Loud fourth heart sound

Note loud S4 in a patient with LV hypertrophy. The sound is presystolic before S₁.

Loud S4 is heard in:

Pressure overload
Stiff myocardium

• Hypertension
• Coronary artery disease
• Aortic stenosis
• Cardiomyopathy
• Pulmonary hypertension
• Pulmonary stenosis