Skip to main content
SpringerLink
Log in

The third heart sound for diagnosis of acute heart failure

  • Published:
Current Heart Failure Reports Aims and scope Submit manuscript

Abstract

Dyspnea is a common presenting complaint in the emergency department (ED). Rapid identification of heart failure as the etiology leads to early implementation of targeted therapies. Although having only intermediate sensitivity, the S3 is a highly specific finding among older adults with heart failure. Identification of an S3 by routine auscultation can be problematic given the chaotic and noisy ED environment, patient comorbid conditions, and intolerance of ideal positioning for auscultation. Technologies using computerized analysis of digitally recorded heart tones have recently been developed to aid the clinician with bedside detection of abnormal heart sounds. Data using these technologies and their applications in the ED are reviewed as well as implications for future use and research.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References and Recommended Reading

  1. Springfield CL, Sebat F, Johnson D, et al.: Utility of impedance cardiography to determine cardiac vs noncardiac cause of dyspnea in the emergency department. Congest Heart Fail 2004, 10(Suppl 2):14–16.

    Article  PubMed  Google Scholar 

  2. Tsao LG, Gibson CM: Heart failure: an epidemic of the 21st century. Crit Pathways Cardiol 2004, 3:194–204.

    Google Scholar 

  3. American Heart Association: Heart Disease and Stroke Statistics—2007 Update. Dallas: American Heart Association; 2007.

  4. McCullough PA: Scope of cardiovascular complications in patients with kidney disease. Ethn Dis 2002, 12:S3-44–S3-48.

    Google Scholar 

  5. O’Connell JE, Brown J, Hildreth AJ, Gray CS: Optimizing management of congestive heart failure in older people. Age Ageing 2000, 29:371–372.

    Article  PubMed  CAS  Google Scholar 

  6. Croft JB, Giles WH, Pollard RA, et al.: Heart failure survival among older adults in the United States: a poor prognosis for an emerging epidemic in the Medicare population. Arch Intern Med 1999, 159:505–510.

    Article  PubMed  CAS  Google Scholar 

  7. Rich MW: Epidemiology, pathophysiology, and etiology of congestive heart failure in older adults. J Am Geriatr Soc 1997, 45:968–974.

    PubMed  CAS  Google Scholar 

  8. Wang CS, FitzGerald JM, Schulzer M, et al.: Does this dyspneic patient in the emergency department have congestive heart failure? JAMA 2005, 294:1944–1956.

    Article  PubMed  CAS  Google Scholar 

  9. Hunt SA: ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure). J Am Coll Cardiol 2005, 46:e1–e82.

    Article  PubMed  Google Scholar 

  10. Hunt SA, Abraham WT, Chin MH, et al.: ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation 2005, 112:e154–e235.

    Article  PubMed  Google Scholar 

  11. Gheorghiade M, Zannad F, Sopko G, et al.: Acute heart failure syndromes: current state and framework for future research. Circulation 2005, 112:3958–3968.

    Article  PubMed  Google Scholar 

  12. Aurigemma GP, Gaasch WH: Clinical practice. Diastolic heart failure. N Engl J Med 2004, 351:1097–1105.

    Article  PubMed  CAS  Google Scholar 

  13. Bhatia RS, Tu JV, Lee DS, et al.: Outcome of heart failure with preserved ejection fraction in a population-based study. N Engl J Med 2006, 355:260–269.

    Article  PubMed  CAS  Google Scholar 

  14. Owan TE, Hodge DO, Herges RM, et al.: Trends in prevalence and outcome of heart failure with preserved ejection fraction. N Engl J Med 2006, 355:251–259.

    Article  PubMed  CAS  Google Scholar 

  15. Adams KF Jr, Fonarow GC, Emerman CL, et al.: Characteristics and outcomes of patients hospitalized for heart failure in the United States: rationale, design, and preliminary observations from the first 100,000 cases in the Acute Decompensated Heart Failure National Registry (ADHERE). Am Heart J 2005, 149:209–216.

    Article  PubMed  Google Scholar 

  16. Cleland JG, Swedberg K, Follath F, et al.: The EuroHeart Failure survey programme—a survey on the quality of care among patients with heart failure in Europe. Part 1: patient characteristics and diagnosis. Eur Heart J 2003, 24:442–463.

    Article  PubMed  CAS  Google Scholar 

  17. Komajda M, Follath F, Swedberg K, et al.: The EuroHeart Failure Survey programme—a survey on the quality of care among patients with heart failure in Europe. Part 2: treatment. Eur Heart J 2003, 24:464–474.

    Article  PubMed  CAS  Google Scholar 

  18. Davie AP, Francis CM, Caruana L, et al.: Assessing diagnosis in heart failure: which features are any use? QJM 1997, 90:335–339.

    Article  PubMed  CAS  Google Scholar 

  19. Stevenson LW, Perloff JK: The limited reliability of physical signs for estimating hemodynamics in chronic heart failure. JAMA 1989, 261:884–888.

    Article  PubMed  CAS  Google Scholar 

  20. Zema MJ, Restivo B, Sos T, et al.: Left ventricular dysfunction—bedside Valsalva manoeuvre. Br Heart J 1980, 44:560–569.

    Article  PubMed  CAS  Google Scholar 

  21. Kono T, Suwa M, Hanada H, et al.: Clinical significance of normal cardiac silhouette in dilated cardiomyopathy—evaluation based upon echocardiography and magnetic resonance imaging. Jpn Circ J 1992, 56:359–365.

    PubMed  CAS  Google Scholar 

  22. Mahdyoon H, Klein R, Eyler W, et al.: Radiographic pulmonary congestion in end-stage congestive heart failure. Am J Cardiol 1989, 63:625–627.

    Article  PubMed  CAS  Google Scholar 

  23. Collins SP, Lindsell CJ, Storrow AB, Abraham WT: Prevalence of negative chest radiography results in the emergency department patient with decompensated heart failure. Ann Emerg Med 2006, 47:13–18.

    Article  PubMed  Google Scholar 

  24. Rihal CS, Davis KB, Kennedy JW, Gersh BJ: The utility of clinical, electrocardiographic, and roentgenographic variables in the prediction of left ventricular function. Am J Cardiol 1995, 75:220–223.

    Article  PubMed  CAS  Google Scholar 

  25. Silver MT, Rose GA, Paul SD, et al.: A clinical rule to predict preserved left ventricular ejection fraction in patients after myocardial infarction. Ann Intern Med 1994, 121:750–756.

    PubMed  CAS  Google Scholar 

  26. Harvey S, Harrison DA, Singer M, et al.: Assessment of the clinical effectiveness of pulmonary artery catheters in management of patients in intensive care (PAC-Man): a randomised controlled trial. Lancet 2005, 366:472–477.

    Article  PubMed  Google Scholar 

  27. Binanay C, Califf RM, Hasselblad V, et al.: Evaluation study of congestive heart failure and pulmonary artery catheterization effectiveness: the ESCAPE trial. JAMA 2005, 294:1625–1633.

    Article  PubMed  Google Scholar 

  28. Richard C, Warszawski J, Anguel N, et al.: Early use of the pulmonary artery catheter and outcomes in patients with shock and acute respiratory distress syndrome: a randomized controlled trial. JAMA 2003, 290:2713–2720.

    Article  PubMed  CAS  Google Scholar 

  29. Sokolow M: Physical Examination. In Clinical Cardiology, 5 edn. Norwalk, CT: Appleton & Lange; 1990.

    Google Scholar 

  30. Reddy PS, Salerni R, Shaver JA: Normal and abnormal heart sounds in cardiac diagnosis: Part II. Diastolic sounds. Curr Probl Cardiol 1985, 10:1–55.

    CAS  Google Scholar 

  31. Abrams J: Current concepts of the genesis of heart sounds. II. Third and fourth sounds. JAMA 1978, 239:2029–2030.

    Article  PubMed  CAS  Google Scholar 

  32. Harvey WPL: Cardiac pearls. Dis Mon 1994, 40:41–113.

    PubMed  CAS  Google Scholar 

  33. Adolph RJ: In defense of the stethoscope. Chest 1998, 114:1235–1237.

    Article  PubMed  CAS  Google Scholar 

  34. Craige E: Should auscultation be rehabilitated? N Engl J Med 1988, 318:1611–1613.

    PubMed  CAS  Google Scholar 

  35. Fletcher RH, Fletcher SW: Has medicine outgrown physical diagnosis? Ann Intern Med 1992, 117:786–787.

    PubMed  CAS  Google Scholar 

  36. Marcus GM, Vessey J, Jordan MV, et al.: Relationship between accurate auscultation of a clinically useful third heart sound and level of experience. Arch Intern Med 2006, 166:617–622.

    Article  PubMed  Google Scholar 

  37. Weitz HH, Mangione S: In defense of the stethoscope and the bedside. Am J Med 2000, 108:669–671.

    Article  PubMed  CAS  Google Scholar 

  38. Lok CE, Morgan CD, Ranganathan N: The accuracy and interobserver agreement in detecting the ‘gallop sounds’ by cardiac auscultation. Chest 1998, 114:1283–1288.

    Article  PubMed  CAS  Google Scholar 

  39. Ishmail AA, Wing S, Ferguson J, et al.: Interobserver agreement by auscultation in the presence of a third heart sound in patients with congestive heart failure. Chest 1987, 91:870–873.

    Article  PubMed  CAS  Google Scholar 

  40. Held P, Lindberg B, Swedberg K: Audibility of an artificial third heart sound in relation to its frequency, amplitude, delay from the second heart sound and the experience of the observer. Am J Cardiol 1984, 53:1169–1172.

    Article  PubMed  CAS  Google Scholar 

  41. Reddy PS: The third heart sound. Int J Cardiol 1985, 7:213–221.

    Article  PubMed  CAS  Google Scholar 

  42. Sloan A: Cardiac gallop Rhythm. Medicine (Baltimore) 1958, 37:197–215.

    CAS  Google Scholar 

  43. Evans W: The use of the phonocardiograph in clinical medicine. Lancet 1951, 1:1083–1085.

    Article  PubMed  CAS  Google Scholar 

  44. Harlan WR, Oberman A, Grimm R, Rosati RA: Chronic congestive heart failure in coronary artery disease: clinical criteria. Ann Intern Med 1977, 86:133–138.

    PubMed  CAS  Google Scholar 

  45. Patel R, Bushnell DL, Sobotka PA: Implications of an audible third heart sound in evaluating cardiac function. West J Med 1993, 158:606–609.

    PubMed  CAS  Google Scholar 

  46. Drazner MH, Rame JE, Dries DL: Third heart sound and elevated jugular venous pressure as markers of the subsequent development of heart failure in patients with asymptomatic left ventricular dysfunction. Am J Med 2003, 114:431–437.

    Article  PubMed  Google Scholar 

  47. Rame JE, Sheffield MA, Dries DL, et al.: Outcomes after emergency department discharge with a primary diagnosis of heart failure. Am Heart J 2001, 142:714–719.

    Article  PubMed  CAS  Google Scholar 

  48. Glover DR, Littler WA: Factors influencing survival and mode of death in severe chronic ischaemic cardiac failure. Br Heart J 1987, 57:125–132.

    Article  PubMed  CAS  Google Scholar 

  49. Collins SP, Arand P, Lindsell CJ, et al.: Prevalence of the third and fourth heart sound in asymptomatic adults. Congest Heart Fail 2005, 11:242–247.

    Article  PubMed  Google Scholar 

  50. Spodick DH, Quarry VM: Prevalence of the fourth heart sound by phonocardiography in the absence of cardiac disease. Am Heart J 1974, 87:11–14.

    Article  PubMed  CAS  Google Scholar 

  51. Bethell HJ, Nixon PGL Atrial gallop in coronary heart disease without overt infarction. Br Heart J 1974, 36:682–686.

    Article  PubMed  CAS  Google Scholar 

  52. Benchimol A, Desser KBL: The fourth heart sound in patients without demonstrable heart disease. Am Heart J 1977, 93:298–301.

    Article  PubMed  CAS  Google Scholar 

  53. Aronow WS, Uyeyama RR, Cassidy J, Nebolon J: Resting and postexercise phonocardiogram and electrocardiogram in patients with angina pectoris and in normal subjects. Circulation 1971, 43:273–277.

    PubMed  CAS  Google Scholar 

  54. Erikssen J, Rasmussen K: Prevalence and significance of the fourth heart sound (S4) in presumably healthy middleaged men, with particular relation to latent coronary heart disease. Eur J Cardiol 1979, 9:63–75.

    PubMed  CAS  Google Scholar 

  55. Jordan MD, Taylor CR, Nyhuis AW, Tavel ME: Audibility of the fourth heart sound. Relationship to presence of disease and examiner experience. Arch Intern Med 1987, 147:721–726.

    Article  PubMed  CAS  Google Scholar 

  56. Prakash R, Aytan N, Dhingra R, et al.: Variability in the detection of a fourth heart sound—its clinical significance in elderly subjects. Cardiology 1974, 59:49–56.

    Article  PubMed  CAS  Google Scholar 

  57. Swistak M, Mushlin H, Spodick DH: Comparative prevalence of the fourth heart sound in hypertensive and matched normal persons. Am J Cardiol 1974, 33:614–616.

    Article  PubMed  CAS  Google Scholar 

  58. Marcus GM, Gerber IL, McKeown BH, et al.: Association between phonocardiographic third and fourth heart sounds and objective measures of left ventricular function. JAMA 2005, 293:2238–2244.

    Article  PubMed  CAS  Google Scholar 

  59. Collins SP, Lindsell CJ, Peacock WF, et al.: The combined utility of an S3 heart sound and B-type natriuretic peptide levels in emergency department patients with dyspnea. J Card Fail 2006, 12:286–292.

    Article  PubMed  CAS  Google Scholar 

  60. Collins SP, Lindsell CJ, Peacock WFT, et al.: The effect of treatment on the presence of abnormal heart sounds in emergency department patients with heart failure. Am J Emerg Med 2006, 24:25–32.

    Article  PubMed  Google Scholar 

  61. Shapiro M, Moyers B, Marcus GM, et al.: Diagnostic characteristics of combining phonocardiographic third heart sound and systolic time intervals for the prediction of left ventricular dysfunction. J Card Fail 2007, 13:18–24.

    Article  PubMed  Google Scholar 

  62. Collins S, Peacock F, Clopton P, et al.: Heart Failure and Audicor Technology for Rapid Diagnosis and Initial Treatment of ED Patients with Suspected Heart Failure (HEARD-IT). Acad Emerg Med 2007, 14(Suppl 1):S164.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Vanderbilt University Medicial Center, 703 Oxford House, 1313 21st Avenue, South, Nashville, TN, 37232-4700, USA

    Michael Johnston

Authors
  1. Michael Johnston
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Sean P. Collins
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Alan B. Storrow
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Michael Johnston.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Johnston, M., Collins, S.P. & Storrow, A.B. The third heart sound for diagnosis of acute heart failure. Curr Heart Fail Rep 4, 164–169 (2007). https://doi.org/10.1007/s11897-007-0036-z

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11897-007-0036-z

Keywords

Search

Navigation