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The human heart: Application of the golden ratio and angle

Article  in  International Journal of Cardiology · June 2011

DOI: 10.1016/j.ijcard.2011.05.094 · Source: PubMed

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 International Journal of Cardiology 150 (2011) 239–242

Contents lists available at ScienceDirect

International Journal of Cardiology

j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / i j c a r d

Editorial

The human heart: Application of the golden ratio and angle

Michael Y. Henein a,⁎ and the Golden Ratio Collaborators: Ying Zhao a,b,1, Rachel Nicoll a,1, Lin Sun b,1,
Ashraf W. Khir c,1, Karl Franklin a,1, Per Lindqvist a,1
a
Department of Public Health and Clinical Medicine, and Heart Centre, Umea University, Sweden
b
Ultrasound department, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
c
Brunel Institute for Bioengineering, Brunel University, Middlesex, UK

a r t i c l e i n f o a b s t r a c t

Article history: The golden ratio, or golden mean, of 1.618 is a proportion known since antiquity to be the most aesthetically
Received 27 April 2011 pleasing and has been used repeatedly in art and architecture. Both the golden ratio and the allied golden
Accepted 14 May 2011 angle of 137.5° have been found within the proportions and angles of the human body and plants. In the
Available online 23 June 2011
human heart we found many applications of the golden ratio and angle, in addition to those previously
described. In healthy hearts, vertical and transverse dimensions accord with the golden ratio, irrespective of
Keywords:
human heart
different absolute dimensions due to ethnicity. In mild heart failure, the ratio of 1.618 was maintained but in
golden ratio end-stage heart failure the ratio significantly reduced. Similarly, in healthy ventricles mitral annulus
dimensions accorded with the golden ratio, while in dilated cardiomyopathy and mitral regurgitation patients
the ratio had significantly reduced. In healthy patients, both the angles between the mid-luminal axes of the
pulmonary trunk and the ascending aorta continuation and between the outflow tract axis and continuation
of the inflow tract axis of the right ventricle approximate to the golden angle, although in severe pulmonary
hypertension, the angle is significantly increased. Hence the overall cardiac and ventricular dimensions in a
normal heart are consistent with the golden ratio and angle, representing optimum pump structure and
function efficiency, whereas there is significant deviation in the disease state. These findings could have
anatomical, functional and prognostic value as markers of early deviation from normality.
© 2011 Elsevier Ireland Ltd. All rights reserved.

The golden ratio (also known as the golden mean or divine
proportion) is so called when on a line consisting of a longer length
(A) plus a shorter length (B), the proportion (A + B)/A equals A/B. This
was described by Pythagoras as ‘the small is to the large as the large is
to the whole’. It is expressed as an irrational mathematical constant
phi (φ) of approximately 1.618. This proportion is said to be the most
aesthetically pleasing and many artists and architects have incorpo-
rated it into their work [1,2]. The golden ratio was also known to
Euclid, known as the father of geometry, and the mathematician
Fibonacci; in the Fibonacci sequence, where each number is the sum
of the two previous numbers, if the calculation above is applied to any
two consecutive numbers, the mean result approximates to1.618
[3,4]. The golden ratio has also been found within the proportions of
the human body, including limbs, facial features, teeth and the DNA
molecule, and quantum field theory [5–8]. Allied to this is the golden
angle, calculated by sectioning the circumference of a circle (c) into
two arcs, such that the ratio of the length of the larger arc (a) to the
length of the smaller arc (b) is the same as the ratio of the full cir-
⁎ Corresponding author at: Heart Centre and Department of Public Health and
Clinical Medicine, Umeå University, Sweden. Tel.: + 46 90 785 0000; fax: + 46 90 137
633.
E-mail address: michael.henein@medicin.umu.se (M.Y. Henein).
1
The Golden Ratio Collaborators.
cumference to the length of the larger arc (i.e. c/a = a/b). The golden
angle is the angle subtended by the smaller arc (b) and measures
137.5°. The golden ratio decimal (0.618) equates to an angle of 222.5°,
the reverse of the golden angle, with the sum adding up to 360°. It has
been found among branches and leaves on plant stems [7].
We hypothesised that since the golden ratio and angle are so
deeply rooted in nature, they must have some correspondence in the
healthy heart structure and function. Accordingly, we studied the
heart dimensions and function using 2D or 3D cardiac ultrasound
imaging technology at end-diastole, the resting phase of the heart
cycle or CT scanning. Individual study data were compared using the
unpaired t test.
Study 1A: To assess the effect of ethnicity on the left ventricle, the most
important heart pump, we took vertical and transverse cardiac
measurements from 30 normal Swedish adults (Fig. 1) and compared
these with measurements from 30 healthy matched Chinese. We found
that Chinese left ventricle dimensions were smaller by 8±1 mm and 5±
0.5 mm, compared to Swedes but the golden ratio was maintained at
approximately 1.618. Our findings suggest that it is the dimensions ratio
that is important for healthy functioning and not the absolute dimensions.
Study 1B: To assess whether the ratio of these dimensions differs
in heart failure, we tested them in 40 Swedish patients; 20 with
mild heart failure and 20 with end-stage heart failure. In mild heart
failure, the left ventricular ratio was reduced (p b 0.001) but the right

0167-5273/$ – see front matter © 2011 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ijcard.2011.05.094
240 M.Y. Henein et al. / International Journal of Cardiology 150 (2011) 239–242
Fig. 1. An echocardiographic example of normal 4 chambers of the heart showing
measurements of the vertical and transverse cardiac axes. LV, left ventricle and RV, right
ventricle.
ventricular ratio was increased due to the enlarged left ventricle
encroaching on the right ventricular dimensions (p b 0.001); overall
the cardiac ratio remained at around 1.64. However, in end-stage
heart failure, the left ventricular ratio was significantly reduced
(p b 0.01) and this distorted the cardiac ratio to around 1.4 (p b 0.005),
consistent with pathological remodeling resulting in a more spherical
shape to the heart. These patients had 50% mortality over the course of
36 months' follow up, compared with 100% survival in the mild group
(Fig. 2a and b). Consequently, it appears that as long as the cardiac
ratio is maintained at approximately 1.618, survival is likely but a
significant deviation from the golden ratio is associated with a poor
Fig. 2. Echocardiograms (a) from 2 patients with heart failure, mild (left) and severe (right). Graph showing statistical measurements differences between the two heart failure
groups and normals (error bars represent standard error).
outcome. This downward spiral is known to result in mitral and
tricuspid valve regurgitation and enlargement of the atria [9].
Study 2: We have previously shown that the normal mitral valve
annulus dimensions ratio equates to 1.6 [10]. We then evaluated the
left ventricular inlet length and width (mitral annulus dimensions) in
15 normal individuals and 12 age matched patients with dilated
cardiomyopathy and functional mitral regurgitation. In normals, the
relative mitral annulus circumference length and width proved to
be 6.8 ± 0.8 cm and 4.2 ± 0.8 cm respectively, giving a ratio of 1.62,
compared with the dilated cardiomyopathy patients, whose di-
mensions were 8.3 ± 1.8 cm and 5.8 ± 1.1 cm respectively, giving a
ratio of 1.42 (p b 0.001). This reduced ratio in patients with dilated
left ventricle is consistent with disturbance in mitral valve function
and the development of mitral regurgitation, known for its clinical
complications and poor prognosis [11–13]. Furthermore, others have
shown that the structure and function of the tricuspid and mitral
annuli are not independent of each other but are based around the
golden ratio of 1.618 [14,15]. The same ratio applies to the extent of
the amplitude of the longitudinal motion of the tricuspid and mitral
annuli, a clinical measure taken to reflect right and left ventricular
function, respectively [16].
We have also previously demonstrated that the golden ratio is
seen in normal foetal myocardial function development, where the
heart muscle diastolic function matures at a rate of 1.6 mm/s per week
between 20 and 40 weeks of age [17], while a healthy adult heart
muscle loses velocity of 1.6 cm/s each decade between age 20 and 80
years [18], indicating a close relationship between ageing and ven-
tricular myocardial function. Finally, others have shown that the end
product of normal cardiac function, the blood pressure ratio of
120/80 mmHg, also approximates to the golden ratio of 1.618 and
carries significant prognostic value [19]. Additionally, myocardial
muscle fibre orientation takes a helical shape, with the coils of each
 M.Y. Henein et al. / International Journal of Cardiology 150 (2011) 239–242
segment of the apical loop being of different lengths and having a
harmonic proportion which conforms to the golden ratio [20]. When
these myocardial fibres become horizontal or transverse, as is the case
in heart failure, they weaken overall ventricular function [21].
Study 3A: We assessed the anatomical angle between the right
ventricular inlet axis and outflow tract axis in 16 healthy subjects and
19 patients with severe pulmonary hypertension and right heart
failure. We found that the normal angle between the axes is ap-
proximately 43 ± 3°. The angle between the outflow tract axis and
continuation of the inflow tract axis is therefore 138 ± 4°, which is
approximately 137.5°. This angle increased significantly to 160 ± 4°
(p N 0.001) in right heart failure patients, as the right ventricle became
cylindrical and lost its native shape, reducing the inflow-outflow tract
angle to approximately 20° from 43° (unpublished). Hence it can be
seen that the complex anatomy of the right ventricle, as well as its
myocardial fibre architecture, support the unique role of this angle in
preserving the peristaltic circulation inside the right ventricle. With
severe disease, right ventricular cavity enlargement and remodelling
combine to produce loss of the normal golden angle, contributing to
the intractable right ventricular pump decompensation.
Study 3B: We then measured the angle between the mid-luminal
axes of the pulmonary trunk and the proximal ascending aorta in
the same 16 healthy subjects. This angle approximated to a mean of
39.5 ± 3.6°, making the angle between the pulmonary trunk and the
continuation of the ascending aorta approximately 139 ± 3°, which
corresponds with the golden angle of 137.5° (unpublished) (Fig. 3).
Normal systolic pressure in the aorta is almost six times that in
the pulmonary artery, hence the need for a pressure recovery space
between the two arteries to avoid pressure transmission across their
thin walls. In hypertension, the pressure difference between the aorta
and the pulmonary artery could increase to 10 times the norm. Had
the aorta and pulmonary artery been closely parallel, this could
potentially have created a significant afterload to the right ventricle,
which is avoided by the space provided by the angle between the axes.
In addition to these two great arteries, the same angle seems to be
adopted by the central and peripheral arterial tree; early anatomical
studies demonstrated the branching pattern of the coronary and
peripheral arteries to be compatible with the golden angle [22,23]. It
appears that the golden angle is not only important for coronary
vasculature packing but also for optimising the branching pattern so
that perfusion of the myocardial bed is maximised [12].
Electrical function of the heart also seems to follow a parallel
pattern [24]: the range of electrical potential of a normal heart lay
between −30° and + 110°, representing a total angle of 140°, or
approximately 137.5°. An overall optimum healthy heart function
has also been observed when there is a graph of convergence of the
Fig. 3. Diagrams showing the golden angle between the ascending aorta and pulmonary
trunk (left), and between inlet and outflow tract axes of the right ventricle (right). AO:
aorta; PA: pulmonary artery; RA: right atrium; RV: right ventricle.
241
Fibonacci numbers and a phi relationship between the T waves on the
surface electrocardiogram [9,10].
Our findings show that the overall cardiac and ventricular di-
mensions in a normal heart are consistent with an approximation of
the golden ratio of 1.618 and the golden angle of 137.5°, representing
optimum pump structure and function efficiency. These findings are
not only of philosophical interest but may have a significant anatomical,
functional and prognostic value. Application of these ratios and angles
in our daily clinical practice may lead to development of simple and
reliable markers of early deviation from normality, which could be
treated before irreversible alteration in cardiac structure and function
develops.
Acknowledgements
Dr. Ying Zhao is partially supported by Umeå University and
Swedish Heart and Lung Foundation.
The authors of this manuscript have certified that they comply
with the Principles of Ethical Publishing in the International Journal of
Cardiology [25].
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