The Heart

S1: Character of auscultation 1) Area: apex 2) Pitch 3) Lasting time: 4) Together with apex impulse
S2: Vibration of the closure of AV, PV, during the beginning of ventricular diastole, Indicates the beginning of ventricular diastole
A2: hypertension P2 : pulmonary hypertension in MS, MI A2: AS ,AI P2 : PS, PI
Change in quality of heart sound
When the myocardial muscle is damaged severely, S1 is similar to S2. The heart sound like a pendular— pendular uallyaccompany with tachycardia—embryocardia.
• Protodiastolic gallop rhythm
• S3 gallop, ventricular gallop rhythm. • S1 + S2 + pathologic S3
In early diastole, the blood through into ventricle from atrium in failing myocardium, the ventricular wall tension is poor, produce vibration. Reflex that the ventricular function

Editorial CommentBad Kidneys are Bad for the Heart:But What Can We Do About It?Timothy D.Henry,1*MD and Charles A.Herzog,2,3MD 1Minneapolis Heart Institute Foundation,Abbott Northwestern Hospital,Minneapolis,Minnesota2Hennepin County Medical Center,University of Min-nesota,Minneapolis,Minnesota3Cardiovascular Special Studies Center,United States Renal Data System,Minneapolis,MinnesotaChronic kidney disease(CKD)is a major risk factor in patients with cardiovascular disease[1–3].Patients with CKD who present with acute coronary syndromes, or undergo revascularization with either percutaneous coronary intervention(PCI)or coronary artery bypass graft surgery(CABG)have increased mortality.Patients with end-stage renal disease(ESRD)on dialysis are at particularly high risk.In this issue of CCI,Parikh et al.report the in-hos-pital mortality on25,018patients undergoing PCI over a4-year period at four New York state hospitals, stratified by renal function[4].Nearly30%of patients had moderate CKD(estimated glomerularfiltration rate(eGFR) 60)(26.4%)or ESRD on dialysis (1.9%).All-cause in-hospital mortality was markedly higher in patients with ESRD(2.1%)and moderate CKD(1.3%)versus patients with preserved renal func-tion(0.3%).The results confirm previously reported data that patients with either CKD or ESRD have high risk characteristics including age,higher rates of prior coronary revascularization,peripheral arterial disease, previous stroke,congestive heart failure,and diabetes. These patients also have more complex coronary anat-omy including calcification and diffuse disease[5]. Importantly,they are also less likely to receive guide-line recommended therapy including antiplatelet agents,anticoagulants,and revascularization[6].In this registry,they were less likely to receive drug-eluting stents even though they are at higher risk for restenosis.The authors concentrated on in-hospital mortality in their report,but the real clinical issue is what happens after the patient leaves the hospital,a problem not restricted to PCI[7,8].Long-term mortality for ESRD remains extremely high in a wide spectrum of cardio-vascular disease(Figure1).In2009,there were approximately399,000dialysis patients.The overall mortality rate in2009for US dialysis patients was200 deaths/1,000patient years.Thefive-year mortality of dialysis patients has improved over time,but it remains depressingly high:66%for a patient starting dialysis in 2004.In contrast,thefive-year mortality for renal transplant recipients was27%for the same time period [9].Approximately,45%of the mortality in dialysis patients is attributed to a cardiovascular etiology. About14%of cardiac deaths are ascribed to acute myocardial infarction;66%of cardiac deaths(or26% of all-cause mortality)are attributed to arrhythmic mechanisms[9].Patients with ESRD are particularly vulnerable to sudden cardiac death:the combination of obstructive coronary artery disease,left ventricular hy-pertrophy(at least75%of dialysis patients),myocar-dialfibrosis,autonomic dysfunction(including obstruc-tive sleep apnea),and microvascular dysfunction in patients with diabetes places the ESRD patient at heightened risk for sudden death.Coronary revasculari-zation does not nullify the risk:even after surgical re-vascularization with a left internal mammary graft,the two-year mortality of dialysis patients is43%[10]. Other adverse outcomes such as readmission,revas-cularization,myocardial infarction,and bleeding are all markedly higher in these patients as well.The authors discuss the myriad of potential reasons for the increased risk but the solution remains elusive.As the prevalence of diabetes increases and the pop-ulation ages,the number of patients with CKD will continue to increase.Nearly,one-third of the patients in this report had a eGFR<60.CKD presents a major public health challenge in the US and abroad.It is estimated that about12%of the US population(25 million)have CKD,but even more importantly from Conflict of interest:Nothing to report.*Correspondence to:Timothy D.Henry,Minneapolis Heart Institute Foundation,920East28th Street,Suite300,Minneapolis,MN 55407.E-mail:****************Received16July2012;Revision accepted16July2012DOI10.1002/ccd.24567Published online8August2012in Wiley Online Library ().'2012Wiley Periodicals,Inc.Catheterization and Cardiovascular Interventions80:358–360(2012)an interventional cardiology perspective,40%or more of people over age 70have CKD [11].The cardiology world has become ‘‘comfortable’’with CKD stages and the concept of eGFR <60as a ‘‘threshold of risk’’but a single dichotomous cutpoint is actually a dull discriminator.A more accurate and comprehensive risk-based CKD staging system which takes into account both eGFR and ranges of proteinuria will take its place in the near future [11].So,bad kidneys are bad for the heart,but what can we do about it?While earlier detection and subsequent prevention of CKD is clearly desirable,we suspect this will continue to be a major challenge.Clinical trials designed specifically to address patients with CKD and ESRD are sorely needed.Perhaps the best approach for interventional cardiologists is to focus on the use of appropriate guideline-based medications and revas-cularization.This is not so simple as these patients are at increased risk for bleeding and are more likely to present with atypical symptoms.The ideal method of reperfusion in these patients also remains controversial.There are limited randomized clinical trials and it is extremely challenging to have comparable groups in registries such as this [8].Frequently,CKD and partic-ularly ESRD patients are not candidates for surgical revascularization.Reflecting this issue,patients in this registry with ESRD and CKD had higher rates ofintervention on bypass grafts,the LAD,and the left main than patients with normal renal function.In summary,CKD is increasingly common and a major risk factor for adverse outcomes in all cardio-vascular disease.An ongoing focus on prevention,clin-ical trials designed specifically for CKD and ESRD,use of guideline recommended therapies including re-vascularization and careful clinical follow-up remain our best hope to address this growing challenge.REFERENCES1.Collins AJ,Foley R,Herzog C,Chavers B,Gilbertson D,Ishani A,Kasiske B,Liu J,Mau LW,McBean M,Murray A,St Peter W,Xue J,Fan Q,Guo H,Li Q,Li S,Li S,Peng Y,Qiu Y,Roberts T,Skeans M,Snyder J,Solid C,Wang C,Weinhandl E,Zaun D,Zhang R,Arko C,Chen SC,Dalleska F,Daniels F,Dunning S,Ebben J,Frazier E,Hanzlik C,Johnson R,Sheets D,Wang X,Forrest B,Constantini E,Everson S,Eggers P,Agodoa L.Excerpts from the United States Renal Data System 2007an-nual data report.Am J Kidney Dis 2008;51:S1–S320.2.Go AS,Chertow GM,Fan D,McCulloch CE,Hsu CY.Chronic kidney disease and the risks of death,cardiovascular events,and hospitalization.N Engl J Med 2004,351:1296–1305.3.Osten MD,Ivanov J,Eichhofer J,Seidelin PH,Ross JR,BaroletA,Horlick EM,Ing D,Schwartz L,Mackie K,Dzavı´k V.Impact of renal insufficiency on angiographic,procedural,and in-hospital outcomes following percutaneous coronary interven-tion.Am J Cardiol2008;101:780–785.Fig.1.January 1,2005point prevalent ESRD patients,age 20and older,with a first cardiovascular diagnosis or procedure in 2005–2007.Modified from USRDS 2009ADR.Catheterization and Cardiovascular Interventions DOI 10.1002/ccd.Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).Bad Kidneys Are Bad for the Heart 3594.Parkih PB,Jeremias A,Naidu SS,Brener SJ,Lima F,SholfmitzRA,Pappas T,Marzo KP,Grubert L.Impact of severity of renal disfunction on determinants of in-hospital morality among patients undergoing percutaneous coronary intervention.Catheter Cardiovasc Interv2012;DOI10.1002/ccd.23394.5.Gruberg L,Rai P,Mintz GS,Canos D,Pinnow E,Satler LF,Pichard AD,Kent KM,Laird JR Jr,Lindsay J Jr,Waksman R, Weissman NJ.Impact of renal function on coronary plaque mor-phology and morphometry in patients with chronic renal insuffi-ciency as determined by intravascular ultrasound volumetric anal-ysis.Am J Cardiol2005;96:892–896.6.Tsai TT,Maddox TM,Roe MT,Dai D,Alexander KP,Ho PM,Messenger JC,Nallamothu BK,Peterson ED,Rumsfeld JS.Contra-indicated medication use in dialysis patients undergoing percutaneous coronary intervention.JAMA2009;302:2458–2464.7.Herzog CA,Ma JZ,Collins AJ.Poor long-term survival afteracute myocardial infarction among patients on long-term dialy-sis.N Engl J Med1998,339:799–805.8.Herzog CA,Ma JZ,Collins parative survival of dialysispatients in the United States after coronary angioplasty,coronary artery stenting,and coronary artery bypass surgery and impact of diabetes.Circulation2002;106:2207–2211.9.United States Renal Data System2011Annual Data Report:Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States.Bethesda,MD:National Institutes of Health,National Institute of Diabetes and Digestive and Kidney Diseases,2011./.Accessed July13,2012.10.Herzog CA,Strief JW,Collins AJ,Gilbertson DT.Cause-specificmortality of dialysis patients after coronary revascularization: Why don’t dialysis patients have better survival after coronary intervention?Nephrol Dial Transplant2008;23:2629–2633.11.Levey AS,de Jong PE,Coresh J,El Nahas M,Astor BC,Mat-sushita K,Gansevoort RT,Kasiske BL,Eckardt KU.The defini-tion,classification,and prognosis of chronic kidney disease:A KDIGO Controversies Conference report.Kidney Int2011;80:17–28.Catheterization and Cardiovascular Interventions DOI10.1002/ccd.Published on behalf of The Society for Cardiovascular Angiography and Interventions(SCAI). 360Henry and Herzog。

the heart is a lonely hunter 英文原版The Heart is a Lonely HunterIn the dimly lit room, the ticking of the clock seemed to echo through the silence, a constant reminder of the passage of time. The air was heavy with a sense of melancholy, as if the very walls were imbued with the weight of unspoken emotions. It was here, in this solitary space, that the heart found its solace, a refuge from the bustling world outside.The heart, a complex and enigmatic organ, had long been a subject of fascination and contemplation. Its rhythmic beats, the life-sustaining force that coursed through the veins, were often seen as a symbol of the human experience – a representation of the depths of emotion, the highs and lows that define our existence.Yet, in this moment, the heart felt a profound sense of isolation, a loneliness that transcended the physical boundaries of the body. It was as if the heart had been severed from the very connections it was meant to foster, left to wander in a vast and unforgiving landscape, searching for a kindred spirit to share its burdens.The heart's journey had been a tumultuous one, marked by the ebb and flow of love, loss, and the ever-present search for meaning. It had witnessed the joys and sorrows of human existence, the laughter and the tears, the moments of triumph and the depths of despair. And yet, despite the multitude of experiences it had endured, the heart remained a solitary entity, its innermost desires and yearnings known only to itself.As the clock ticked on, the heart found itself drawn to the window, gazing out at the world beyond. The bustling streets, the faces of strangers, the hum of life – all of it seemed to mock the heart's solitude, a constant reminder of the connections it craved but could not find.In those quiet moments, the heart would reflect on its past, the choices it had made, the paths it had taken. It would revisit the memories of love and loss, the moments of vulnerability and the times when it had felt most alive. And in the midst of this introspection, the heart would be struck by a profound realization: that its very nature, its capacity to feel deeply, was both its greatest strength and its greatest burden.For the heart, to love was to risk, to open oneself up to the possibility of pain and heartbreak. And yet, the heart could not help but long for that connection, that sense of belonging that seemed toelude it at every turn. It was a paradox, a constant struggle between the desire for intimacy and the fear of being truly known.As the days turned into weeks, the heart found itself growing weary, its once-vibrant spirit slowly fading into the shadows of its own isolation. The ticking of the clock seemed to taunt it, a constant reminder of the relentless passage of time and the opportunities that had slipped through its grasp.And yet, even in the midst of this despair, the heart refused to surrender. It clung to the faint glimmer of hope that somewhere, out there, there was a kindred spirit, a soul that could understand the depths of its yearning and offer the solace it so desperately craved.The heart's journey was one of resilience, of a constant struggle to find its place in a world that often seemed indifferent to its needs. It was a testament to the enduring power of the human spirit, a reminder that even in the darkest of times, the heart's capacity to love and to be loved remained a beacon of light, guiding it through the endless sea of loneliness.And so the heart continued its vigil, its steady beats echoing through the silence, a silent prayer for the connection it so deeply desired. For in the end, the heart's loneliness was not a curse, but a testamentto its very essence – a heart that could never be truly tamed, a heart that would forever seek the elusive embrace of another.。

How the Heart WorksThis is the VOA Special English Health Report.We talked last week about the life of famed heart doctor Michael DeBakey. He died this month at age ninety-nine.Today, we talk about the object of his work. The heart is a complex organ that starts beating a few weeks after conception. At this point the heart is a tube. In the coming days, it grows and bends into the shape of the heart.Later, it divides into four parts. As the heart beats, it pumps blood through these chambers and the blood vessels in the body. The body is estimated to have at least ninety-six thousand kilometers of blood vessels.That is about the same as two and a half times around the Earth. But blood goes the distance in about twenty seconds on its way back to the heart. Each day the heart pumps about eight thousand liters of blood.The blood feeds the brain and other organs with oxygen and nutrients. It also carries away carbon dioxide and other waste.The heart pumps by expanding and contracting of muscle. In a healthy adult, the heart beats an average of seventy-two times a minute -- about one hundred thousand times a day.A healthy adult heart is about the size of two fists and looks like a piece of red meat. But in overweight people, it can look yellow because of fat.Rates of heart disease started growing sharply in the second half of the twentieth century. As machines did more and more work, people did less and less. Not only did physical activity decrease, but people started eating more and more processed foods.Experts say a diet low in fats and high in fruits, vegetables, proteins and whole grains may help reduce the risk of heart disease. At least thirty minutes a day of physical activity, enough to work up a sweat, can also help. Also important to good health is a good night's sleep.Cardiovascular disease is caused by disorders of the heart and blood vessels. It includes heart attacks, strokes and high blood pressure. The World Health Organization says there are three major causes: tobacco use, physical inactivity and an unhealthy diet.The W.H.O. says cardiovascular disease is the world's leading cause of death. And it is predicted to remain that way unless more action is taken. Experts estimate that it could kill twenty million people a year by twenty fifteen. An estimated seventeen and a half million people died in the year two thousand five. Around eighty percent of them died in low- and middle-income countries. And that's the VOA Special English Health Report, written by Caty Weaver. I'm Steve Ember.。