"[1][full citation needed][2] One can also use the phrase "A-stiff-wall" to help with the cadence (a S4, stiff S1, wall S2), as well as the pathology of the S4 sound.

If the problem lies with the left ventricle, the gallop rhythm will be heard best at the cardiac apex.

If the problem is in the right ventricle, the abnormal sound will be most evident on the lower left hand side of the sternum and will get louder with exercise and quick, deep inspiration.

If the heart rate is also very fast (tachycardia), it can become difficult to distinguish between S3 and S4 thus producing a single sound called a summation gallop.

The S4 heart sound itself does not require treatment; rather plans should be laid to stop the progression of whatever causes the underlying ventricular dysfunction.