Gallop Rhythm of the HeartII. Quadruple Rhythm and its Relation to Summation

and Augmented Gallops

By JOSEPH GRAYZEL, M.D.

The 2 fundamental types of gallop are ventricular gallop and atrial gallop. Adequatecardiac acceleration modifies these gallops and may produce a summation gallop, an aug-

mented ventricular gallop, or an augmented atrial gallop. The summation and augmentedgallops were examined and their relation to the 2 fundamental gallops was quantitated.The cardiac rate at which summation and augmentation occur is unique. A graph and2 corresponding equations were derived which relate the summation cardiac rate andcorresponding cycle length to familiar electrocardiographic and phonocardiographicintervals.

G ALLOP rhythm has been defined as a"mechanical hemodynamic event associ-

ated with a relatively rapid rate of ven-tricular filling and characterized by aventricular bulge and a low-frequencysound."' From this definition it follows thatthe cardiac gallop is a diastolic event. Ofthe 5 divisions of diastole-protodiastole ofWiggers, isometric ventricular relaxation,rapid ventricular filling, slow ventricularfilling, and atrial contraction-a relativelyrapid rate of ventricular filling occurs dur-ing 2 periods, the rapid-filling phase, whichfollows immediately upon opening of theatrioventricular valve, and the atrial phase,which follows contractiomi of the upper cham-l)er. Two corresponding types of gallop exist.These are the rapid-filling (or ventricular)gallop and the atrial gallop, respectively.Both types of gallop are ventricular phe-nomena and each may be generated in eitherventricle. Therefore, it is desirable to specifywhether a gallop originates from the rightor left side of the heart.

Gallop may occur at any heart rate. Asso-ciated mechanical aspects of the gallop have

From the Departments of Medicine, Duke Univer-sity School of Medicine, Durham, N.C., and NewYork University College of Medicine, New York,N.Y.

This investigation was supported in part by Re-search Fellowship 8557 from the National Heart In-stitute, U. S. Public Health Service.

been recorded with the electrokymogram,2slit roentgenkymogram,3 ballistocardiogram,4'5and apex cardiogram.'

Ventricular gallop appears indicative ofdiastolic overload. It occurs with an abnormalrelation between the rate of rapid filling andthe ventricle's ability to accommodate its in-creasing diastolic volume. The wave of rapidleft ventricular filling is increased in mitralinsufficiency, ill which left atrial volume islarge, the atrial pressure is high, and mitralstenosis is not of a decree to restrain the rateof flow from atrium to ventricle.

In aortic insufficiency the regurgitamitblood stream augments left ventricular fillingand the total rapid-filling wave exceeds thatnormally present.

Left-to-right shunts at the ventricularlevel or between the great vessels result inincreased left ventricular diastolic filling andstroke volume. Examples are interventricularseptal defect, patent ductus arteriosus, andaortic-pulmonary window.

Interatrial septal defect increases diastolicfilling of the right ventricle and rapid-fillinggallop of the right ventricle may occur.More common than ventricular gallop due

to an increased filling wave is ventriculargallop due to altered accommodation duringthe volume changes of diastole. The most fre-quent cause is heart failure, in which theventricle is dilated and myocardial tone ispoor.

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Left ventricular gallop occurs 0.15 secondafter the onset of the second heartsound.1' 4'4' 7 An exception is mitral insuffi-ciency, in which this gallop begins 0.10 secondafter the second heart sound1 due to earlieropening of the mitral valve when left atrialpressure is elevated, ending a shortened pe-riod of isometric ventricular relaxation.

Atrial gallop appears indicative of systolicventricular overload. It is generated on theleft side of the heart in essential hyperten-sion and aortic stenosis, and on the right sidein pulmonary hypertension of varied etiologyand in pulmonic stenosis.When atrial gallop is present in essential

hypertension, there is invariably evidence ofleft ventricular hypertrophy, either fromphysical examination, roentgenograms, orthe electrocardiogram' 8 The atrial gallopwill often persist when the blood pressurein a known hypertensive person is withinnormal range. This observation suggests thatthe ventricular changes, rather than the ele-vated blood pressure per se, are essential forthe production of this presystolic gallop. Inthe known hypertensive person the presenceof an atrial gallop warrants a diagnosis ofhypertensive heart disease.The interval from the onset of the P wave

of the electrocardiogram to the left atrialgallop is 0.14 second.1' 6, 9 The inaudible vi-brations of mechanical atrial contraction occurearlier than the atrial gallop. Many of theatrial sounds heard in various degrees ofheart block occur later than true atrial gallop.

Quadruple rhythm denotes the presence of4 heart sounds. The special case of concernhere is quadruple rhythm due to the occur-rence of both left ventricular and left atrialgallops in addition to the normal first andsecond heart sounds.As the heart rate increases, the cycle length

decreases, principally at the expense of dias-tole. More specifically, the period of slowventricular filling is shortened and even to-tally eliminated with tachycardia of sufficientdegree. At this point a slight additional in-crease in rate results in superposition and

summation of the rapid-filling phase andatrial contraction (summation phenomenon).When both the rapid-filling and atrial gal-lops are present, they are superimposed assummation occurs. The resulting single, in-tense gallop is called summation gallop. Thesingle sound is usually much louder thanwould be obtained from simple addition ofthe 2 component sounds; this gives the im-pression that the intensities are multipliedrather than summed as the name implies.When the summation gallop occurs, me-

chanical and auscultatory aspects of the 2component gallops appear summated. Thereis summation of the respective ventricularthrusting forces as well as summation of thesounds.A rapid ventricular filling gallop is greatly

intensified when a previously silent phase ofatrial contraction is superimposed upon it byan increased heart rate. The single ventricu-lar gallop intensified by this mechanism isaugmented both mechanically and acousti-cally, and is called augmented ventriculargallop. Similarly, an atrial gallop superim-posed upon a silent period of rapid ventricu-lar filling is intensified and is called aug-mented atrial gallop. Thus, the mechanismof the augmented gallop and the true sum-mation gallop is similar in that superpositionof the rapid ventricular filling period andthe period of atrial contraction is essentialto both.The intensity of an augmented gallop and

the loudness of the true summation gallopmake these easily audible . and probably ac-count for the repeated statement that a gallopis only heard during tachycardia.A single loud gallop sound present during

tachycardia may be either an augmentedgallop or a true summation gallop. The dis-tinction can be made only when the heartrate is slowed. The summation gallop willchange to a quadruple rhythm at the slowerrate. The augmented gallop will only decreasein intensity, the sound remaining single. Ifan augmented ventricular gallop is present,the sound will retain its relation to the

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second heart sound and remain in early dias-tole. If an augmented atrial gallop is present,the sound will retain its relation to the Pwave and remain presystolic.

METHOD AND MATERIALSPhonocardiogramiis were recorded simultaneous

with the electrocardiogram and apex cardiogramon a Sanborn Twin-beam at a paper speed of75 mmll. per second with vertical time lines at0.04 second. The patients were in the supineposition.The method for recording. local precordial move-

muents has been described previously.' An upwarddeflection on the apex cardiogram represented aforward movement in the region of maximumcardiac pulsation.

Observations on 5 patients with gallop soundsand the pertinent clinical details are presented.Quadruple rhythm due to the presence in eachcardiac cycle of both the rapid-left-ventricular-filling gallop and the left atrial gallop was recordedin 2 patients. The various time intervals associatedwith these gallops have been included among pre-vious observations.' An augmented gallop or atrue summation gallop was recorded in 3 patients.

CASE REPORTSCase 13

E.C. was a 52-year-old Negro with a historyof progressive exertional dyspnea for 2 years andrecent orthopnea. On physical examination theblood pressure was 180/110, there was grade-IIhypertensive retinopathy, and rales were presentat both lung bases. The heart was moderately en-larged, and no murmurs were audible. Excursionsat the point of maximum cardiac pulsation werecomplex: a prominent early diastolic bulge waspresent as well as a presystolic bulge, the lattergiving the impression of a double systolic impulse.Upon auscultation the normal first and secondheart sounds were* easily identified. Two low-pitched sounds were present in diastole. The firstoccurred soon after the second heart sound andcorresponded in timing to the early diastolie, leftventricular bulge. The second low-pitched soundoccurred with the presystolic bulge.A phonocardiogram (fig. 1) showed the low

frequency (fundamental 25 c.p.s.) early diastolicsound occurring 0.16 second after the second heartsound. The presystolic sound was also of low fre-quency (fundamental 25 c.p.s.) and followed theP wave by 0.12 second. Both diastolic sounds oc-curred simultaneously with a prominent ventricu-lar bulge on the apex cardiogram, indicating thepresence of rapid-filling gallop and atrial gallop.respectively.

Comment. Atrial gallop of the left heart, whichis associated with systolic overload of the leftventricle, was caused in this patient by essentialhypertension. The electrocardiogram was normal.Rapid-filling gallop, which accompanies diastolicoverload, in this ease was the result of heartfailure.

Case 14

W.O.H. was a 24-year-old white man who hadexperienced recurrent episodes of acute hemnor-rhagic glomierulonephritis since childhood. In 1954hypertension and impaired renal function werepresent. In 1958 he was hospitalized for severeheart failure and terminal renal failure. At thistime the blood pressure was 180/110. There wasgrade-III hypertensive vascular retinopathy. Raleswere heard over both lung fields. The heart was en-larged to the anterior axillary line. No murmurswere audible. The cardiac pulsations were undu-lating in character and suggested myocardial dis-ease. A relatively distinct forward movementcould, however, be consistently discerned in earlydiastole and was more distinct than the svstolicimpulse. Coincident with this early diastolic bulgewas a low-pitched sound, loudest near the apicalregion. A faint presystolic sound of low pitchwas also heard at the apex, but was loudest in theleft fourth interspace. The neck veins were dis-tended, the liver was tender and enlarged, andthere was 4-plus pitting edema of the legs andankles.The hematocrit value was 22 per cent and the

blood urea nitrogen was 228 mg. per 100 ml. Theelectrocardiogram was within normal limits. Aphonocardiogranm recorded both diastolic soundswith fundamental frequencies of 35 and 50 e.p.s.,respectively. The early diastolic sound was loudestnear the apex (fig. 2B) and the presystolic soundwas loudest in the left fourth interspace (fig. 2A).The apex cardiogram (fig. 2C) illustrated the un-dulating cardiac movement felt through the chestwall. However, a prominent early diastolic bulgeappeared consistently, simultaneous with theearly diastolie sound, and indicated the presenceof a rapid-filling gallop. A frank presystolic bulgesimultaneous with the atrial presystolic gallopsound was not demonstrable. Presumably, thepresystolic undulating wave occurring with thesound was in part due to the gallop bulge.

Contient. The atrial presystolic gallop in thiscase reflected hypertensive heart disease resultingfrom hypertension of 4 years' duration, secondaryto renal disease. Left ventricular hypertrophy wasconfirmed at postmortem examination, althoughelectrocardiographic evidence of hypertrophy wasnot present. The rapid-filling gallop reflected the

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FIG. 1 Top. Case 13. Phonocardiogram. with simul-taneous electrocardiogram, lead I (A), and apex

cardiogram (B). The ventricular gallop (vG) occurs

in early diastole. The presystolic atrial gallop (aG)follows the P wave hut precedes the QRS complex.The first andl second heart sounds are indicated by

1 and 2, respectively. Each gallop sound (vG and

aG) occurs simultaneously with a gallop bulge (G).In the second cycle in B a definite ventricular gallopsound was not recorded though the gallop was stilliresent, as evidenced by a prominent precordial move-

ment (G) in early diastole.FIG. 2 Bottom. Case 14. A. Phonocardiograra in the

fourth interspace left of the sternum and simultane-otis electrocardiograni, lead I. The presystolic atrial

gallop sound is prominent while the early diastolicventricular gallop sound is very soft. B. Phono-cardiogram at the cardiac apex and simultaneouselectrocardiogram, lead I. In this location the ven-

tricular gallop sound is louder than the atrial gallopsound. C. Simultaneous phonocardiogram and apex

cardiogram. A sharp, prominent precordial bulge con-

sistently occurs with each ventricular gallop sound.The atrial gallop sound is not accompanied by sucha definite movement. The undulating wave at thetime of the atrial gallop sound is probably due, inpart, to the gallop bulge.

mnyocardial failure. It is commonly found, as inthis case, that the atrial and ventricular gallopsounds are loudest in different areas of the pre-cordium.

Case 15L.L. was a 51-year-old obese Negro with known

hypertension for 6 years and symptoms of con-gestive heart failure during the 3 years prior tothis hospitalization for severe dyspnea, orthopnea,and massive edema.The blood pressure was 192/130 with 12 nmm.

of systolic alternation. The minute pulse rate was107. The ocular fundi showed grade-II hyperten-sive vascular changes. There were basilar rales inboth lungs. The heart was enlarged to the anterioraxillary line. No murmurs were audible, but 3heart sounds were present: the first sound wassoft, and the second sound and the extra diastolicsound were of equal intensity, but the latter wasof low pitch. The chest wall was obese and adiastolic ventricular bulge could not be detected.The neck veins were distended and there was 4-plus pitting edema of the ankles, legs, and lowerthighs. An electrocardiogram showed left axisdeviation but no evidence of hypertrophy.A phonocardiogram (fig. 3) demonstrated the

diastolic sound of low frequency (fundamental 50cycles per second) which occurred 0.15 secondafter the second heart sound and 0.13 second afterthe P wave of lead II. A satisfactory apex car-diogram could not be recorded through the obesechest wall.Comment. The diastolic gallop sound followed

the second heart sound by the proper interval fora rapid-filling left ventricular gallop and followedthe P wave by the proper interval for a left atrialgallop. It is justified to conclude that the summa-tion phenomenon was present. Subsequently. witha minute cardiac rate of 90, quadruple rhythmwas present due to the occurrence of the ventricu-lar and atrial gallops separately with each cardiaccycle. Therefore, the single diastolic sound re-corded at a heart rate of 107 represented a truesummation gallop as opposed to an augmentedgallop as defined above. Atrial gallop in this hy-pertensive patient indicated inyocardial hyper-trophy. Ventricular gallop was the result of dias-tolic ventricular overload secondary to heartfailure.

Case 16W.I. was a 32-year-old Negro who had been

observed for 21/2 years with congestive heart fail-ure. The clinical impression was "idiopathic myo-cardial failure," commonly seen in young Negroes.At this time the blood pressure was 120/70 andthe minute pulse 108. Basilar rales were heardbilaterally. The heart was enlarged well to the

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anterior axillary line. A blowing grade-II apicalsystolic murmur was audible. A loud low-pitcheddiastolic sound was present and coincided with arelatively large forward movement of the region ofmaximum cardiac pulsation. The liver descended 1fingerbreadth below the right costal margin and wastender. There was 1-plus ankle edema. An electro-cardiogram was within normal limits.A phonocardiograin (fig. 4A) demonstrated the

gallop sound occurring 0.16 second after thesecond heart sound and 0.13 second after the Pwave of lead II. The simultaneous ventricularbulge on the apex cardiogram was striking (fig.4B).

Comment. The time interval from the secondheart sound to the gallop was appropriate for ara pid-filling left ventricular gallop. The intervalfrom the P wave to the gallop was appropriatefor a left atrial gallop. Thus, the summation phe-nomnenon is present. At a slower cardiac rate thegallop remained single, was of less intensity, andmaintained its relation to the second heart sound.The record shown (fig. 4) is therefore, an ex-ample of an augmented ventricular gallop.

Case 17J.H.S. was a 35-year-old white man who had been

observed for 2 years with heart failure. The clini-cal impression was "idiopathic myoeardial failure."There was never any evidence of hypertension orcoronary artery sclerosis. The blood pressure was105/90 and the minute pulse 104. The ocularfundi were unremarkable. Rales were heard atboth lung bases. The heart was moderately en-larged. A very low pitched diastolic sound wasaudible and coincided with a prominent apicalbulge. This gallop sound was the loudest of the 3heart sounds. The first heart sound was particu-larly soft. The neck veins were slightly distendedand there was 3-plus ankle edema. An eleetrocar-diogram showed complete left bundle-branch block.A phonocardiogram (fig. 5A) demonstrated a

gallop sound of high intensity and low frequency(fundamental 4,5 e.p.s.), which occurred simulta-neously with the sharp spike on the apex eardio-gram (fig. 5B).Comment. The simultaneous sharp ventricular

bulge established the diastolic sound to be :agallop. It occurs 0.13 second after the secondheart sound, which is slightly less than the meanvalue for this interval but still appropriate for aleft ventricular gallop. The P wave was lost inthe preceding T wave with a P-R interval of 0.20to 0.22 second. The interval between the P waveand the gallop was in the range appropriate for aleft atrial gallop. The great intensity of the gallopcompared to the first and second heart soundsfurther supports the conclusion that the summa-

FIG. 3. Case 15. Simultaneous phonocardiograni andelectrocardiogram, lead II. A summation gallop oc-curs in iiiid-diastole; it follows the second heart soundby 0.15 second amid the P wave by 0.13 second, andclearly precedes the QRS complex.

tion phenomenon was present. This patient wasnot observed at a slower cardiac rate and we aretherefore unable to say whether the gallop was a

true sunmmation gallop or ail augmented gallop.

DISCUSSIONOver the range of cardiac rates usually

encountered the rapid-filling or ventriculargallop sound bears a constant relation to thesecond heart sound.1 The mean value for theinterval between the second heart sound andthe left ventricular gallop (2-vG interval) is0.15 second. The ventricular gallop ill mitralregurgitation is a special case and is notincluded in the calculatioim of this mean value.The left atrial gallop follows the P wave

(P-aG interval) by 0.14 second. When ear-diac acceleration is sufficient to eliminate theperiod of slow ventricular filling and causesuperposition of the ventricular and atrialgallop sounds, the true summation gallop re-sults. Therefore, the true summation gallopshould possess those timing features character-istic of its 2 component gallops. It shouldfollow the second heart sound by 0.15 secondand follow the P wave by 0.14 second. Itbecomes evident that the heart rate at whichprecise summation occurs is not a matter ofchance but is uniquely determined by thedifferent time intervals that comprise a singlecardiac cycle.

Figure 6 illustrates a single auscultatorycardiac cyele from one first heart sound tothe n-ext. The second heart sound and thesummation gallop are also indicated. Above

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FIG. 4 Top. Case 16. A. Simultaneous phonocardio-gram and electrocardiogram, lead I. The mid-(1iastolicgallop sound follows the second heart sound by 0.16second, follows the P wave by 0.13 second, and pre-cedes the Q-RS complex. B. Simultaneous phonocardio-gram and apex cardiogram. The gallop sound is bestseen in the secon(l cycle show n. The transmlittelgallop bulge is large, prominent, and consistentlypresent. The minute heart rate is 107.

PIG. 5 Bottom. Case 17. A. Simultaneous phono-eardiogrammi and electrocardiogram, lead I. Completeleft bundle-branch block is present. The P waveoccurs during the end of the T wave with a P-Rgallop (G) is the loudest of the 3 heart sounds. Itimiterval of 0.20 to 0.22 second. TIle mid-diastolicfollows the second heart sound (2) by 0.13 second,follows the P wave by approximately 0.12 second,and precedes the QRS complex. The first heart sound(1) is very soft. B. Simultaneous phonocardiograiinand apex cardiogram. The undulating precordial move-mnent is indicative of severe myocardial disease. Amidstthese undulations is a sharp, distinct gallop bulge(G) simultaneous with the gallop sound. The gallopbulge produces the most prominent of the precordialmovements. The minute heart rate is 102.

the auscultatory cycle is the simultaneouselectrocardiogram showing the P wave andthe QRS complex. The single cycle is dividedinto intervals to enable calculation of thecycle duration at which the summation gallopoccurs. The duration of this cycle is the sumof its component subdivisions as constructed.We observe from figure 6 thatSummation cycle length (seconds/eycle) =

S+(2-vG)+(PR)-(P-aG)+(Q-1) (1)This expression is accurate for any given

case but is cumbersome for general use. It issimplified by substituting for some of theintervals their numerical mean values. Thefollowing values are employed: S = 0.29second. This is the interval between the firstand the second heart sounds at a cardiac rateof 109. This rate lies in the middle range ofrates at which summation occurs. (2-vG) =0.15 second. (P-aG) = 0.14 second. Theseare the most accurate mean values to 2 sig-nificant figures for the left heart. The P-aGinterval was determined in hypertensiveheart disease, which is the most frequentcause of left atrial gallop. It may be a validmean for other conditions of systolic over-load, such as aortic stenosis, but such a statis-tical study is not available. (Q-1) = 0.07second. This is the mean value for this in-terval in hypertensive heart disease.i, 10

The P-R interval is left as a variable sinceits variations are random and occur over awide range.On substitution of the above values, equa-

tion 1 becomes

Summation cycle length (seconds/cycle) =(0.29) + (0.15) +PR-(0.14) + (0.07)

seconds/cycle = 0.37 + PR (2)

Taking reciprocals on both sides of equation2 yields

c~ycles'second = +0.37 ± PR

Multiplication by 60 gives minute heart rate60

cycles/min. = 0.37 -- PR (3)

Equation 3 provides a useful relation be-tween the heart rate in beats per minute

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(PR)- (RAG)"PRR ORS

-(PAG)

2 :G

S) \2-vG)-~iQ)

(PR)- (RAG)

CYCLE LENGTH (S)+(2-vG)+~'PR)- (PAG) + (Q-1)

~~~~~~~~~RAPID-T 1WL~~~~~FILLIN IGALLOPGALP WIT

~~~~~~PR~ ~~~~INTERVAL CYL

67 0.90

86

100

109

120' 'I I --I- -ji+i+I4 +- -] 0.500O1 0.2 0.3 0.4 OS 0.6 037 0.8 0.9 SECOND

FIG. 6 Top. Schematic representation of simultane-ous electrocardiogram (upper tracing) and phono-cardiogram (lower tracing) for a single auscultatorycycle in which the summation phenomenon occurs

precisely. Then, the gallop sound (G) should possess

the timing features of both a rapid-filling gallopand an atrial gallop. The single cycle is then dividedinto intervals to enable calculation of the cycle lengthin terms of known quantities. The P wave and theQRS complex are labeled as such. 1, first heart sound;2, second heart sound; G, summation gallop or aug-

mented gallop; S, duration of auscultatory systole;2-vG, interval from the second heart sound to therapid-ventricular-filling gallop; PR, electrical P-R(P-Q) interval; P-aG, interval from onset of theP wave to the atrial gallop; Q-1, interval from onsetof the QRS complex to the first heart sound.

FIG. 7 Bottom. Graphic representation of a singleauscultatory cycle from one first heart sound to the

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at which precise summation occurs (i.e., thesummation rate) and the P-R interval inseconds. Table 1, column 2, lists correspondingvalues for the summation cardiac rate and theP-R interval, as calculated from equation 3.The relation expressed by equations 2 and

3 is depicted graphically in figure 7. Thisgraph was constructed by employing themean values for the 2-vG, P-AG, and Q-1intervals. The horizontal width of the figureat any level represents the duration of asingle cycle at the corresponding heart rate.The timing of the first, second, rapid-fillinggallop, and atrial gallop sounds is indicatedby the appropriate straight line. The time ofoccurrence of the atrial gallop depends uponthe timing of the P wave and therefore willvary with the P-R interval. The point of in-tersection of the time lines representing therapid-filling and atrial gallops is the pointof precise or complete summation. Theordinate or horizontal level of this pointgives the cycle duration or the cardiac rateat which summation occurs. The graph illus-trates the dependence of the summation car-diac rate upon the P-R interval.The summation rates for various P-R in-

tervals, determined from the graph, arelisted in table 1. At a P-R interval of 0.18second the summation rate is 109 and isidentical with that obtained from equation 3.

next. Cycle duration in seconds is represented on

the vertical axis (ordinate) and appears on the right;the corresponding minute heart rate appears on theleft. Distance along the horizontal axis (abscissa)represents time elapsed from the first heart soundthat begins the cycle. The constant relation betweenthe second heart sound and the rapid-filling gallop isrepresented by respective parallel lines 0.15 secondapart. The constant relation between the P wave andthe atrial gallop results in a constant interval fromthe atrial gallop to the ensuing first heart sound fora given P-R interval. The lines representing the timeof atrial gallop for a given P-R interval and theensuing first heart sound are parallel and the distancebetween them is PR - (PAG) + (Q-1) = PR - 0.14+ 0.07 = PR 0.07 (in seconds). The intersectionof the 2 time lines representing the 2 gallops is thepoint of precise summation. The ordinate of thispoint is the summation rate (left of figure) or thesummation cycle length (right of figure).

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TABLE 1.-Summation Rate as a Function of theP-R Interval

Summation rate, beats per minute,calculated from

P-R interval(sec.) Equation 3 Graph (fig. 7)

0.14 118 120

0.16 113 114

0.18 109 109

0.20 105 104

0.22 102 100

This precise agreement reflects the substitu-tion in equation 1 of 0.29 second for S, theduration of auscultatory systole at a minuteheart rate of 109. The graph of figure 7takes account of the slight variation of sys-

tole with heart rate, and is more accurateto this degree than is equation 2 or 3. Never-theless, in the range of normal P-R intervalsthe error of equation 3 resulting from thesubstitution of a constant value for S is lessthan 2 per cent.

These calculations may be extended to in-(lude the augmented ventricular gallop andthe augmented atrial gallop. When ventricu-lar gallop alone is present, cardiac accelera-tiomn can superimpose this gallop on the timewhen atrial gallop would occur (i.e., 0.14second after the onset of the P wave). Theventricular gallop is then augmented, as evi-denced by the marked increase in sound in-tensity and often by the magnitude of theventricular bulge. The same is true for an

existing atrial gallop superimposed upon theappropriate portion of the rapid-filling pe-

riod (i.e., 0.15 second after the onset of thesecond heart sound). Therefore, equations 2and 3 and the graph are valid for the 2types of augmented gallop as well as for thetrue summation gallop.The fortuitous timing of a premature atrial

contraction can momentarily superimpose thephase of atrial contraction upon the periodof rapid-ventricular filling and thereby pro-duce the summation phenomenon. When bothventricular and atrial gallops are present, andthe premature P wave begins 0.14 second

before the ventricular gallop, the 2 gallopsare superimposed to produce a summationgallop. If only a ventricular gallop wereoriginally present, the same premature atrialcontraction will momentarily augment the ex-isting ventricular gallop. For the abbreviatedcycle which is ended by the premature atrialcontraction equation 2 is valid and expressesthe duration of the shortened cycle in termsof the P-R interval of the premature atrialsystole, only if the summation phenomenonhas occurred. Conversely, if the values forthe P-R interval of the premature atrial sys-tole and the length of the abbreviated cyclesatisfy equation 2, then summation certainlyhas occurred. Reexamination of figure 6provides a visual aid in understanding suni-mnation due to a premature atrial contrac-tion. One must now imagine that the P waveand the QRS complex shown are those of thepremature atrial contraction, which has en-croached upon the normal diastolic periodto produce summation.

Clinical Significance. The true summationgallop and the augmented gallops occur whenthe heart rate is sufficiently fast. The signifi-(cance of the true summation gallop is thatof its 2 components. The significance of theaugmented gallop is that of the single gallopidentified when the heart rate is slower.Summation and augmentation only reflect thenore rapid heart rate.

SUMMARY

Adequate cardiac acceleration will super-impose the phase of atrial contraction uponthe period of rapid ventricular filling. Thesuperposition of these 2 periods is called thesummation phenomenon. The cardiac rate atwhich precise summation occurs and its corre-sponding cycle length are termed the sum-mation rate and the summation cycle length,respectively.Both the ventricular gallop and the atrial

gallop may be present in each cardiac cycle,producing a quadruple rhythm. When car-diae acceleration is sufficient to produce thesummation phenomenon, the 2 gallops are

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superimposed to produce the true summationgallop.When a ventricular or ail atrial gallop

alone is present the summation phenomenonwill augment the intensity of the existinggallop. It is then called augmented ventricu-lar gallop or augmented atrial gallop, re-spectively.A single, loud gallop present during tachy-

cardia may be either an augmented gallopor a true summation gallop. The distinctioncan be made only when the heart rate isslowed, at which time the true summationgallop will change to a quadruple rhythmwhile the augmented gallop remains a singlesound of reduced intensity.Examples of quadruple rhythm, summation

gallop, and augmented gallop are shown.Two equations were derived that express

the summation cycle length or the summationrate, respectively, as a function of the P-Rinterval. A graphic representation of thisrelation was also constructed. Of the criticaltime intervals the P-R interval is the onlyrandom variable affecting the summationrate, and its range is the largest.The equation for the summation cycle

length is also valid when the summation isproduced by a premature atrial contraction.The cycle in which summation occurs is theshortened cycle, prematurely ended. Theduration of such a summation cycle is a func-tion of the P-R interval of the prematureatrial contraction, as expressed by the equa-tion derived for the more usual case of sum-mation resulting from cardiac acceleration.

SUMMARIO IN INTERLINGUA

Adequate acceleration cardiac imupone lephase de contraction atrial super le periodode rapide replenation ventricular. Le super-imposition de iste duo periodos es appellatele phenomeno de summation. Lie frequentiacardiac al qual un summation precise occurree le correspondente longor de cyclo es de-signate, respectivemente, como le frequentiade summation e le longor de evelo de sum-mation.

Tanto le galopo ventricular (,onio etiamn legalopo atrial pote esser presente in un cyclocardiac individual, con le resultante produc-tion de un rhythmo quadruple. Quanido leacceleration cardiac es sufficieiitciiiemete iii-tense pro producer le l)lieilomelio de sumin-mation, le duo galopos es superinlpollite ieun al altere con le resultante production delver galopo de summation.Quando un galopo ventricular sol o un

galopo atrial sol es presente, le phenomenade summation augmenta le intensitate delgalopo existente. Alora illo es appellate uimaugmentate galopo ventricular o, respective-miente, un augmentate galopo atrial.Un sol e forte galopo que es presetite diir-

ante tachycardia pote esser (1) uii galopoaugmentate o (2) un ver galopo de summa-tion. Le distinction inter le duo pote esserfacite solmente post retardar le frequentiacardiac, quando le ver galopo de summationse transforma in un rhythmo quadruple,durante que le galopo augmentate remanaie 1msol sono de intensitate reducite.Es presentate exemplos de rlhytliiiio quad-

ruple, de galopo de summation, () (de galopoaugmentate.

Esseva derivate duo equatioiies que ex-prime, respectivemente, le longor de cyclo desummation e le frequentia de summationomo funetiones del intervallo P-R. Un re-

p)resentation graphic de iste relation esseva

etiam construite. Inter le critic intervallosde tempore, le intervallo P-R es le sol varia-bile de hasardo que affice le frequentia desummation, e su gamma de valores possibilees le plus extense.Le equation pro le longor de cyclo de sum-

mation remane valide quando le summationes producite per un premnatur contractionatrial. Le cyclo in que le summation occurrees le cyclo abbreviate con termination pre-matur. Le duration de un tal cyclo de summa-tion es un function del intervallo P-R delcontraction atrial prematur, exprimite per leequation que es derivate pro le easo plususual de summation resultante ab accelerationcardiac.

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GRAYZELL

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7. WOLFERTH, C. C., AND MARGOLIES, A.: Gal-lop rhythm and the physiological thirdheart sound. Am. Heart J. 8: 441, 1933.

8. WEITZMAN, D.: The mechanism and signifi-cance of the auricular sound. Brit. Heart J.17: 70, 1955.

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9lThou, wondrous Harvey, whose Immortal Fame,By thee instructed, grateful Schools proclaim,Thou, Albion's Pride, didst first the winding Way,And circling Life's dark Labyrinth display.Attentive from the Heart thou didst pursueThe starting Flood, and keep it still in view,Till thou with Rapture saw'st the Channels bringThe Purple Currents back, and from the Vital Ring

SIR RICHARD BLACKMORE, Creation. A Philosophical Poem Demonstrating the Existenceand Providence of a God. In Seven Books. Svo. London, 1712. [Blackmore, who wentfrom schoolmaster to physician in ordinary to William III ("His pupils grew blockheadsand his patients died.") was violently attacked by Pope, Dryden and Swift, but nothinggagged his muse, and the equally intemperate praise lavished on the "Creation" by Dr.Johnson, Addison and Dennis seemed to justify him.]

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JOSEPH GRAYZELSummation and Augmented Gallops

Gallop Rhythm of the Heart: II. Quadruple Rhythm and its Relation to

Print ISSN: 0009-7322. Online ISSN: 1524-4539 Copyright © 1959 American Heart Association, Inc. All rights reserved.

75231is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TXCirculation

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