gallop) sound, having the same phonocardiographic 4 (Atrial gallop) characteristics. The normal third sound is pro- Fig. 1. Development of S, and S4 gallops. (Adapted duced in the open left and from Shale.) toward the end of the period of rapid empty- ing of the atrial contents into the ventricle. Luisada2 stated: failure has grave prognostic significance after The third sound occurs when intraventricular volume and "accommodation" of the ventricular wall reach a myocardial infarctions. The atrial gallop, on balance, and intramural tension begins to rise once the other hand, may persist forever. more. A possible energy source is embodied in the blood volume present in the ventricles at the time of Atrial gallop transition from active relaxation to passive distention. Once "active relaxation" has ceased, each ventricle The atrial gallop is an accentuation of the must of necessity adjust to accommodate the volume of fourth heart sound in late diastole and re- blood it contains. An increased intraventricular volume would increase the distending force and ac- sembles the sound of the word "Tennessee." centuate the third sound. This concept explains the Harvey. stated: accentuated third sound which is observed both in con- ditions with increased residual volume () This gallop sound is related to atrial contraction and and in those with volume overload and high output. may occur with or without any clinical evidence of cardiac decompensation. The sound is usually inaudible in normal adults, but may become exaggerated and The normal fourth heart sound is produced audible in patients with an abnormal state in by vibration of the blood column in the open which the volume of early filling is increased or atrium and ventricle during atrial contraction. there is incomplete emptying during the prior Shah and associates5 in 1968 proposed an out- systole. On the the third line (Fig. 1) of the mechanisms involved in heart sound occurs between 0.12 and 0.18 sec- the production of atrial and ventricular gallop. ond after the aortic component and corre- The atrial gallop usually occurs close to the sponds to the end of the rapid filling wave of first heart sound and follows the "a" wave of the apexcardiogram. Master and Friedman3 the apexcardiogram. Harvey said: reported in 1942 that a third sound was dem- If one searches carefully for an atrial sound or onstrated in 47 percent of patients with acute gallop, it is most commonly heard in those having coronary disease, and at times this may be one myocardial infarction. More recently Hill and of the first clues from the as to associates4 reported a 65 percent incidence of the presence of underlying heart disease. . . . The ventricular gallop with acute infarction. atrial gallop sound associated with myocardial infarc- tion may be prominent or faint. The sound is often Harvey commented: louder during the episode of acute coronary pain, or The deliberate effort to search for will during the initial phases of myocardial infarction. be rewarded, because the ventricular diastolic gallop Subsequently, usually with improvement, the gallop is may be the first and only clinical sign of a failing fainter, but if carefully searched for, can generally be myocardium. It may serve as the first indication for heard. digitalization and restriction Of sodium in the diet. Hill and associates4 reported that 98 percent It is believed that a ventricular gallop that of patients with acute myocardial infarction persists despite treatment for congestive heart had atrial gallop. Since almost all patients

772/50 X

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Fig. 2. Simultaneous recording of EKG, low frequency phonocardiogram, and apexcardiogram with S3 and S gallops in patient with acute inferior infarct.

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Fig. 3. Simultaneous recording of EKG and low frequency phonocardiogram with Ss and S4 gallops in patient with acute inferior infarct.

Journal AOA/vol. 71, May 1972 773/51 Abnormal heart sounds with acute myocardial infarction

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Fig. 4. Simultaneous recording of EKG, low frequency phonocardiogram, and apexcardiogram with S, gallop in a patient with acute anterior septal infarct.

with acute myocardial infarction had an atrial who was hospitalized with acute of diastolic gallop, they concluded that when this 8 hours duration. The electrocardiogram and sound is absent in a patient with chest pain serum enzyme levels confirmed the diagnosis and sinus rhythm the probability of a diag- of infarction of the inferior wall. The phono- nosis of acute myocardial infarction is les- cardiogram shows both ventricular and atrial sened. gallop. Digitalization was begun, and the pa- Figures 2-4 are phonocardiograms of sev- tients ventricular and atrial gallops persisted. eral patients who suffered acute myocardial Eventually, ventricular fibrillation developed, infarction. They illustrate the presence of and the patient died. pathologic ventricular and atrial gallops. The Figure 3 is the phonocardiogram of a 58- phonocardiograms were taken with a Sanborn year-old Caucasian man who was hospitalized recorder utilizing a Krohn-hite band-pass fil- with chest pain and shortness of breath. Serum tration system. enzyme elevation and the electrocardiogram Figure 2 shows the phonocardiogram and confirmed a diagnosis of inferior wall infarc- apexcardiogram of a 58-year-old Negro man tion. The phonocardiogram of this patient

774/62 showed marked improvement in his shortness confirm the diagnosis and provide early signs of breath. The ventricular gallop disappeared of cardiac decompensation. several days after digitalization. However, the atrial gallop persisted and was present at the

time of discharge from the hospital. 1. Harvey, W.P.: Gallop sounds, clicks, snaps, and other sounds. Figure 4 is the phonocardiogram of a 60- In the heart, and . Ed. 2. Edited by J.W. Hurst and R.B. Logue. McGraw-Hill Book Co., New York, 1970 year-old Caucasian man who was hospitalized 2. Luisada, A.A.: Phonocardiography. A dynamic interpretation with severe pain in the left shoulder and arm of the normal and abnormal precordial vibrations. In Clinical cardiopulmonary physiology. Ed. 3. Edited by B.L. Gordon, R.A. and accompanying nausea and emesis 24 hours Carleton, and L.P. Faber. Grune and Stratton, New York, 1969 prior to admission. The electrocardiogram and 3. Master, A.M., and Friedman, R.A.: Phonocardiographic study of the heart sounds in acute coronary occlusion. Am Heart J serum enzyme elevations confirmed the diag- 24:196-208, Aug 42 4. Hill, J.C., et al.: The diagnostic value of the atrial gallop in nosis of anterior septal infarction. The phono- acute myocardial infarction. Am Heart J 78:194-201, Aug 69 cardiogram of this patient revealed a prom- 5. Shah, P.M., et al.: Determinants of atrial (S 4 ) and ventricular (S3) gallop sounds in primary myocardial disease. N Engl J inent atrial gallop, which persisted and was Med 278:753-8, 4 Apr 68 present at the time of discharge 4 weeks after- ward.

Summary The genesis and importance of gallop rhythm Dr. Haspel was the recipient of a 1970-71 National Osteopathic Foundation grant through the cooperation in the diagnosis, treatment, and prognosis of of the Smith Kline and French Foundation. patients suffering acute myocardial infarction have been considered. Ventricular gallop appears less frequently than atrial gallop with myocardial infarction but is an early indication of cardiac decompen- sation. If it persists, the prognosis is poor. This paper was written while Dr. Atrial gallop occurs in almost all cases of acute Haspel was serving a fellowship in at Mt. Sinai Medical Center, myocardial infarction and may persist for a Chicago Medical School. He is now on lifetime. It represents a decrease in compliance the staff of Chicago Osteopathic Hos- pital. of the left ventricle. Dr. Haspel, 1700 E. 56th St., Chicago Both ventricular and atrial gallop should be 60637. sought vigorously in any patient suspected of myocardial infarction, since they both help to

Journal AOA/vol. 71. May 1972 775/53