Module 4: Discussion ? Must post first. Subscribe Mrs. K is a 60-year-old white female who presented to the ER with complaints of her heart ?beating out of my chest.? She is complaining that she is having increased episodes of shortness of breath over the last month and in fact has to sleep on 4 pillows. She also notes that the typical swelling she?s had in her ankles for years has started to get worse over the past two months, making it especially difficult to get her shoes on toward the end of the day. In the past week, she?s been experiencing fatigue and decreased urine output. Her past history is positive for an acute anterior wall myocardial infarction and coronary artery bypass surgery. She was a 2 pack a day smoker, but quit 8 years ago. On physical examination, auscultation of the heart revealed a rumbling S3 gallop and inspiratory crackles. She has +3 edema of the lower extremities

. Discuss the pathophysiology of an S3 heart sound and include causes for an S3 gallop? Post your initial response by Wednesday at midnight. Respond to one student by Sunday at midnight. Both responses must be a minimum of 150 words, scholarly written, APA formatted, and referenced. A minimum of 2 references are required (other than your text). Refer to grading rubric for online discussion. Feedback 100 / 100 Giselle, thank you for your thorough response.? I hope you are enjoying the course so far. View Graded Rubric Start a New Thread Discussion Filter by: All Threads Sort by: Most Recent Activity? Least Recent Activity? Newest Thread? Oldest Thread? Author First Name A-Z? Author First Name Z-A? Author Last Name A-Z? Author Last Name Z-A? Subject A-Z? Subject Z-A Mod 4 S3 Heart Sound/S3 GallopSubscribe Candice Russell posted Feb 9, 2021 3:39 PM Contains unread posts ??????????? ?

The heart is the organ that pumps blood with oxygen and nutrients into all the body organs by a rhythmic cycle overlapping between contraction and dilation? (Bourouhou et al., 2020, p. 64). Dwivedi et al. (2019) state ?electrical activity of the cardiovascular system causes atrial and ventricular contractions that assist in blood circulation between the chambers of the heart and around the body? (p. 8318) ?Mechanical interactions between the blood flow and the different valves that operate to regulate the circulation of blood, contribute to rhythmic heart sounds and murmurs? (Dwivedi et al., 2019, p. 8318).??The term gallop describes the cadence of the three heart sounds occurring in a rapid succession. Jean-Baptiste Bouillaud coined the term ?gallop rhythm?. His pupil, Pierre Potain stated, ?In addition to the two normal sounds, this burit completes the triple rhythm of the heart? this is the bruit de gallop? (Silverman 1990, as cited by Ramani & Weber, 2017). Pathological ventricular dysfunction during a third heart sound, the term gallop is used. S3 gallop is thought to occur ?in the presence of volume overload and ventricular dysfunction when rapid filling phase ends abruptly? (Talley & O?Connor. 2013, as cited by Ramani & Weber, 2017). Symptoms reported by Mrs. K, she appears to be suffering from CHF, left-sided.?Reference????Shono, A., Mori, S., Yatomi, A., Kamio, T., Sakai, J., Soga, F., Tanaka, H., & Hirata, K. I. (2019). Ultimate Third Heart Sound.?Internal medicine (Tokyo, Japan),?58(17), 2535?2538. UnreadUnread6 ViewsViews 6 1 1 RepliesReplies 1 View profile card for Caroline Otto Last post?February 15 at 2:21 AM?by Caroline Otto ? ????????? Ramani, S. and Weber, B.N. (2017), Detecting the gallop: the third heart sound and its significance.?Medical Journal of Australia,?206: 198-199.? Pechetty, R., & Nemani, L. (2020). Additional Heart Sounds-Part 1 (Third and Fourth Heart Sounds).?Indian Journal of Cardiovascular Disease in Women.?5?(2), 155-164.? Bourouhou, A., Jilbab, A., Nacir, C., & Hammouch, A. (2020). 

Heart Sound Signals Segmentation and Multiclass Classification.?International Journal of Online and Biomedical Engineering (IJOE),?16(15), 64.? A. K. Dwivedi, S. A. Imtiaz and E. Rodriguez-Villegas. (2019). ?Algorithms for Automatic Analysis and Classification of Heart Sounds?A Systematic Review,? in IEEE Access,?7, 8316-8345, doi: 10.1109/ACCESS.2018.2889437. If a third heart sound is audible during auscultation, this is not necessarily due to heart disease. S3 heart sounds are often seen in young healthy individuals. Dwivedi et al. (2019) state, ?S3 is noted as a benign sound in the case of young people, athletes, and during pregnancy? (p. 8319).? In cases not mentioned previously, a third heart sound is considered ?an important indicator of reduced systolic function? (Dwivedi et al., 2019, p. 8319). Sono et al. (2019) stated ?Among valvular diseases, a third heart sound is most commonly auscultated with mitral regurgitation? (p. 2537). The third heart is an indicator of left-sided heart failure. S3 is said to be ?an initial clue to left heart failure and is associated with severe mitral regurgitation, a low ejection fraction, restrictive diastolic filling, functionally severe heart failure, and cardiovascular mortality? (Sono et al., 2019, p. 2537). ??????????? First and second heart sounds, S1 and S2, are normal and expected findings, during auscultation. S1 and S2 are considered ?fundamental? heart sounds. Third and fourth heart sounds, S3 and S4, are abnormalities. An S3 heart sound is produced during early diastolic filling in the ventricles, caused by blood rushing in from the atria (Dwivedi et al., 2019). When S3 is present, it?s a low-pitched sound, usually heard shortly after S2. 

Other terms used for third heart sound are ventricular gallop, early diastolic gallop, protodiastolic gallop, and ventricular early filling sound. Pechetty and Nemani (2020) defined the physiology of a third heart sound as, ?in early diastole, when ventricular pressure falls below the atrial pressure, the atrioventricular valves open wide and blood drains rapidly from atria into the ventricles, producing S3? (p. 155). Fritzinger NSG 530 Discussion Wk 4Subscribe Cassie Fritzinger posted Feb 10, 2021 7:28 AM Contains unread posts Mrs. K. presents to the Emergency Department with classic signs of Left sided heart failure. Her symptoms, which are classic signs of heart failure include: dyspnea (shortness of breath), orthopnea (dyspnea when lying down) fatigue, edema (increased swelling of her legs, ankles, & feet), as well as rapid or irregular heartbeat (Mayo Clinic, 2020). Mrs. K.?s history of smoking 2 packs a day placed her at risk of coronary artery disease (CAD), which subsequently resulted in her experiencing an anterior wall myocardial infarction and coronary artery bypass graft surgery (CABG). The anterior wall myocardial infarction is a result of an occlusion of the left anterior descending artery (LAD) causing infarction (tissue death) and subsequent organ dysfunction (Heuther, McCance, & Brasher, 2020). The anterior wall/LAD supplies blood to the left ventricle and anterior septum of the heart (Bansal & Nalabothu 2020).



 Left ventricle infarction/dysfunction causes the heart to become weak and unable to keep up with the metabolic demand of the body (Mayo Clinic, 2020). Ejection fraction may or may not be decreased in heart failure. Heart Failure with/without preserved ejection fraction can affect patients. However, Mrs. K?s most likely experiencing decreased ejection fraction, her decreased urinary output is most likely secondary to the decreased cardiac output (Michigan Medicine University of Michigan, 2021).??????????? Heart failure and decreased cardiac output are secondary to the decreased contractility, resulting in decreased cardiac output/stroke volume. In order to increase preload to improve or compensate and improve the stroke volume the heart dilates or stretches. This dilation eventually leads to a worsening dysfunction of the myocardium contractility and stretches of the coronary arteries which compromises the overall amount of cardiac output (Heuther, McCance, & Brashers, 2020). Bansal K, Gore M, Nalabothu P. Anterior Myocardial Infarction. (2020). StatPearls. Retrieved February 6, 2020.? from:, S. E., McCance, K. L., & Brashers, V. L. (2020). Understanding Pathophysiology (7th ed.). Elsevier.Michigan Medicine University of Michigan. (2021). Heart Failure: Compensation by the Heart and Body. Retrieved February 10, 2021. From?,fatigue%2C%20and%20low%20urine%20output.less1 UnreadUnread6 ViewsViews 6 1 1 RepliesReplies 1 View profile card for Aina Oluwo Last post?February 14 at 11:17 PM?by Aina Oluwo Mayo Clinic. (2020). Heart Failure. Retrieved February 6, 2020. From ?Healio Learn the Heart. (2021). Heart Sounds Topic Review. Retrieved February 10, 2021. 

From References ??????????? A normal cardiac cycle produces sounds from the closure of valves and the tensing of chordae tendineae. Normal heart sounds are called S1 and S2. Other cardiac sounds include a S3 and S4. The S3 is a low-pitch sound which at times can be normal (such as in children or pregnant females)  pathologic. The S3 is also known as the ?ventricular gallop?. This sound occurs just after the normal S2 when the mitral valve opens, and passively allows the filling of the left ventricle. The S3 sound is created from a large amount of blood striking the over stretched left ventricle. The best location to hear the S3 with the bell of a stethoscope is the cardiac apex when the patient is in a left lateral decubitus position (Healio Learn the Heart, 2021).

 HeartSubscribe Sheryl Dixon posted Feb 10, 2021 8:24 PM Contains unread posts During ventricular contraction, the mitral and tricuspid valves are closed, and atrial pressure rises (V wave) from the continuing influx of venous blood into the atria. In early diastole, when ventricular pressure falls below atrial pressure, the atrioventricular valves open wide, and the blood rapidly drains from the atria (Y descent) into the ventricles. The ventricles quickly become distended, moving toward the chest wall, until the elastic distensibility of the ventricular wall is reached and the rapid inflow of blood is checked. At the termination of this early diastolic filling period, a third heart sound may occur. The genesis of this sound is controversial. Previously, it was thought to be an intracardiac sound arising from vibrations in the valve cusps or ventricular wall as diastolic inflow suddenly decelerated. 

Recent studies, however, have shown that the third heart sound is loudest external to the left ventricular cavity, implying that the sound is not radiating from an intracardiac source. Possible explanations include impact of the ventricle against the inner chest wall or a sound originating within the ventricular apex due to sudden limitation of longitudinal expansion (Health jade, 2019).The third heart sound tests the ausculatory skills of the examiner because it is often the most difficult heart sound to hear. This is caused by several factors:The sound does not radiate widely and is audible only over a small area of the chest wall.All extraneous noises?radio, television, visitors, hall noises?should be excluded so that the room is as quiet as possible.?

Any cause of a significant increase in the volume load on the ventricle(s) can cause an S3. Examples include valvular regurgitation, high-output states (anemia, 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.?Health Jade, 2019.Third heart sound. Retrieved from?, M.E (2019).Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Retrieved from UnreadUnread3 ViewsViews 3 1 1 RepliesReplies 1 View profile card for Beth Certain Last post?February 14 at 8:14 PM?by Beth Certain Huether, S. E., & McCance, K. L. & Brashers, V.L. (2020). Understanding Pathophysiology 7th ed. Elsevier Mosby ??????????????????????????????????? ????????????????????

References Although the third heart sound is a very important clue to heart failure or volume overload, it does not appear until the problem is relatively far advanced. In some patients, for reasons that are not clear or because of chest size, obesity, or lung disease, an S3 may never be heard despite severe hemodynamic impairment. Therefore, the absence of a third heart sound cannot be used to exclude ventricular dysfunction or volume overload. In addition, the intensity of the third heart sound is influenced by several factors and correlates only roughly with the clinical status of the patient (Sullivan2019). Any cause of ventricular dysfunction, including ischemic heart disease, dilated or hypertrophic cardiomyopathy, myocarditis, cor pulmonale, or acute valvular regurgitation, may qualify. Myocardial ischemia without ventricular dysfunction or volume overload is not a cause of an S3. The presence of an S3 is the most sensitive indicator of ventricular dysfunction (Huether, McCance & Brashers, 2020). 

Children and adults up to age 35 to 40 may have a normal third heart sound. The explanation for this ?physiologic S3,? which is identical in timing and frequency with its pathologic counterpart, is unknown. Before age 40, the significance of the third heart sound must be judged by the presence or absence of significant heart disease. After age 40, a third heart sound is usually abnormal and correlates with dysfunction or volume overload of the ventricles. The usual frequency (pitch) of the sound is near the lowest level that the human ear can detect. The inexperienced ear is unaccustomed to listening for a sound of this low frequency. The sound is usually of very low intensity and is easily obscured by extraneous room sounds, lung or abdominal noise, or tightening of the chest wall muscles. During diastole there are 2 sounds of ventricular filling:

 The first is from the atrial walls and the second is from the contraction of the atriums. The third heart sound is caused by vibration of the ventricular walls, resulting from the first rapid filling so it is heard just after S2. The third heart sound is low in frequency and intensity. An S3 is commonly heard in children and young adults. In older adults and the elderly with heart disease, an S3 often means heart failure. Module four ? the heartSubscribe Beth Certain posted Feb 10, 2021 6:18 PM Contains unread posts Module 4 ? The heartAccording to Heart Sounds Topic Review (N.D.), reviewing the four heart sounds explains the S1 is the first heart sound resulting from the closure of the mitral ad tricuspid valves.The S3 sound is heard at the beginning of the middle third of diastole. Hall (2016) explained, ?in the early part of diastole, the ventricles are not sufficiently filled to create enough elastic tension necessary for reverberation.? Interestingly, the S3 sound may be typical in children, adolescents, and young adults, whereas hearing the S3 in an older adult may indicate systolic heart failure.Heart sounds are described as intensity, pitch, location. Intensity means how loud the sound is

. The sound can be intense (loud), decreased in intensity (soft), or absent. Pitch is the quality of the sound, high or low. The location of the heart sound can help determine the etiology.The 3rd?heart sound can be a significant clue to heart failure or volume overload. Unfortunately, by the time a problem appears, it is relatively far advanced. Despite severe hemodynamic impairment, a 3rd?heart sound may not be heard. Ventricular dysfunction or volume overload cannot be excluded by the absence of a 3rd?heart sound (Health Jade (2019).Hall, J.E. (2016).?Guyton and Hall textbook of medical physiology?(13th?ed.). Elsevier????????????https://healthjade.netthird-heart-soundHeart. Retrieved February 9, 2021, from? UnreadUnread3 ViewsViews 3 1 1 RepliesReplies 1 View profile card for Jennifer Bryant Last post?February 14 at 11:30 AM?by Jennifer Bryant Heart Sounds Topic Review (N.D.) Cardiology Reviews Topic Reviews.?Helio Learn the Health Jade. (2019).

Third Heart Sound. By Health Jade team. Retrieved February 9, 2021 References The 3rd?heart sound is also known as the ?ventricular gallop,? occurring just after S2 when the mitral valve opens, allowing passive filling of the left ventricle. The S3 sound is produced by a large amount of blood striking a very compliant LV (Heart Sounds Topic Review, N.D.). In most adults, the LV is not overly compliant, meaning the S3 is usually not loud enough to be auscultated. An S3 can be a normal finding in children, pregnant females, and well-trained athletes (Health Jade, 2019). It has been noted that an S3 can also be a normal variance in younger children, pregnant women, and athletes but is generally indicative of pathology in older adults. The S4 heart sound is almost always abnormal, known as the atrial gallop, and occurs just before S1 when the atria contract to force blood into the LV, The S2 sound is produced when the aortic and pulmonic valve close. There are four sounds the heart produces. These include S1, S2, S3, and S4. Specific cardiac events are what make these sounds. Events such as the ?closure of a valve or tensing of a chordae tendineae produce sounds (Heart Sounds Topic Review, N.D.). Heart Sounds Topic Review explains auscultation of the heart sounds can help to diagnose pathological cardiac conditions. Heart sounds can be discrete, short, and audible from a specific cause.

 Heart murmurs produce a different sound due to turbulence of blood flow and encompass all of systole or diastole. The S3 Heart Sound PathophysiologySubscribe Lois Chappell posted Feb 10, 2021 7:37 PM Contains unread posts ? ? ?The S3 heart sound is usually abnormal if auscultated in a patient greater than age 40 years old and is associated with ventricular dysfunction and volume overload (Heuther, McCance, and Brashers, 2020).? This syndrome is called heart failure and can have a variety of causes.? In our patient who has a history of myocardial infarct (MI), cardiac artery bypass graft (CABG), and smoking, the most likely cause is congestive heart failure from ventricular wall dysfunction due to long-standing hypertension, and damage of the left ventricle from the anterior myocardial infarct.? The S3 heart sound is noted when there is normal or greater than normal cardiac output combined with systemic vascular resistance and is highly specific but not sensitive in heart failure (Long, Koyfron, and Gotlieb, 2019).? There is also a decrease in after load which activates the neurohormones renin and angiotension and increases salt and water retention (Long, Koyfron, and Gotlieb, 2019).? 

In addition, remodeling of the ventricle occurs and there is a release of brain natriuretic peptides (BNP) that can lead to further deterioration of the patient.? The patient with congestive heart failure presents with orthopnea, edema, shortness of breath and fatigue due to the salt and water retention, and reduction of end organ blood flow which increases morbidity and mortality (Long, Koyfron, and Gotlieb, 2019) .ReferencesLong, B., Koyfman, A., and Gottlieb, M.? (2019).? Diagnosis of acute heart failure in the?emergency department: and evidence-based review.? Western Journal of Internal???? 200 (6).? DOI: 10.5811/westjem.2019.9.43732.?less1 UnreadUnread7 ViewsViews 7 1 1 RepliesReplies 1 View profile card for Alfonsina Perez Last post?February 14 at 7:13 AM?by Alfonsina Perez ? ? ?Medicine, Huether, S., McCance, K., and Brashers, V.? (2020).??Understanding Pathophysiology 7th?ed.? Elsevier, Mosby. ? ? ?In addition to the physical exam findings, we would want to perform laboratory testing including a BNP as this is chronically elevated in heart failure, and increases during an exacerbation, kidney function tests to assess end organ damage, and an electrocardiogram (EKG) to rule out presence of a new MI.?

 Treatment would include anti-hypertensives; a good choice would be a diuretic, oxygen, and consideration of morphine to increase vasodilation, reduce preload and improve oxygen delivery.? Mrs. K is also at risk for deep vein thrombosis (DVT) due to immobility and atherosclerosis.? Suspicion for DVT would increase if lower extremity edema were unilateral.? Prevention, screening, and detection of heart failure exacerbations, combined with aggressive treatment, can limit further end organ damage, and improve overall quality of life for patients with coronary artery disease (CAD) and associated complications. Module 4Subscribe Steven Bartos posted Feb 10, 2021 10:37 PM Contains unread posts In this scenario, Mrs. K has an S3 gallop, which is indicative of ventricular dysfunction or volume overload (Ramani & Weber, 2017). An S3 heart sound is commonly found in systolic heart failure, which is also called heart failure with reduced ejection fraction. 

This occurs when the ventricles eject less than 40% of their blood volume and they are unable to pump enough oxygenated blood throughout the body?s tissues, which would account for the other signs and symptoms of heart failure that Mrs. K is experiencing (Huether et al, 2020). The S3 heart sound occurs from the rapid draining of blood from the atria into the ventricles during ventricular diastole. It happens at the end of the rapid filling phase, right when the ventricles transition to the slow filling phase. However, there seems to be debate as far as the exact mechanism which causes the S3 sound

. Ventricular theory believes that the ventricular walls vibrate when the inflow of blood is halted from rapid to slow, causing an intracardiac sound. A second, valvular theory, proposes that the S3 occur due to the vibrations of valve cusps from the immediate decreased inflow of blood. Another theory, impact theory, states that S3 results from the ventricle moving closer to the chest wall when it fills with blood. The last theory, which in the research goes unnamed, suggests that S3 may arise when the ventricles don?t expand enough after early rapid filling. These theories suggest that S3 can be heard in the following situations: 1) when a normal ventricle receives too much incoming blood; 2) when a dilated ventricle receives equal to or less than normal amounts of blood; and 3) when a dilated ventricle receives too much blood and has volume overload (Pechetty & Nemani, 2020). It has been shown that the intensity of the S3 heart sound is affected by ?age, atrial pressure, unobstructed flow across the atrioventricular valve, rapidity of early diastolic filling, compliance of the ventricle, blood volume, ventricular cavity size, and patient positioning? (Ramani & Weber, 2017, p. 198).Heuther, S. E., McCance, K. L., & Brashers, V. L. (2020).?

Understanding pathophysiology?(7th?ed.). Elsevier.Ramani, S., & Weber, B.N. (2017). Detecting the gallop: the third heart sound and its significance.?Medical Journal of Australia, 206(5), 198 ? 199.? UnreadUnread7 ViewsViews 7 1 1 RepliesReplies 1 View profile card for Amandeep Kaur Last post?February 13 at 11:15 PM?by Amandeep Kaur Pechetty, R., & Nemani, L. (2020). Additional heart sounds ? part 1 (third and fourth heart sounds).?Indian Journal of Cardiovascular Disease in Women, 5(2), 155 ? 164.? References Week 4 Discussion Post ? The HeartSubscribed Gisselle Mustiga posted Feb 8, 2021 11:37 PM Contains unread posts ? ? ? ? ? Mrs K. is exhibiting symptoms of Heart Failure. The S3 gallop heard during her physical exam auscultation represents the low-frequented, minimal vibrations during diastole after a rapid diastolic action in either ventricle. It begins a few seconds after S2 and generates a unique cadence.

 The condition only occurs after the middle third of diastole because ventricles are often unfilled sufficiently at the early diastole. This reasoning also gives it names such as ventricular gallop and protodiastolic rhythm. The frequency distinguishes it from the split s2. For instance, a distinct heart sound is existent in the left ventricle with the filling of the passive left ventricle. Such situations only occur when the left ventricle is compliant. Otherwise, the s3 gallop would be too inaudible for auscultation. Its prevalence is normal among patients who are less than forty years of age, expectant women, children, and athletes. Nevertheless, it can also be abnormal in other instances. In systolic heart failure, there is an over compliance on the part of the myocardium (Gocheva et al., 2018). Consequently, the left ventricle becomes dilated. The condition occurs due to causes such as an escalation in the ventricular filling and poor left ventricular function.