Note loud S4 in a pateint 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