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Early systole
9%
20/223
Mid systole
8%
18/223
Late systole
7%
16/223
Early diastole
20%
44/223
Late diastole
46%
102/223
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This patient suffers from left ventricular hypertrophy secondary to his poorly controlled hypertension. One would expect to hear an S4 in this patient, which would occur in late diastole. Left ventricular hypertrophy (LVH) results from the cardiac muscle consistently contracting against an increased afterload. The deep R waves in leads V1-V3 in the EKG would confirm this diagnosis. As the atria contract to fill the ventricles during diastole in a patient with LVH, they start to meet increased resistance as the ventricle fills. As a result, in late diastole, the atria have to undergo more forceful contractions to completely fill the stiff ventricles resulting in an S4. Figure A shows an EKG with deep R waves in the precordial leads V1-V3. This finding is classically seen in left ventricular hypertrophy. LVH is usually seen in clinical situations causing strain on the left heart (uncontrolled hypertension which causes increased afterload). The hypertrophy of the tissue causes deeper waves because more tissue is depolarizing. Incorrect Answers: Answer 1: A murmur in early systole can be heard in patients with aortic stenosis. While this patient’s age puts him at risk for aortic stenosis, his echocardiogram indicated no valvular abnormalities. Thus the heart sound is more likely to be a S4 due to his hypertension. Answer 2: The murmur of mitral/tricuspid regurgitation can be heard during mid-systole. This patient does not have any valvular abnormalities. Answer 3: The murmur of mitral valve prolapse is commonly heard in late systole. This patient does not have any valvular abnormalities. Answer 4: An S3 would be heard in early diastole. An S3 is heard in states of volume overload or increased filling pressures due to increased volume (as seen in mitral regurgitation or CHF). This patient does not have signs of fluid overload. Bullet Summary: Associated with left ventricular hypertrophy, an S4 heart sound can be heard during late diastole as the atria contract more forcefully against a stiff, partially full ventricle.
4.4
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