AuscultifyS3 Kentucky, S4 Tennessee: The Gallop Mnemonic Explained
S3 is Kentucky and S4 is Tennessee. Say "Ken-TUCK-y" and you hear lub-dub-DUH, which is S1, S2 and then the extra S3 in early diastole. Say "TEN-nes-see" and you hear DUH-lub-dub, which is the extra S4 in late diastole followed by S1 and S2. If you have ever written it the other way round, this page will fix it permanently.
The mnemonic in one table
| S3 gallop | S4 gallop | |
|---|---|---|
| Word | Ken-TUCK-y | TEN-nes-see |
| Cadence | lub-dub-DUH | DUH-lub-dub |
| Sequence | S1, S2, S3 | S4, S1, S2 |
| Extra beat falls | At the end, just after S2 | At the start, just before S1 |
| Phase | Early diastole | Late diastole (presystole) |
| Other name | Ventricular gallop, protodiastolic gallop | Atrial gallop, presystolic gallop |
Why the syllables match the sounds
The mnemonic works because both words have three syllables with a distinctive stress pattern, and the stress pattern mimics the loudness and spacing of the sounds in a gallop rhythm.
In Ken-TUCK-y the first two syllables are close together with the accent on the second, like S1 and S2, and the third syllable is a short, soft tail. That tail is the S3: a quiet, low-pitched thud that arrives shortly after S2 while the ventricle is filling rapidly. There is then a pause before the next "Ken", which is the rest of diastole.
In TEN-nes-see the stress lands on the first syllable and the second and third run together. That first stressed syllable is the S4 and the "nes-see" is S1 and S2 crowded up behind it. Because S4 is produced by atrial contraction, it sits right up against S1, and the word reproduces that crowding.
The stress placement is the whole trick. Say each word out loud at about 70 beats a minute and tap the rhythm on the table. That is the cadence you are listening for at the apex. For the physiology behind each sound see S3 heart sound and S4 heart sound.
The common mistake: "S3 Tennessee, S4 Kentucky"
Students swap the states constantly, and the search phrase "S3 Tennessee S4 Kentucky" is nearly as common as the correct one. The reversal is understandable: both are three-syllable American states and nothing about the letters K or T obviously encodes a 3 or a 4. Two hooks keep them straight.
- Alphabetical order. K comes before T in the alphabet, and 3 comes before 4. Kentucky is the lower number, S3. Tennessee is the higher number, S4.
- Where the extra beat falls. Both words have three syllables, but the odd-one-out syllable is at the end of Kentucky and the start of Tennessee. S3 is the extra beat at the end of the lub-dub, so it is Kentucky. S4 is the extra beat before the lub-dub, so it is Tennessee.
A third hook, if you need one: Tennessee starts with a stressed "TEN" and S4 is the sound you get in hyper-TEN-sion, its commonest cause. Kentucky ends in a soft "y" and S3 is the soft sound at the end of a fail-ing heart's filling.
Other S3 and S4 mnemonics
If the states never stick for you, two alternatives encode the mechanism as well as the timing:
- S3 = "SLOSH-ing-in": lub-dub-DUH becomes SLOSH-ing-IN, the sound of blood sloshing into a floppy, volume-loaded ventricle during rapid filling. The stress and cadence match Kentucky exactly.
- S4 = "a-STIFF-wall": DUH-lub-dub becomes a-STIFF-wall, the atrium contracting against a stiff ventricular wall. Some teachers say it as "A-stiff-WALL" to keep the first syllable as the S4; either way the extra beat leads.
You can also lean on numbers. S3 comes after S2, so it is the third sound counted from S1 in one cycle. S4 comes before S1, so it is the fourth sound only if you count on into the next cycle, which is why it lands in presystole.
What each gallop means, briefly
S3 (Kentucky) is produced by rapid ventricular filling into a compliant or dilated ventricle. It is normal in children, young adults, athletes and pregnancy. In adults over about 40 it suggests volume overload or systolic heart failure, and it persists in atrial fibrillation because it does not need atrial contraction.
S4 (Tennessee) is produced by atrial contraction into a stiff ventricle. It is almost always abnormal in adults and points to hypertensive heart disease, left ventricular hypertrophy, aortic stenosis, hypertrophic cardiomyopathy or ischemia. It cannot occur in atrial fibrillation.
Both are low-pitched, best heard with the bell at the apex in the left lateral decubitus position. If both are present with a fast heart rate they can merge into a single summation gallop. The full side-by-side comparison is on the hub page S3 vs S4 heart sounds.
How to practise the cadence with audio
- Play a normal lub-dub recording and say "lub-dub" with it until the timing is automatic.
- Play an S3 recording and say "Ken-TUCK-y" over it. Notice the soft tail after S2.
- Play an S4 recording and say "TEN-nes-see" over it. Notice the lead-in before S1.
- Alternate S3 and S4 recordings without looking at the label and call the state out loud before you check.
- Once you are accurate, drop the words and just listen for whether the extra beat is at the end or the start of the cycle.
The words are scaffolding. The goal is to hear a gallop and know within two cycles whether the extra beat trails S2 or leads S1.
Hear Kentucky and Tennessee back to back in Auscultify
Auscultify has real S3 and S4 recordings captured at the apex. The Heart Sounds quiz mode plays them unlabelled so you have to commit to Kentucky or Tennessee before the answer appears, and spaced repetition brings back the one you keep getting wrong. The Spectrogram view (Pro) shows the extra beat sitting after S2 or before S1 so you can see the cadence as well as hear it.
Train gallops free →FAQ
Is S3 Kentucky or Tennessee?
S3 is Kentucky. Ken-TUCK-y has its stressed syllable in the middle and a soft extra syllable at the end, matching S1, S2 and then the extra S3 in early diastole: lub-dub-DUH.
Is it S3 Tennessee S4 Kentucky?
No, that is the common reversal. The correct pairing is S3 Kentucky and S4 Tennessee. Remember K comes before T in the alphabet just as 3 comes before 4.
What is a Kentucky gallop?
A Kentucky gallop is another name for an S3 gallop, the lub-dub-DUH rhythm of a third heart sound in early diastole. It is normal in young people and suggests volume overload or systolic heart failure in older adults.
What is the Tennessee heart sound?
The Tennessee heart sound is the S4 gallop, the DUH-lub-dub rhythm of a fourth heart sound just before S1. It is produced by atrial contraction into a stiff ventricle and is almost always abnormal in adults.
What is the best S3 vs S4 mnemonic?
Kentucky and Tennessee are the most widely used because they reproduce the cadence you actually hear. Backups are SLOSH-ing-in for S3, the sound of blood sloshing into a floppy ventricle, and a-STIFF-wall for S4, the atrium hitting a stiff ventricle.