Isolated Fourth Heart Sound
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A 77-year-old man with a history of coronary artery bypass grafting presented with general fatigue and dyspnea on effort. He was classified as having New York Heart Association functional classification III heart failure symptoms. His brain natriuretic peptide level was elevated at 569 pg/mL. Initial physical examination on admission to the general ward revealed bradycardia with a pulse rate of 32 beats per minute and an apparent atrial gallop created by the fourth heart sound immediately before the first heart sound. Furthermore, an additional low-pitch …