myocardial infarct myocardial infarction: prognostic

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

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Page 1: Myocardial infarct myocardial infarction: Prognostic

Abnormal heart sounds (Ss and S•) with acute Myocardial infarct

myocardial infarction: Prognostic significanceof changes detected by phonocardiography andauscultationLAWRENCE U. HASPEL, D.O.Chicago, Ill.

Ventricular and atrial gallops shouldbe looked for in anypatient suspected of having myocardialinfarction. They help toconfirm the diagnosis, along with thehistory, electrocardiograms,and serum enzyme values. Ventricularand atrial gallops arepathologic third and fourth heartsounds which occur in diastole.Ventricular gallop isan accentuation of the thirdheart sound. It is a common finding thatmay be present in a greatvariety of heart diseases. Although itdoes not always appearwith myocardial infarction, it may beone of the first detectablesigns of a failing myocardium. Whenthis gallop persists, itindicates a poor prognosis. It is a signof cardiac decompensation.Atrial gallop is an accentuation of thefourth heart sound in latediastole. It represents a decrease inleft ventricular compliance.This sign occurs in nearly all instancesof acute myocardial infarction.Some illustrative phonocardiograms ofpatients suffering from acutemyocardial infarction demonstrate thepresence of pathologicventricular and atrial gallops.

Although in most cases the diagnosis of acutemyocardial infarction can be based on history,the electrocardiogram, and serum enzymelevels, the finding of abnormal heart sounds byauscultation and phonocardiography helps toconfirm the diagnosis.

The purpose of this paper is to review thesignificance of these abnormal sounds (S 3 andS4 ) in terms of frequency of appearance,genesis, characteristics, and effect on prog-nosis.

The abnormal sounds to be discussed arereferred to as gallops (ventricular and atrial) .Both the ventricular and the atrial gallop oc-cur in diastole and represent pathologic thirdand fourth heart sounds. The term galloprhythms refers to the auscultatory finding ofan audible three-sound sequence to each heartbeat, instead of the normal two-sound (lub-dub) pattern of the first and second heartsounds.

The abnormal extra sound never occurs insystole, but is always a diastolic event. It isbrief and of low frequency. In general, galloprhythms produced by the left side of the heartare heard best at the cardiac apex; those pro-duced in the right side of the heart, along thelower • left sternal border. The three-soundsequence to each heart beat at rates above 100per minute sounds on auscultation like ahorse's gallop.

Ventricular gallopThe ventricular gallop is an accentuation ofthe third heart sound and resembles the soundof the word "Kentucky." Harvey' made thiscomment:

The ventricular diastolic gallop often has clinical con-notations different from those of the atrial gallop. Itis frequently one of the first signs that one can de-tect, indicating serious heart disease and/or cardiacdecompensation. This gallop appears in the early partof diastole, later in timing than the opening snap but

Journal AOA/vol. 71, May 1972 771/49

Page 2: Myocardial infarct myocardial infarction: Prognostic

Disease

LV hypertrophy

Compliance

I Early filling

t Atrial boost

S4 (Atrial gallop)

LV dilation

Cardiac output

Filling pressure

Early filling

S3 (Ventricular gallop)

Abnormal heart sounds with acute myocardial infarction

at the same time as the normal physiologic third heartsound found in youth. If searched for, the ventriculardiastolic gallop is a common finding and can appear ina great variety of diseased states of the heart, includ-ing coronary hypertensive, primary myocardial (car-diomyopathies), rheumatic, congenital, and syphiliticdisorders. The common denominator when a ventric-ular diastolic gallop is present, regardless of thecause of the heart disease, is cardiac decompensation.

The ventricular gallop is the pathologiccounterpart of the physiologic third heartsound, having the same phonocardiographiccharacteristics. The normal third sound is pro-duced in the open left ventricle and atriumtoward the end of the period of rapid empty-ing of the atrial contents into the ventricle.

Luisada2 stated:

The third sound occurs when intraventricular volumeand "accommodation" of the ventricular wall reach abalance, and intramural tension begins to rise oncemore. A possible energy source is embodied in theblood volume present in the ventricles at the time oftransition from active relaxation to passive distention.Once "active relaxation" has ceased, each ventriclemust of necessity adjust to accommodate the volume ofblood it contains. An increased intraventricularvolume would increase the distending force and ac-centuate the third sound. This concept explains theaccentuated third sound which is observed both in con-ditions with increased residual volume (heart failure)and in those with volume overload and high output.

The sound is usually inaudible in normaladults, but may become exaggerated andaudible in patients with an abnormal state inwhich the volume of early filling is increased orthere is incomplete emptying during the priorsystole. On the phonocardiogram the thirdheart sound occurs between 0.12 and 0.18 sec-ond after the aortic component and corre-sponds to the end of the rapid filling wave ofthe apexcardiogram. Master and Friedman3reported in 1942 that a third sound was dem-onstrated in 47 percent of patients with acutemyocardial infarction. More recently Hill andassociates4 reported a 65 percent incidence ofventricular gallop with acute infarction.

Harvey' commented:

The deliberate effort to search for gallop rhythm willbe rewarded, because the ventricular diastolic gallopmay be the first and only clinical sign of a failingmyocardium. It may serve as the first indication fordigitalization and restriction Of sodium in the diet.

It is believed that a ventricular gallop thatpersists despite treatment for congestive heart

Fig. 1. Development of S, and S4 gallops. (Adaptedfrom Shale.)

failure has grave prognostic significance aftermyocardial infarctions. The atrial gallop, onthe other hand, may persist forever.

Atrial gallopThe atrial gallop is an accentuation of thefourth heart sound in late diastole and re-sembles the sound of the word "Tennessee."Harvey'. stated:

This gallop sound is related to atrial contraction andmay occur with or without any clinical evidence ofcardiac decompensation.

The normal fourth heart sound is producedby vibration of the blood column in the openatrium and ventricle during atrial contraction.Shah and associates5 in 1968 proposed an out-line (Fig. 1) of the mechanisms involved inthe production of atrial and ventricular gallop.

The atrial gallop usually occurs close to thefirst heart sound and follows the "a" wave ofthe apexcardiogram. Harvey' said:

If one searches carefully for an atrial sound orgallop, it is most commonly heard in those havingcoronary artery disease, and at times this may be oneof the first clues from the physical examination as tothe presence of underlying heart disease. . . . Theatrial gallop sound associated with myocardial infarc-tion may be prominent or faint. The sound is oftenlouder during the episode of acute coronary pain, orduring the initial phases of myocardial infarction.Subsequently, usually with improvement, the gallop isfainter, but if carefully searched for, can generally beheard.

Hill and associates4 reported that 98 percentof patients with acute myocardial infarctionhad atrial gallop. Since almost all patients

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Page 3: Myocardial infarct myocardial infarction: Prognostic

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Fig. 2. Simultaneous recording of EKG, low frequency phonoca'rdiogram, and apexcardiogram with S3 and Sgallops in patient with acute inferior infarct.

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Journal AOA/vol. 71, May 1972 773/51

Page 4: Myocardial infarct myocardial infarction: Prognostic

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Abnormal heart sounds with acute myocardial infarction

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

with acute myocardial infarction had an atrialdiastolic gallop, they concluded that when thissound is absent in a patient with chest painand sinus rhythm the probability of a diag-nosis of acute myocardial infarction is les-sened.

Figures 2-4 are phonocardiograms of sev-eral patients who suffered acute myocardialinfarction. They illustrate the presence ofpathologic ventricular and atrial gallops. Thephonocardiograms were taken with a Sanbornrecorder utilizing a Krohn-hite band-pass fil-tration system.

Figure 2 shows the phonocardiogram andapexcardiogram of a 58-year-old Negro man

who was hospitalized with acute chest pain of8 hours' duration. The electrocardiogram andserum enzyme levels confirmed the diagnosisof infarction of the inferior wall. The phono-cardiogram shows both ventricular and atrialgallop. Digitalization was begun, and the pa-tient's ventricular and atrial gallops persisted.Eventually, ventricular fibrillation developed,and the patient died.

Figure 3 is the phonocardiogram of a 58-year-old Caucasian man who was hospitalizedwith chest pain and shortness of breath. Serumenzyme elevation and the electrocardiogramconfirmed a diagnosis of inferior wall infarc-tion. The phonocardiogram of this patient

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Page 5: Myocardial infarct myocardial infarction: Prognostic

showed marked improvement in his shortnessof breath. The ventricular gallop disappearedseveral days after digitalization. However, theatrial gallop persisted and was present at thetime of discharge from the hospital.

Figure 4 is the phonocardiogram of a 60-year-old Caucasian man who was hospitalizedwith severe pain in the left shoulder and armand accompanying nausea and emesis 24 hoursprior to admission. The electrocardiogram andserum enzyme elevations confirmed the diag-nosis of anterior septal infarction. The phono-cardiogram of this patient revealed a prom-inent atrial gallop, which persisted and waspresent at the time of discharge 4 weeks after-ward.

SummaryThe genesis and importance of gallop rhythmin the diagnosis, treatment, and prognosis ofpatients suffering acute myocardial infarctionhave been considered.

Ventricular gallop appears less frequentlythan atrial gallop with myocardial infarctionbut is an early indication of cardiac decompen-sation. If it persists, the prognosis is poor.Atrial gallop occurs in almost all cases of acutemyocardial infarction and may persist for alifetime. It represents a decrease in complianceof the left ventricle.

Both ventricular and atrial gallop should besought vigorously in any patient suspected ofmyocardial infarction, since they both help to

confirm the diagnosis and provide early signsof cardiac decompensation.

1. Harvey, W.P.: Gallop sounds, clicks, snaps, and other sounds.In the heart, arteries and veins. Ed. 2. Edited by J.W. Hurst andR.B. Logue. McGraw-Hill Book Co., New York, 19702. Luisada, A.A.: Phonocardiography. A dynamic interpretationof the normal and abnormal precordial vibrations. In Clinicalcardiopulmonary physiology. Ed. 3. Edited by B.L. Gordon, R.A.Carleton, and L.P. Faber. Grune and Stratton, New York, 19693. Master, A.M., and Friedman, R.A.: Phonocardiographic studyof the heart sounds in acute coronary occlusion. Am Heart J24:196-208, Aug 424. Hill, J.C., et al.: The diagnostic value of the atrial gallop inacute myocardial infarction. Am Heart J 78:194-201, Aug 695. Shah, P.M., et al.: Determinants of atrial (S 4 ) and ventricular(S3) gallop sounds in primary myocardial disease. N Engl JMed 278:753-8, 4 Apr 68

Dr. Haspel was the recipient of a 1970-71 NationalOsteopathic Foundation grant through the cooperationof the Smith Kline and French Foundation.

This paper was written while Dr.Haspel was serving a fellowship incardiology at Mt. Sinai Medical Center,Chicago Medical School. He is now onthe staff of Chicago Osteopathic Hos-pital.

Dr. Haspel, 1700 E. 56th St., Chicago60637.

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