In a 71‑year‑old man with dilated cardiomyopathy, ejection fraction ~20 % (heart failure with reduced ejection fraction), type 2 diabetes mellitus, hypertension, peripheral vascular disease, and chronic obstructive pulmonary disease, what heart sounds and murmurs are typically heard on physical examination?

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Heart Sounds in Heart Failure with Reduced Ejection Fraction

Key Auscultatory Findings in HFrEF

In a patient with dilated cardiomyopathy and severely reduced ejection fraction (~20%), the most characteristic heart sound is an S3 gallop, which is present in approximately 23% of patients with advanced heart failure and indicates elevated left ventricular filling pressures and poor prognosis. 1

Primary Heart Sounds

  • S3 gallop (ventricular gallop): This low-pitched sound occurs in early diastole and is audible in 23% of patients with heart failure, reflecting rapid ventricular filling into a dilated, poorly compliant ventricle with elevated end-diastolic pressure 1
  • S4 gallop (atrial gallop): May be present if the patient is in sinus rhythm, though less specific for HFrEF 1
  • Diminished S1: The first heart sound may be reduced in intensity due to decreased contractility and poor valve closure 1
  • Accentuated or split S2: The second heart sound may show abnormal splitting patterns, though this is less specific 1

Murmurs Associated with HFrEF

  • Functional mitral regurgitation: A holosystolic murmur at the apex is common due to left ventricular dilation causing annular dilation and incomplete mitral valve coaptation 1
  • Functional tricuspid regurgitation: A holosystolic murmur at the lower left sternal border that increases with inspiration may be present if right ventricular dysfunction has developed 1

Signs of Advanced Disease and Decompensation

  • Elevated jugular venous pressure with prominent V waves: Indicates elevated right atrial pressure and possible tricuspid regurgitation 1
  • Pulsatile hepatomegaly: Reflects severe right-sided heart failure with tricuspid regurgitation 1
  • Peripheral edema and ascites: Physical signs of volume overload, present in 32% of patients with advanced heart failure 1

Prognostic Significance

The presence of an S3 gallop and elevated jugular venous pressure have been shown to have significant prognostic value, indicating worse outcomes and higher mortality risk in patients with heart failure. 1 These findings suggest advanced disease with elevated filling pressures and should prompt aggressive medical optimization including consideration for device therapy (ICD, CRT) given the severely reduced ejection fraction 1.

Clinical Context in This Patient

Given this patient's multiple comorbidities (diabetes, hypertension, COPD, peripheral vascular disease), the physical examination should specifically assess for:

  • S3 gallop as the hallmark finding indicating volume overload and elevated left ventricular end-diastolic pressure 1
  • Functional mitral regurgitation murmur due to severe left ventricular dilation 1
  • Signs of right heart failure (elevated JVP, tricuspid regurgitation murmur, hepatomegaly, peripheral edema) which commonly develop in advanced dilated cardiomyopathy 1

References

1
Guideline

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Dr.Oracle Medical Advisory Board & Editors, 2025

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