12/08/2025
The 3rd additional heart sound, designated as S3, arises when blood strikes the ventricular wall during rapid filling at the beginning of diastole. A physiological S3 is normal in children and healthy young adults.
⚙️ Mechanism of Origin
S3 is produced by the abrupt deceleration of blood flow as it moves from the atria into the ventricles (mainly the left ventricle) during early diastolic filling. This rapid filling creates vibrations in the ventricular walls and surrounding structures, generating the sound.
🔬 Clinical Significance
S3 can be physiological or pathological, making it an important diagnostic finding.
Physiological S3 (Normal)
• It is commonly observed in children, adolescents, and young adults (as noted in the provided text).
• It can also be normal in pregnant women and highly trained athletes.
• In these cases, it reflects a pliable, elastic ventricle and rapid blood filling.
Pathological S3 (Indication of Disease)
• If S3 is heard in adults (particularly middle-aged and older), it generally indicates pathology, most commonly heart failure (HF).
• A pathological S3 is often referred to as a protodiastolic gallop rhythm, as the sequence of S1-S2-S3 resembles the sound of a galloping horse.
Pathological S3 is associated with:
• Left ventricular dysfunction (systolic HF): Suggests impaired contractility or increased residual volume after systole and is a sensitive sign of ventricular dysfunction.
• Volume overload: Seen in significant mitral or tricuspid regurgitation, where excessive blood returns to the ventricle and increases filling.
The presence of S3 in an adult is therefore an important early sign of heart failure or other conditions causing marked cardiac volume overload.
📚 Source: O’Gara, P. T., & Loscalzo, J. (2022). Auscultation of the Heart. Harrison’s Principles of Internal Medicine, 21st ed.