Which heart sound could be indicative of poorly controlled hypertension or ischemic heart disease?

The presence of an S4 heart sound, also known as a "triple gallop" or "atrial gallop," is typically associated with conditions that lead to a stiff or hypertrophied left ventricle. In poorly controlled hypertension, the heart muscle can undergo hypertrophy due to the increased workload imposed by the elevated blood pressure, resulting in a decreased ability to relax during diastole. This alteration in the ventricular function is what allows the S4 to be heard during auscultation.

In ischemic heart disease, the heart may also become less compliant due to damage from past myocardial infarctions or chronic ischemia, leading to similar changes in ventricular filling dynamics. The S4 sound occurs just before the S1 heart sound, corresponding to the sound of blood being forced into a stiff ventricle during atrial contraction. Therefore, when either of these conditions is present, the S4 sound can be an important clinical finding, indicating underlying cardiac stress or adaptive changes due to the heart's response to chronic pressure overload.

While other heart sounds, such as physiologic or fixed split S2 and S3, might be associated with different cardiovascular states, they do not have the same contextual relevance for poorly controlled hypertension or ischemic heart