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Abstract Aims A fourth heart sound (S4) was reported to be almost never present in patients with amyloid light‐chain cardiomyopathy. There have been no reports on S4 in patients with wild‐type transthyretin amyloid cardiomyopathy (ATTRwt‐CM). This study aimed to clarify the clinical implications of S4 in patients with ATTRwt‐CM. Methods and results Seventy‐six patients with ATTRwt‐CM (mean age: 80.4 ± 5.4 years, 68 males) who had undergone phonocardiography (PCG) were retrospectively assessed. We measured S4 amplitude on digitally recorded PCG. S4 was considered to be present when its amplitude was 1.0 mm or greater on the PCG. Distinct S4 was defined as S4 with an amplitude of 2.0 mm or greater, which is usually recognizable by auscultation. According to the rhythm and presence or absence of S4, the patients were divided into three groups, namely, sinus rhythm (SR) with S4, SR without S4, and non‐SR. Non‐SR consisted of atrial fibrillation, atrial flutter, and atrial tachycardia. Thirty‐six patients were in SR and the remaining 40 patients were in non‐SR. In the 36 patients in SR, S4 was shown by PCG to be present in 17 patients (47%), and distinct S4 was recognized in 7 patients (19%) by auscultation. In patients who were in SR, those with S4 had higher systolic blood pressure (124 ± 15 vs. 99 ± 8 mmHg, P |