What is the clinical significance of an S4 heart sound in a 72-year-old patient with diabetes (diabetes mellitus) and hypertension (high blood pressure)?

From the Guidelines

The presence of an S4 heart sound in a 72-year-old patient with diabetes and hypertension is a significant clinical finding that warrants further evaluation and management to reduce the risk of cardiovascular morbidity and mortality. The S4 heart sound is typically associated with decreased left ventricular compliance and increased stiffness of the heart muscle, which can be caused by long-standing hypertension and/or diabetic cardiomyopathy [ 1 ]. This abnormal heart sound occurs when blood from the atrium enters a stiff, non-compliant ventricle during late diastole, creating an audible "gallop" sound just before the normal S1 sound.

Key Considerations

• The patient's diabetes and hypertension increase the risk of cardiovascular disease, and the S4 heart sound may indicate early heart failure with preserved ejection fraction (HFpEF) [ 1 ].
• Optimizing blood pressure control to a target of <130/80 mmHg is crucial in managing this patient's condition, as evidenced by the 2019 standards of medical care for type 2 diabetes in China [ 1 ].
• Diabetes management, aiming for an HbA1c <7%, is also essential in reducing the risk of cardiovascular complications [ 1 ].
• Medications such as ACE inhibitors, ARBs, or beta-blockers may be initiated or adjusted to manage the patient's condition, and diuretics may be needed if fluid retention is present [ 1 ].

Management Strategies

• Further cardiac evaluation, including echocardiography, should be performed to assess ventricular function, wall thickness, and filling pressures.
• The patient's blood pressure and diabetes management should be closely monitored, and adjustments made as necessary to achieve the target values.
• The S4 gallop itself is not treated directly, but rather serves as an important physical examination finding that reflects underlying pathophysiology of decreased ventricular compliance in this high-risk patient.

From the Research

Clinical Significance of S4 Heart Sound

The clinical significance of an S4 heart sound in a 72-year-old patient with diabetes and hypertension is related to the patient's increased risk of cardiovascular disease.

• The S4 heart sound is often associated with conditions such as left ventricular hypertrophy, which can be caused by hypertension 2.
• Diabetes and hypertension are independent risk factors for cardiovascular-related morbidity and mortality, and the presence of an S4 heart sound may indicate increased stiffness of the left ventricle 3.
• The management of hypertension in patients with diabetes is crucial to reduce the risk of cardiovascular events and kidney disease progression 4.
• Optimal blood pressure targets for elderly patients with diabetes and hypertension are still debated, but a target of less than 130/80 mmHg is often recommended 2, while others suggest a target of less than 140-150/90 mmHg 5.
• The presence of an S4 heart sound in this patient population may require closer monitoring of blood pressure and cardiovascular risk factors, as well as individualized treatment to prevent excessive blood pressure lowering 5.

Cardiovascular Risk Assessment

• Conditions that increase cardiovascular risk in people with diabetes include age, male gender, history of relative suffering from premature coronary heart disease, high blood pressure, and high LDL levels 3.
• Several models have been developed to assess cardiovascular risk in people with and without diabetes, and the use of biomarkers is an emerging way of risk assessment in patients with diabetes mellitus 3.
• The clinical significance of an S4 heart sound in this patient population should be considered in the context of overall cardiovascular risk assessment and management 3.

Treatment Considerations

• The treatment of hypertension in patients with diabetes should be individualized, taking into account the patient's overall cardiovascular risk profile and the presence of any comorbidities 2, 4.
• Lifestyle intervention is a key component of the effective management of diabetes and hypertension, and can markedly reduce event rates of both heart and kidney outcomes 4.
• Certain classes of antihypertensive agents may confer significant benefits in reducing cardiorenal outcomes in patients with diabetes 4.