Golden Ratio and the heart: A review of divine aesthetics

Highlights

• Golden ratio and Fibonacci Series ubiquitously exist in every manifestation of life.

• ‘Fibonacci Cascade’ associates with branching patterns of coronary arteries.

• Left ventricular diameters represent the concept of golden ratio.

• Golden Ratio manifests itself in systolic and diastolic intervals of the heart.

• Evaluation of golden proportions might serve as a potential therapeutic guide.

Abstract

In human history, certain mathematical figures or concepts had gained a significant reputation largely due to their occult and esoteric meanings. Among these, Golden Ratio and associated concepts, namely golden proportions, had elicited a tremendous breakthrough in our human awareness and perception regarding mundane and spiritual aspects of physical existence. Golden Ratio or Number (with a numerical value of 1.618) that is also referred to as the Greek letter Phi (φ), has been universally expressed on a line partitioned into two unequal lengths (L, the longer and S, the shorter) in such a manner that L / S = (L + S) / L. Besides, appearing in certain number sequences (Fibonacci Series, etc.), golden proportions, to the consternation of observers, appear to be strikingly prevalent across all levels of physical existence from the innermost structures to the colossal galaxies of the universe potentially labeling these concepts as the measures of divine aesthetics.

Accordingly, the human body also serves as an epitome of these mysterious concepts as exemplified by its outward appearance including general stature and extremities along with a variety of inner organ systems. Based on preliminary studies, the human cardiovascular system might also be suggested to serve as a major predilection site of divine aesthetics as measured with Golden Ratio and its allies. This appears to be completely in line with the ancient knowledge associating the human heart with the esoteric and spiritual components of human nature including human soul. Within this context, the present paper primarily aims to discuss human manifestations of divine aesthetics as measured with ‘Golden Ratio’ and associated indices with a particular and detailed emphasis on their potential link with the human cardiovascular system.

Introduction

Since ancient times, certain mathematical figures or symbols had been the focus of substantial interest around the globe probably due to their obscure and esoteric messages associated with basic and fundamental questions of physical existence. Leonardo of Pisa, the renowned medieval mathematician, also nicknamed as “Fibonacci," had described a number series (in his masterpiece known as Liber Abaci (1202)) that led to a significant upheaval in our understanding of mathematical aspects of nature [1], [2], [3]. This sequence, namely Fibonacci Series or Sequence, constitutes an infinite chain of numbers starting with ‘0’ or ‘1’ and following as 0, 1, 1, 2, 3, 5, 8, 13, 21… particularly implying that the sum of two consecutive integers equals the subsequent one [1], [2], [3]. As the ‘Magnum Opus’ has been constantly attributed to Leonardo of Pisa (Fibonacci) worldwide, Pingala (the Indian Mathematician) who had actually recognized Fibonacci Series much earlier, and Edouard Lucas who also extensively studied on this series in the 19th century [1], have generally received far less reputation as compared with Fibonacci. Interestingly, this sequence potentially represents a concept that might be encountered in a variety of natural settings including design and branching of botanic structures etc. regarded as domains of phyllotaxis [1], [4]. Furthermore, the usefulness of Fibonacci Series has also been reported in man-made settings including establishment of financial and biological models along with the design of electronics [5].

The most notable concept that might be drawn from the Fibonacci Sequence appears to be the Golden Ratio (also synonymous with Golden Number or Golden Mean) [1], [2], [3]. Principally, this phenomenon underscores the notion that the ratio of any two consecutive numbers in Fibonacci Sequence approximates to the numerical value of 1.618 that refers to the Greek letter Phi (φ) [1], [3]. Moreover, as the numerical values of the sequential numbers in the ratio get higher, the approximation of 1.618 becomes more precise [1], [3]. As described by Pythagoras and Euclid, the precise value of Golden Ratio may also be expressed on a line partitioned into two unequal lengths (shorter length (S) and longer length (L)) in such a manner that L / S = (L + S) / L = Golden Ratio (1.618) [6]. ‘Golden Ratio’ or ‘Golden Number’, has been the focus of interest not only for its apparent aesthetic pleasure in the domains of art, architecture and music but for its association with human structure and its functions as well [1], [2], [6], [7], [8], [9], [10]. Based on the latest evidence, and to the increasing consternation of observers, the concepts of ‘Fibonacci Sequence’, ‘Golden Ratio’ and a variety of associated indices appear to be strikingly prevalent across all levels of physical existence (from human genome to galaxies) beyond a simple spontaneity or coincidence potentially suggesting a hand of all-pervading supreme intellect in their emergence. Therefore, one should render these predetermined and replicable measures as potential reflections of divine aesthetics within the universe. Accordingly, the present review primarily aims to focus on human manifestations of divine aesthetics as demonstrated with ‘Golden Ratio’ and associated indices with a particular emphasis and detailed information on their association with the human cardiovascular system.

There also exist a variety of indices primarily based on the concepts of Fibonacci Series and Golden Ratio that also merit particular attention in an effort to further outline the subtle features of the human body and components of the universe: for ins; sequential multiplication by 1.618 or division by 0.618 (starting from 1) gives rise to a cascade of numbers (1, 1.618, 2.618, 4.236, 6.854, 11.09…) termed as ‘Fibonacci Cascade’ that was previously proven to be associated with branching patterns of human coronary arteries and a variety of botanic structures in nature as well as the predilection site of atherosclerotic disease in human coronary arteries [3].

Certain geometric shapes primarily based on the rule of golden proportions are universally referred to as ‘golden geometric shapes’ [2]. Within this context, the term ‘Golden Rectangle’ signifies a specific golden geometric shape whose length to width ratio equals Golden Ratio [1], and is known to have high visual aesthetics. Interestingly, this rectangle might be split into a square and another golden rectangle that might subsequently be partitioned into another square and a golden rectangle as well primarily based on the order of the Fibonacci Sequence [1]. In other terms, sequential creation of squares within the consecutive golden rectangles (corresponding to the smaller numerical values of the Fibonacci Series) results in the complete occupation of the initial golden rectangle with squares (with diminishing sizes after each step) [1]. When the diagonals of each square are joined by an arc (quarter-circle), the final geometric shape approximates a ‘Golden Spiral’ [1]. True or approximate Golden Spirals are well known to manifest in sea shell, human ear [1] as well as in some galaxies. The rule of golden proportions might also apply to a variety of other geometric shapes including pentagrams and in certain settings, triangles [2].

‘Golden Angle’ (137.5°) emerges as another reference concept based on partitioning the circumference of a circle into smaller (S) and larger (L) arches in such a proportion that L / S = (L + S) / L = Golden Ratio (1.618) [6]. The angles represented by these arches also conform to this equation with the angles of arches L and S measuring 222.5° and 137.5°, respectively. The latter is referred to as ‘Golden Angle’ exemplified, in nature, by a variety of botanic structures including leaves and branches of plant stems [6]. Even though, the term ‘golden or divine proportion’ is generally used as a synonym for ‘Golden Ratio’ in most references [1], [6], we deem it more appropriate to suggest the concept of ‘golden proportions’ as a general umbrella term that encompasses both the concept of ‘Golden Ratio’ and all the abovementioned associated concepts including golden geometric shapes, spirals, and angle (Fig. 1).

Fibonacci Sequence and Golden Ratio might, to a large extent, be exemplified by a healthy human body and its organ systems in a proper manner: general stature, facial textures as well as phalangeal lengths of the digits even hands and forearm from the tips to the base, were previously suggested to be in complete harmony with Fibonacci values in an aesthetic human [3], [6], [10]. In contrast, a previous radiological study on cadaveric fingers failed to yield any evidence of Fibonacci Series (hence; Golden Ratio) through roentgenographic evaluation; yet still suggesting a variety of constant ratios other than Golden Ratio (1 and 1.3) among the phalangeal lengths [11]. On the other hand, a clenched hand superimposed on a Golden Rectangle along with the route of fingertips during hand extension and flexion as well as the gross appearance of inner ear structures in a human body might demonstrate a striking analogy to the Golden Spiral [1], [8], [12], [13]. Regarding the general stature, the ratio of foot to belly to belly to head (top point) distances also equals golden ratio in a healthy and aesthetic human [3].

The potential components of anatomical beauty have been extensively investigated for many years ultimately suggesting that facial charm appears to be in close harmony with anatomical symmetry [9], [14]. On the other hand, as far as the aesthetic nomenclature is concerned, it is widely accepted that the concept of physical beauty harbors an inherent subjectivity that is not amenable to standardization, and largely varies with time, place and sociocultural status [1]. Yet, there exists a myriad of paragons uniformly agreed upon their beauty around the globe who invariably manifest the concept of Golden Ratio in their physical appearance as a concrete evidence of their charm. Accordingly, investigations on facial beauty generally hover around the concept of golden proportions, and mostly focus on mouth and teeth that are primary textures of human face [1]: within this context, Rickets regarded the concept of golden proportions as a prerequisite in an aesthetic woman face [10], and accordingly investigated the potential impact of Golden Ratio and Fibonacci Series on the production of an aesthetic smile [1], [15], [16]. Moreover, he considered the concept of golden proportions as a part of management strategy in his patients [1], [10], [15], [16].

In a more subtle manner, divine aesthetics might also manifest itself at the core of a variety of inner organ systems extending beyond gross perception: regarding central visual dynamics, Elliot and his friends demonstrated the potential link between aesthetic preference and Golden Ratio suggesting that golden sectioning in brain activities might have an impact on the efficiency of visual processing [17]. Golden Ratio has also been an area of interest in gynecology: in a retrospective study investigating ultrasonographic (USG) measurements of non-pregnant uteri, mean values of length/width ratio were reported to have an inverse correlation with age and number of gravidity [18]. More surprisingly, this ratio appeared to be 1.618 at peak fertility (at the age of 21) exactly concording with the Golden Ratio [18]. These findings [18] may suggest that divine aesthetics are more likely to manifest itself in organ systems at their peak function and capacity potentially implying that conforming to the measures of divine reflection including Golden Ratio might be regarded as an auspicious sign of perfection in these systems.

Moreover, there exists evidence of golden proportions at the innermost structure of the human body, namely human genome primarily regarded as the core of human inception and physical existence: the potential association among Fibonacci Sequence, fractals and human genome was first studied in 1982 by Benoit Mandelbot ultimately concluding that DNA and its organization pattern constituted a structure manifesting as fractals [1], [19]. A decade after this resounding; yet inchoate supposition, human genomic structure was demonstrated to harbor a fractal trend along with an organization pattern strongly associated with Fibonacci Series and golden proportions [1], [20]. Lastly, Yamagishi et al. further substantiated the evidence revealing the existence of Fibonacci Series throughout the whole genomic structure [1], [21].

Currently, there exists a burgeoning interest towards the concepts of Golden Ratio and Fibonacci Sequence along with their potential implications in the cardiovascular field. As described below, a variety of studies associating these concepts with anatomy, physiology, electrocardiogram (ECG) and echocardiogram of the heart have been published in the literature, all exclusively yielding positive results. Undoubtedly, these outstanding results strongly suggest that the cardiovascular system might serve as a major predilection site of divine aesthetics as measured with golden ratio and its allies.

Regarding structural and functional characteristics of the cardiovascular system, normal reference values relative to body size, age and gender had long-since been standardized with only trivial alterations among various ethnic groups. This might allow widespread utility of certain diagnostic tools including echocardiogram that mirror even the slightest deviation from normal values in cardiovascular parameters with high sensitivity. Consistent with this, Henein et al. investigated the potential existence of Golden Ratio and Golden Angle in a variety of cardiac and vascular parameters measured echocardiographically in their multi-faceted study [6]. The authors made a comparison between two diverse racio-ethnic groups (30 healthy Swedish vs. 30 healthy Chinese subjects) with regard to their left ventricle (LV) transverse and vertical dimensions measured echocardiographically [6]. As expected, transverse and vertical dimensions were found to be smaller by 5 ± 0.5 mm and 8 ± 1 mm, respectively, in the Chinese group [6]. However, the ratio of these dimensions (LV ratio) in both groups yielded a constant numerical value of 1.618 that was identical with the Golden Ratio suggesting the importance of proportions rather than the absolute values of cardiac structures in assessing functional perfection of the heart [6]. Moreover, the authors tested whether LV ratio demonstrated a significant alteration in the setting of heart failure corresponding to the severity of the disease [6]. LV ratios in patients with mild and with terminal-stage heart failure appeared to be around 1.64 and 1.4, respectively, indicating a more striking impairment in the latter group possibly due to extensive structural remodeling leading to a more globoid LV pattern in these patients [6]. Furthermore, overall survival rates in patients with severe heart failure (with a LV ratio significantly deviated from normal value (1.618)) remained only around 50% at 3 years' follow-up suggesting the prognostic importance of Golden Ratio in heart failure patients [6].

In a similar manner, we (Yetkin E et al.) previously investigated whether left ventricular diameters represent the concept of golden ratio in a retrospectively designed study comprising a population of 1412 subjects with normal left ventricular ejection fraction (LVEF) values [24]. Mean values of end-diastolic and end-systolic dimensions of the LV (LVEDd and LVESd, respectively) appeared to be 4.54 and 2.81 cm, respectively through M-mode echocardiogram along with a mean value of LVEF measuring 68% in our study group [24]. Further analysis and calculation of LVEDd/LVESd and LVESd/(LVEDd − LVESd) ratios yielded mean numerical values of 1.614 ± 0.08 and 1.624 ± 0.21, respectively, both in complete harmony with the Golden Ratio [24].

Mitral anulus is well known to constitute a fibrous skeleton with a resilient nature against tensile forces, and provides a substantial amount of sustenance for mitral valves and base of the heart. However, maintenance of its normal functions and dimensions appears to be strongly dependent on LV structure and functions, and to some extent, vice versa. Ratio of anular dimensions in normal mitral valve was reportedly to measure 1.6, and had a close proximity to golden ratio [6]. To further investigate this issue, Henein et al. made a comparison between healthy subjects (n = 20) and patients with dilated cardiomyopathy (suffering functional mitral regurgitation) (n = 20) with regard to dimensions of mitral anulus [6]. As mean values, width and length of mitral anulus were reported as 4.2 ± 0.8 cm and 6.8 ± 0.8 cm, respectively in healthy subjects whereas the same values appeared to measure 5.8 ± 1.1 cm and 8.3 ± 1.8 cm in patients with cardiomyopathy, respectively, suggesting a disproportionate enlargement of mitral anulus in the setting of cardiomyopathy [6]. Accordingly, length/width ratios of mitral anulus in normal subjects and patients with cardiomyopathy yielded ratios of 1.62 and 1.42, respectively [6]. These findings suggest that mitral anular dimensions and functions, to a large extent, conform to divine aesthetics in normal subjects, and that enlargement of this structure is invariably accompanied by a significant deviation from Golden Ratio that portends functional mitral regurgitation [6]. As expected, the same supposition might apply to tricuspid valve [6] and probably other cardiac valvular structures.

Great arteries of the heart and right sided structures also demonstrate a striking concordance with divine aesthetics in the study by Henein et al. [6]: patients with right heart failure (with pulmonary hypertension) (n = 19) and healthy controls (n = 16) were compared in terms of anatomical angle between outlet and inlet tracts of right ventricle [6]. The angle between continuity of inlet tract and outflow tract measured 138 ± 4° and 160 ± 4° in normal subjects and in patients with right heart failure, respectively [6]. In other terms, the angle between these two axes normally corresponds with the Golden Angle (137.5°) with a probable step-wise deviation from this value on a parallel with worsening right ventricle (and structural remodeling) and pulmonary hypertension [6]. In the same study, healthy controls were also found to have a mean angle of 139 ± 3° between pulmonary trunk and continuity of proximal ascending aorta nearly conforming to the Golden Angle [6]. It seems plausible that space created between aortic and pulmonary arteries emerges as a manifestation of divine aesthetics that primarily counteracts the potential pressure transmission across these arteries leading to substantial increments in right ventricular afterload [6].

Human coronary arteries serve as highly organized vessel networks of human cardiac structure that might also mirror the signs of divine reflection in their anatomical design and physiological functions as well as the predilection pattern of involving pathologies along their course: Gibson et al. searched the predilection site of culprit lesions accounting for STEMI in their study starting with a preliminary hypothesis that Fibonacci Sequence might manifest itself in the locations of culprit lesions along the major epicardial arteries [3]. Based on data retrieved retrospectively from the major Thrombolysis In Myocardial Infarction (TIMI) trials (TIMI-14, 20, 23 and 24), the authors reported that division of median length of all coronary arteries (15.3 cm) by 4.236 (a number in Fibonacci Cascade equal to 2.618 × 1.618 or 2.618/0.618) appeared to result in a predicted value of 3.62 cm (manifesting as 24% of the total distance down the coronary the ostium) [3]. Interestingly, the median distance of culprit lesion accounting for STEMI was found to be 3.78 cm down from the origin of the coronary artery (24.7%) that was almost identical with the predicted value [3]. This is reportedly the first study in the literature uncovering the link between Fibonacci Cascade and the distrubution of culprit lesion location along the coronary arteries [3]. Furthermore, it was also speculated that Fibonacci Cascade might also apply to the location of side branches along the coronary arterial tree potentially allowing maximum perfusion of the related myocardium [3]. This organization pattern has a striking resemblance to a variety of branching plants in the nature that receive optimum amount of sunlight owing to the appearance of Fibonacci cascade in their branching patterns [3]. However, in comparison to these botanic structures, coronary arteries harbor far more complex and self-regulating mechanisms that determine perfusion dynamics particularly at the microvascular level on top of their meticulously arranged branching patterns.

In a similar manner, Ashrafian et al. also suggested that the structure of coronary arterial branching system demonstrates a complete analogy to the leaf branching pattern of trees [22]. Furthermore, through investigation of 36 mammalian species [23] it was inferred that the ratio of cardiac diameters to the sum of the diameters of all 13 major coronary branches appeared to be on a parallel with the Golden Ratio [22]. As a concluding remark, the authors also suggested that Fibonacci Series might be of clinical value for the establishment of novel bio-mathematical models of coronary arterial tree and development of metabolic maps of myocardium as well as the prediction of geometric and territorial characteristics of coronary artery disease [22]. Moreover, these groundbreaking approaches might have the potential to be incorporated into a variety of diagnostic tools including magnetic resonance imaging (MRI), myocard perfusion scintigraphy and computed tomography (CT) with the ultimate goal to enhance their diagnostic yield in the clinical setting [22].

Interestingly, divine aesthetics not only manifest itself at snapshot records of cardiovascular structures, but, in a more insidious manner, emerge as a constant scale of time-dependent alterations in cardiovascular functions as well: accordingly, a previous study (comprising 60 healthy subjects with 20 to 80 years of age) particularly investigated the impact of aging on left ventricular longitudinal functions as measured with tissue Doppler [25]. The authors demonstrated an age-dependent decline of early diastolic velocity corresponding to a value of 1.6 cm/s per decade [25]. More interestingly, there even exists a divine constant in the maturation of cardiac functions during fetal life: a gestational study (comprising a population of 159 healthy fetuses after 20 weeks of gestation) reported a weekly increment of 1.6 mm/s in the early diastolic flow velocity of fetal myocardium as measured with tissue Doppler at the basal portion of left heart [26]. These time-dependent alterations in cardiac functions (even commencing before birth) [25], [26] that seem to be in complete harmony with the Golden Ratio, and are not grossly detectable at a single time yet uncovered only through a temporal observation, might potentially signify the fact that divine aesthetics also harness the fourth dimension, namely ‘time’ in its self-manifestation.

In general, cardiac functions, to a large extent, appear to be determined by the efficacy and duration of myocardial contraction and relaxation phases, namely cardiac systole and diastole, respectively. Based on a cardiologic perspective, systolic phase typically corresponds to the time interval from the peak of R wave to the end of T wave whereas substraction of this phase from the R–R interval (one cycle comprising systolic plus diastolic phases) yields diastolic time interval on a surface ECG [2]. In a population of 162 healthy volunteers aged between 20 and 40 years of age, our group (Yetkin G et al.) investigated whether Golden Ratio also manifests itself in cardiac systolic and diastolic time intervals of the heart in the resting state [2]. Of note, only those with a heart rate of 60 to 80/min were included as study participants in an effort to minimize the potential impact of confounding factors (including heart rate) particularly on cardiac diastole [2]. Based on aforementioned definitions of cardiac phases, the ratios of diastolic/systolic and R–R/diastolic time intervals appeared to be 1.611 and 1.618, respectively suggesting the close harmony between cardiac phases and Golden Ratio [2]. Study findings were rendered, and thereafter expressed as a spectacular phrase by our group saying ‘Golden Ratio is beating in our heart’ that also served as the title of the article [2]. From an esoteric and holistic point of view, these findings might not be regarded with such a huge consternation based on the fact that our hearts, according to a uniformly agreed spiritual concept, are well known to harbor our souls [2] that serve as part and parcel of the primordial divine energy reflected within us.

Lastly, we (Yetkin E et al.) tested the hypothesis whether parameters of blood pressure evaluated through ambulatory monitoring, conform to the Golden Ratio in a retrospectively designed study comprising a population of 462 subjects [27]. Mean values of diastolic and systolic pressure levels (DBP and SBP) as well as pulse pressure (PP) (defined as SBP–DBP) during 24-h, day-time and night-time recordings were assessed to calculate the ratios of SBP/DBP and DBP/PP in these particular periods [27]. Interestingly, only night-time (but not 24-h or day-time) ratios of SBP/DBP and DBP/PP were found to demonstrate a striking concordance with the Golden Ratio as shown by their values of 1.64 and 1.62, respectively [27]. Enhanced physical activity [28] along with an autonomic imbalance in favor of sympathetic stimulation [29] might serve as potential confounders that might masquerade the occurrence of Golden Ratio in day-time BP values in our study [27]. In other terms, as the impact of sympathetic hyperactivity significantly diminishes [30] along with an enhancement of counterbalancing parasympathetic system during sleep, divine reflection becomes more likely to manifest itself in a variety of physiological functions including regulation of blood pressure. This presumptive notion might also apply, probably in a more striking manner, to a variety of meditative techniques including Sahaja Yoga that, as experienced by many, elicit robust increments in parasympathetic activity [31], [32], and hence create a complete union with the divine energy. In other terms, these techniques [31], [32] might, to a large extent, help establish divine reflection as manifested with appearance of divine proportions in a variety of physiological parameters of human body (BP, etc.) as well. Table 1 summarizes a variety of cardiovascular structures and functions conforming to the golden proportions in the setting of a healthy cardiovascular system.

In summary, the cardiovascular system serves as a major predilection site of divine reflection as confirmed by a variety of studies [2], [3], [6], [22], [23], [24], [25], [26], [27] reporting the existence of Golden Ratio and its allies in various aspects of cardiovascular structure and function. As previously mentioned, this is in complete harmony with the ancient knowledge strongly associating human heart with occult and spiritual constituents of human body including soul [2] where the primordial divine energy reflects itself. On the other hand, current literature on this issue, though quite appealing, are still at a preliminary stage necessitating further scientific awareness that might unravel esoteric mysteries and riddles in human cardiovascular system.

Besides reinforcing our philosophical beliefs and attitudes [6] towards an ever-existing supreme intellect pervading the whole universe, and hence aiding in the maturation of our spiritual aspect, investigation of divine aesthetics throughout the human body might also confer a variety of medical implications particularly regarding human cardiovascular system:

Firstly, harnessing Golden Ratio and its allies might serve as an adjunctive diagnostic modality particularly in the relatively early stage of cardiovascular disease course where routine diagnostic modalities hardly detect or even miss the diagnosis in certain conditions. In other terms, even the slightest deviation from divine proportions in an apparently normal heart might signify a subclinical disease, and might portend an imminent pathology with the potential to progress to the irreversible stage, if left untreated [6]. This might warrant further analysis and close supervision of the seemingly normal cardiac structures with abnormal divine proportions: for ins; heart failure patients with a mitral anulus failing to conform to the Golden Ratio in terms of its dimensions (length/width ratio), yet with otherwise normal characteristics (with no grossly visible dilatation and functional mitral regurgitation on echocardiography), should alert the clinician against an existing subclinical mitral annular disease that would possibly deteriorate in the near future. This might indicate the additional use of more sensitive diagnostic modalities in the initial stage (MRI, invasive ventriculography) along with a more frequent echocardiographic evaluation on follow-up for these patients.

Secondly, golden proportions might inherently yield a variety of prognostic implications [6] as exemplified by their potential use as independent risk-stratifiers in the setting of certain heart failure syndromes on top of well-known prognosticators. For instance; it might be speculated that dilated cardiomyopathy (D-CMP) patients who still preserve golden proportions in the ratio of vertical/transverse diameters of their LV, might have much higher survival rates as compared with those who do not (with otherwise similar characteristics including left ventricular ejection fraction (LVEF), NYHA, and markers of arrhythmogenesis). Prognostic implications might also apply to the setting of blood pressure (BP): hypertensive subjects with the ratios of SBP/DBP and DBP/PP around the value of Golden Ratio might probably have a more lenient clinical course characterized by much less severe forms of end organ damage in comparison to those with the ratios significantly deviated from this value. This might be exemplified by isolated systolic hypertension (ISHT) of the elderly that is primarily characterized by systolic and diastolic pressure values of ≥ 140 mmHg and < 90 mmHg, respectively [33], and invariably fails to conform, by its inherent nature, to the Golden Ratio (as measured by the ratios of SBP/DBP and DBP/PP). Based on a general consensus, this form of hypertension is largely attributable to the impaired compliance of great arteries [34] leading to a gradual enhancement in systolic–diastolic pressure difference manifesting as widened PP and diastolic hypoperfusion. In clinical terms, ISHT is also notorious for its association with other risk factors including diabetes mellitus (DM) and chronic renal failure, and might pose a significant risk to a variety of organs largely dependent on diastolic perfusion pressure including the heart. Consistent with this, systolic blood pressure was suggested as a stronger determinant of cardiovascular prognosis as compared with diastolic blood pressure [34]. Therefore, deviation from divine proportions in BP values as measured by the ratios of SBP/DBP and DBP/PP might potentially portend an ominous course, and hence; a clinical evaluation incorporating these ratios in clinical practice on top of absolute measurement of BP values might help better risk stratification of hypertensive subjects.

Lastly, assessing divine proportions in the cardiovascular setting might probably aid in decision making of certain therapeutic strategies: current guidelines of valvular heart disease strongly encourage, on top of LVEF and symptomatic evaluation, the use of certain threshold values of left ventricular end-systolic and diastolic diameters for regurgitant valvular pathologies in determining the optimal time of surgical intervention before the irreversible stage ensues [35]. However, a portion of patients still progress to the end-stage heart failure despite timely management of the valvular pathology. This might possibly emerge due to the significant deviation in the ratio of left ventricular diameters from divine proportions at the time of surgery in these patients. Therefore, incorporation of Golden Ratio assessment on top of conventional parameters (LV diameters, etc.) might allow a more timely management of patients with regurgitant valvular pathologies potentially obviating the progress to the end-stage heart failure in these patients. In a similar manner, reverse remodeling in systolic heart failure (SHF) (a favorable sign defined as a significant and time-dependent recovery in systolic functions) might emerge spontaneously or after initiation of invasive management strategies including correction of valvular pathologies (mitral regurgitation, etc.) or cardiac resynchronization therapy (CRT) or in response to positive inotropic agents including levosimendan therapy [36]. However, not all patients with SHF invariably incur the process of reverse remodeling potentially suggesting certain predictors of this phenomenon [37]. It seems plausible that a substantial approximation to the golden proportions in the initial (pre-therapeutic) LV dimensions might also serve as a potential predictor of reverse remodeling (spontaneous or device-related, etc.) on top of well-known predictors in patients with SHF. Therefore, evaluation of golden proportions might serve as a potential therapeutic guide on top of conventional indices in the setting of a variety of valvular pathologies and certain forms of cardiomyopathies, etc.

In summary, even though the abovementioned clinical scenarios regarding the potential implications of Golden Ratio in cardiovascular field, to some extent, appear to be at a speculative level, and have yet remained to be tested through further studies, it seems quite promising, inspiring as well as tempting to harness the measures of divine aesthetics in every aspect of cardiovascular conditions on top of conventional methods.