By M.D. Aldo A. Luisada

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In the early forties, the term fourth sound was suggested for the atrial sound. Even though this term is a misnomer (it gives the highest number to a phenomenon that actually occurs during the initiation of the cardiac cycle), it is in common usage and cannot be easily changed. The atrial sound is heard and recorded more often than the third sound in patients with ischemic (Parry and Mounsey) or *This coincidence was determined in three ways: by means of the apex or epigastric cardiogram; by means of the electrokymogram of the left ventricle; and by means of right heart catheterization.

FIGURE 47. Quadruple rhythm with recording of both a third and a fourth sound during long diastoles.

Cause of the wider splitting by delaying the pulmonary pulse rebound and the pulmonary component of the second sound while an opposite, though lesser, change is shown by the aortic component. The delay between the two components usually decreases with age and may disappear between 40 and 60 years of age. This fact can be explained by the greater pulmonary arteriolar resistance in mature adults, which would cause an earlier pulmonary pulse rebound and an earlier pulmonary component of the second sound.

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