Which auscultation finding would support a diagnosis of angina pectoris in a patient with a significant smoking history?

A finding of S4, which is known as an "atrial gallop," can support a diagnosis of angina pectoris, particularly in a patient with risk factors such as a significant smoking history. The S4 sound is typically associated with increased left ventricular stiffness and can occur in conditions like hypertensive heart disease or ischemic heart disease, both of which can arise due to long-term smoking effects. The presence of an S4 indicates that the atria are contracting against a stiff or hypertrophied ventricle, often seen in patients with compromised cardiac function, such as those experiencing angina.

This finding is particularly relevant because angina pectoris itself is linked to myocardial ischemia, which may be exacerbated by risk factors like smoking that contribute to vascular pathology. Therefore, identifying an S4 during auscultation could suggest that the heart is under physical stress, aligning with the symptoms of angina.

In contrast, findings like S3, which signifies volume overload and heart failure, or a split S2, which could indicate various physiological or pathological states unrelated to angina specifically, do not directly correlate with the condition in question. S1, being the first heart sound associated with the closure of atrioventricular valves,