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S3 heart sound is heard after the S2 heart sound (the sound made by the closure of the aortic and pulmonary valves following systole). It therefore happens in early-mid diastole, when the ventricles are beginning to fill.

The sound is caused by a vibration of the ventricles as they encounter blood flow. Though an S3 may be normal in children and young adults, in other populations it may indicate a pathology in 1) a higher than usual amount of blood returning to the ventricle (such as in hypervolemic states), or 2) a stiff ventricle that's more prone to reverberation (e.g. remodeling secondary to heart failure) .

S4 is also due to a vibration in the ventricle wall but occurs later in diastole, when contraction of the atrium forces the final amount of blood into the ventricles. The vibration occurs because the ventricle is too full to contain the additional blood. This can occur in pathologic states such as ventricular hypertrophy.

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