ContextThe third (S 3 ) and fourth (S 4 ) heart sounds detected by phonocardiography are considered to represent the criterion standards of the gallop sounds, but their test characteristics have not been explored.Objective To determine the diagnostic test characteristics of the S 3 and S 4 for prediction of left ventricular dysfunction using a computerized heart sound detection algorithm.Design, Setting, and Participants Prospective study of 90 adult patients undergoing elective left-sided heart catheterization at a single US teaching hospital between August 2003 and June 2004. The mean age was 62 (SD, 13) years (range, 24-90 years) and 61 (68%) were male. Within a 4-hour period, participants underwent computerized heart sound phonocardiographic analysis, cardiac catheterization, transthoracic echocardiography, and blood sampling for assessment of an S 3 /S 4 , left ventricular end-diastolic pressure (LVEDP), left ventricular ejection fraction (LVEF), and B-type natriuretic peptide (BNP), respectively.Main Outcome Measures Diagnostic test characteristics of the computerized phonocardiographic S 3 and S 4 using markers of left ventricular function as criterion standards.Results Mean (SD) LVEDP was significantly elevated (18.4 [6.9] mm Hg vs 12.1 [7.3] mm Hg; PϽ.001), mean (SD) LVEF was reduced (49.4% [20.2%] vs 63.6% [14.8%]; PϽ.001), and median (interquartile range) BNP was elevated (330 [98-1155] pg/mL vs 86 pg/mL; PϽ.001) in those with an S 3 , S 4 , or both compared with patients without a diastolic heart sound. The sensitivities of these heart sounds to detect an elevated LVEDP, reduced LVEF, or elevated BNP were 41%, 52%, and 32% for an S 3 , and 46%, 43%, and 40% for an S 4 , respectively. For abnormal levels of the same markers of ventricular function, the specificities of the S 3 were 92%, 87%, and 92%, while the specificities of the S 4 were 80%, 72%, and 78%, respectively.Conclusions Neither the phonocardiographic S 3 nor the S 4 is a sensitive marker of left ventricular dysfunction. The phonocardiographic S 3 is specific for left ventricular dysfunction and appears to be superior to the moderate specificity of the phonocardiographic S 4 .

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Background: Poor performance by physicians-intraining and interobserver variability between physicians have diminished clinicians' confidence in the value of the third heart sound (S3). Methods: To determine whether auscultation of a clinically useful S3 improves with advancing levels of experience, we performed a prospective, blinded, observational study of 100 patients undergoing left-sided heart catheterization. Patients underwent blinded auscultation by 4 physicians (each from 1 of 4 different levels of experience), phonocardiography, measurement of blood B-type natriuretic peptide levels, echocardiography for measurement of left ventricular ejection fraction, and cardiac catheterization for measurement of left ventricular end-diastolic pressure. Results: Whereas residents' and interns' auscultatory findings demonstrated no significant agreement with phonocardiographic findings, an S3 auscultated by cardiology fellows (=0.37; PϽ.001) and cardiology attendings See also pages 603 and 610

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Phonoelectrocardiographic measures of systolic time intervals are insensitive but highly specific tests for detecting abnormalities in objective markers of left ventricular function. EMAT and EMAT/LVST provide diagnostic information independent of BNP for detecting patients with left ventricular dysfunction.