Dyspnea on exertion and fatigue - If severe there may be evidence of pulmonary edema (inspiratory crackles on auscultation, pleural effusions). Pulmonary hypertension and right ventricular failure may develop. - Late in diastole, arterial contraction with rapid ejection of blood into the noncompliant ventricle may give ride to an S4 gallop. EKG often reveals evidence of left ventricular hypertrophy, and chest xray shows pulmonary congestion without cardiomegaly. There also may be evidence of underlying coronary disease, hypertension, or valvular disease.