S₄ gallop in a patient with severe hypertension and left ventricular dysfunction

Phonocardiogram recorded at the apex in a 20-year-old patient with Takayasu aortitis associated with severe systemic hypertension and severe left ventricular dysfunction (ejection fraction 23 percent). In the recording, an S₄ is heard coincident with the P wave on the electrocardiogram during the period of atrial contraction.