Examination in chronic heart failure frequently reveals which of the following heart sounds?

• A. S3
• B. splitting of S2
• C. paradoxical splitting of S2
• D. holosystolic murmur

Answer: (A)

An S3 gallop is the sound most often seen in chronic heart failure due to volume overload and a dilated ventricle. It appears in early diastole, just after S2, when rapid passive filling of a compliant but overloaded ventricle causes a rapid deceleration of inflowing blood. This low-pitched, ventricular “gallop” is best heard with the bell at the apex with the patient in the left lateral decubitus position. In adults, an S3 typically indicates systolic dysfunction with elevated LV filling pressures and is a common finding in congestive heart failure. By contrast, S4 would point to a stiff ventricle, and splitting or paradoxical splitting of S2 or a holosystolic murmur are not the hallmark sounds of chronic HF.