The fourth heart sound is a low-pitched sound coincident with late diastolic filling of the ventricle due to atrial contraction. It thus occurs shortly before the first heart sound. Although it is also called the atrial sound, and its production requires an effective atrial contraction, the fourth heart sound is the result of vibrations generated within the ventricle. Commonly, its presence indicates increased resistance to filling of the left or right ventricle because of a reduction in ventricular wall compliance, and it is accompanied by a disproportionate rise in ventricular end-diastolic pressure. In patients with a fourth heart sound, its palpable correlate is often present: a concomitant brief presystolic outward movement of the chest wall.