Elliot Kim
The third heart sound, or S3, is a low-frequency sound that occurs during diastole and is associated with heart failure. It is caused by vibrations within the myocardial wall and the atrioventricular valve, and can indicate left or right ventricular origin depending on its location. While it may be a typical heart sound for certain individuals, such as children, pregnant people, and athletes, it can also indicate heart problems such as systolic heart failure. Doctors remain unsure of the exact mechanisms that create S3 sounds, but recent research suggests that the diameter of the mitral valve annulus is an important factor in its production.
| Characteristics | Values |
|---|---|
| Frequency | Low |
| Pitch | Low |
| Intensity | Soft to moderate |
| Cause | Vibrations within the myocardial wall and the atrioventricular valve |
| Occurrence | After the S2 sound |
| Age | Common in children and young adults |
| Occurrence in healthy individuals | May occur in children, pregnant people, and well-trained athletes |
| Heart conditions | Systolic heart failure, diastolic heart failure, dilated cardiomyopathy, mitral regurgitation, ventricular dysfunction, volume overload, myocardial ischemia, hypertrophic cardiomyopathy, myocarditis, cor pulmonale, acute valvular regurgitation, and tachycardia |
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What You'll Learn
S3 in healthy individuals
The S3 heart sound is a rare extra heart sound that occurs soon after the two typical heart sounds, S1 and S2. While the S3 sound is usually associated with heart failure, it can also occur in healthy individuals, especially children and young adults.
The S3 heart sound occurs when the ventricles in the heart rapidly fill with blood. It is a type of gallop rhythm, characterised by an extra sound, and is best heard with a stethoscope placed on the chest wall while the patient lies on their left side. The S3 sound is lower in pitch than the normal heart sounds and is usually faint.
In healthy individuals, the S3 sound may be a normal finding that disappears with age. It is thought to be caused by the undulation of blood back and forth between the walls of the ventricles, initiated by the inflow of blood. The S3 sound in healthy individuals may be related to the abnormally rapid deceleration of early diastolic left ventricular inflow.
The presence of the S3 sound in healthy individuals does not seem to be dependent on the state of left ventricular systolic function. Instead, it is associated with diastolic filling, which is characterised by a predominance of early inflow with a rapid flow deceleration rate. The S3 sound in healthy individuals may also be influenced by factors such as age, atrial pressure, rate of early diastolic relaxation, distensibility of the ventricle, and blood volume.
While the S3 sound in healthy individuals may not require treatment, it is important to note that the re-emergence of this sound later in life could indicate serious problems such as heart failure. Therefore, it is advisable to consult a healthcare professional for a proper evaluation if the S3 sound is present or re-emerges.
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S3 as a sign of heart failure
The third heart sound, or S3, is a rare extra heart sound that occurs soon after the normal two "lub-dub" heart sounds (S1 and S2). S3 is associated with heart failure and is usually an early sign of congestive heart failure. It occurs at the beginning of the middle third of diastole, approximately 0.12 to 0.18 seconds after S2. This produces a rhythm that can be compared to the cadence of the word "Kentucky", with the final syllable ("-CKY") representing S3. One may also use the phrase "Slosh’-ing-IN" to help with the cadence (Slosh S1, -ing S2, -in S3).
S3 is a low-frequency, brief vibration occurring in early diastole at the end of the rapid diastolic filling period of the right or left ventricle. It is a very low-frequency vibration, in the range of 25 to 50 Hz, and has a dull, thudding quality. At times, it may be difficult to tell if it is an actual sound or more of a sensation. When intense, a few after-vibrations may add to its duration and suggest a short diastolic murmur. The S3 sound is lower in pitch than the normal sounds, usually faint, and best heard with the bell of the stethoscope.
S3 may be present in healthy children, young adults, pregnant people, and well-trained athletes. However, in adults over 40, it is almost always abnormal, representing an early sign of congestive heart failure. An S3 is sometimes called a "ventricular gallop". The term "gallop" was first used in 1847 by Jean-Baptiste Bouillaud to describe the cadence of three heart sounds occurring in rapid succession.
Techniques that increase venous return or the size of the ventricular cavity—such as a recumbent position, elevation of the legs, exercise, squatting, and volume expansion—augment the intensity of S3. Conversely, the sound becomes softer or disappears with standing, diuresis, haemorrhage, or dialysis. The presence of an S3 is the most sensitive indicator of ventricular dysfunction. Any cause of a significant increase in the volume load on the ventricles can cause an S3. Examples include valvular regurgitation, high-output states (anaemia, pregnancy, arteriovenous fistula, or thyrotoxicosis), left-to-right intracardiac shunts, complete A-V block, renal failure, and volume overload from excessive fluids or blood transfusion.
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S3 as a sign of ventricular dysfunction
The third heart sound or S3 is a rare extra heart sound that occurs soon after the two normal heart sounds (S1 and S2). S3 is associated with heart failure. It occurs at the beginning of the middle third of diastole, approximately 0.12 to 0.18 seconds after S2. S3 is a dull, low-pitched sound best heard with the bell placed over the cardiac apex with the patient lying in the left lateral decubitus position.
S3 is thought to be caused by the undulation of blood back and forth between the ventricle walls, initiated by the inflow of blood from the atria. Recent research suggests that the diameter of the mitral valve annulus — the junction between the ventricle and left atrium — is important in S3 sound creation. Doctors traditionally assumed that blood rushing into an overloaded ventricle caused the sound, for example, during an exacerbation of acute heart failure.
S3 is usually present in children and young adults, implying the presence of a supple ventricle that can undergo rapid filling. However, when heard in a middle-aged or older adult, an S3 is often a sign of disease, indicating increased ventricular filling due to congestive heart failure or severe mitral or tricuspid regurgitation. The presence of an S3 is the most sensitive indicator of ventricular dysfunction. Any cause of ventricular dysfunction, including ischemic heart disease, dilated or hypertrophic cardiomyopathy, myocarditis, cor pulmonale, or acute valvular regurgitation, may qualify.
The third heart sound is an important clue to heart failure or volume overload, but it does not appear until the problem is relatively advanced. The absence of an S3 sound does not necessarily indicate the absence of ventricular dysfunction or volume overload. The intensity of the third heart sound is influenced by several factors and correlates only roughly with the patient's clinical status.
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S3 as a sign of valve issues
The S3 heart sound is a rare extra heart sound that occurs soon after the normal two "lub-dub" heart sounds (S1 and S2). It is a low-frequency, short vibration sound that happens after the S2 sound. Typically, the S2 is a high-pitched sound, which is how doctors can distinguish the low, dull S3 sound. Doctors may also refer to the S3 sound as a ventricular gallop. This may be because the three heart sounds — S1, S2, and S3 — in quick succession create a cadence, or rhythm, like a galloping horse.
The S3 heart sound occurs when the ventricles in the heart rapidly fill with blood. It occurs at the beginning of the middle third of diastole, approximately 0.12 to 0.18 seconds after S2. This produces a rhythm that can be compared to the cadence of the word "Kentucky," with the final syllable ("-CKY") representing S3.
While the S3 heart sound can occur in healthy individuals, such as children, pregnant people, and well-trained athletes, it can also indicate heart problems in others. In some cases, the S3 heart sound may suggest valve issues within the organ, including severe tricuspid or mitral valve regurgitation. Regurgitation means that the heart valve becomes leaky, allowing blood to flow in the wrong direction.
Recent research suggests that the diameter of the mitral valve annulus, or the junction between the ventricle and left atrium, is important in producing the S3 sound. The S3 heart sound occurs as the mitral valve opens and allows blood to fill the left ventricle. This sound happens as a result of blood striking the left ventricle during early diastole.
The presence of an S3 heart sound is a significant indicator of ventricular dysfunction or volume overload. It can be caused by any condition that significantly increases the volume load on the ventricles, such as valvular regurgitation, high-output states, left-to-right intracardiac shunts, complete A-V block, renal failure, or volume overload from excessive fluids or blood transfusion.
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S3 in children and young adults
The third heart sound or S3 is a rare extra heart sound that occurs soon after the normal two "lub-dub" heart sounds (S1 and S2). S3 is associated with heart failure. It occurs at the beginning of the middle third of diastole, approximately 0.12 to 0.18 seconds after S2. This produces a rhythm that can be compared to the cadence of the word "Kentucky", with the final syllable ("-CKY") representing S3. S3 is a low-frequency, short vibration sound that happens after the S2 sound. Typically, the S2 sound is high-pitched, which is how doctors can distinguish the low, dull S3 sound.
S3 is a normal occurrence in children and young adults up to the age of 35 to 40. It implies the presence of a supple ventricle that can undergo rapid filling. However, the presence of significant heart disease must be ruled out before age 40, as an S3 sound in older adults is often a sign of disease. In middle-aged or older adults, an S3 indicates increased ventricular filling due to congestive heart failure or severe mitral or tricuspid regurgitation. Regurgitation means that the heart valve becomes leaky.
The exact mechanism for creating S3 heart sounds is still unknown. Traditionally, it was assumed that blood rushing into an overloaded ventricle caused the sound, such as during an exacerbation of acute heart failure. Recent research suggests that the diameter of the mitral valve annulus, the junction between the ventricle and left atrium, is important in S3 sound creation. The S3 heart sound occurs when the mitral valve opens and allows blood to fill the left ventricle passively. The sound happens as a result of blood striking the left ventricle during early diastole.
While S3 can be a typical heart sound for certain individuals, including children, pregnant people, and well-trained athletes, it may also indicate heart problems such as systolic heart failure or diastolic murmur. Diastolic murmur is an unusual finding that suggests valve issues, including severe tricuspid or mitral valve regurgitation.
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Frequently asked questions
The third heart sound or S3 is a rare extra heart sound that occurs soon after the normal two "lub-dub" heart sounds (S1 and S2). It is a low-frequency sound occurring during diastole, attributed to the rapid filling of the ventricles.
The S3 heart sound occurs when the ventricles in the heart rapidly fill with blood. It is caused by vibrations within the myocardial wall and the atrioventricular valve. Recent research suggests that the diameter of the mitral valve annulus is one of the more important factors in producing the S3 sound.
The S3 heart sound is associated with heart failure, which is when the heart cannot pump enough blood for the body's needs. It may also indicate valve issues within the organ, such as severe tricuspid or mitral valve regurgitation.
An S3 heart sound may be normal in children, pregnant people, and well-trained athletes. However, when heard in a middle-aged or older adult, an S3 is often a sign of disease.
Treatment for an S3 heart sound depends on the underlying cause and the patient's overall health. If the S3 occurs in an otherwise healthy individual, treatment may not be necessary. However, if it is associated with heart failure or other conditions, treatment options may include lifestyle changes, medications, surgery, or implantable devices.
