Notes From My Heart


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I want to gorge you with all the joys of the flesh, so that you faint and die. I want you to be amazed by me…. For this smile of yours, this gentleness I find in you and the most interesting moments I have shared with you will never let me forget you here and in the hereafter. I love you my dearest! You are always my rainbow after the storm. I feel safe in your loving arms. You are more than I could have ever hoped for. I love you so much my sweetheart. I love you because you have never yielded in anything; I love you because you never capitulate.


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I love you for your wonderful intelligence, for your literary aspirations, for your unconscious coquetry. I love you because you have the air of doubting nothing! I love in you what is also in me: imagination, the gift for languages, taste, intuition and a host of other things… I love you, Vita, because I have seen your soul…. Last night I dreamed about you.

What happened in detail I can hardly remember, all I know is that we kept merging into one another. I was you, you were me. Finally you somehow caught fire. Because of you, I get to fall asleep feeling happy every single night. Your love makes me happy and peaceful. What is love? It is the smile I get whenever the phone rings, and I realize that it is a text from you.

You make me so happy, thank you sweetheart I never to stop loving you. When you get this note, you should come over and give me the longest kiss we have ever had. Remember, I will always love you. I already love in you your beauty, but I am only beginning to love in you that which is eternal and ever previous — your heat, your soul.

Beauty one could get to know and fall in love with in one hour and cease to love it as speedily; but the soul one must learn to know. Believe me, nothing on earth is given without labor, even love, the most beautiful and natural of feelings. I love you. I believe in you completely. You are my dearest one. My reason for life. You have no idea how much you have changed my life. And, you have no clue how fast my heart beats when I see you. I adore the texture of your mind; and you are a writer and a thinker and beautiful. And you are witty. These things, though they remain scattered, are good and enrich me.

I loved your flowers and your sending them — I have had much pleasure from them and they still bloom…. You have touched me more profoundly than I thought even you could have touched me — my heart was full when you came here today. Henceforward I am yours for everything…. I will never forget about the moment I realized that I loved you. You are the love of my life and my best and truest friend. My greatest torment since I have known you has been the fear of you being a little inclined to the Cressid; but that suspicion I dismiss utterly and remain happy in the surety of your Love, which I assure you is as much a wonder to me as a delight.

I love you, and you love me — at least, you say so, and act as if you did so, which last is a great consolation in all events. But I more than love you, and cannot cease to love you. Think of me, sometimes, when the Alps and ocean divide us — but they never will, unless you wish it. It usually then travels in front of the ascending aorta and then ends in a brachiocephalic node.

The heart receives nerve signals from the vagus nerve and from nerves arising from the sympathetic trunk. These nerves act to influence, but not control, the heart rate. Sympathetic nerves also influence the force of heart contraction. The vagus nerve of the parasympathetic nervous system acts to decrease the heart rate, and nerves from the sympathetic trunk act to increase the heart rate.

The vagus nerve is a long, wandering nerve that emerges from the brainstem and provides parasympathetic stimulation to a large number of organs in the thorax and abdomen, including the heart. The ventricles are more richly innervated by sympathetic fibers than parasympathetic fibers. Sympathetic stimulation causes the release of the neurotransmitter norepinephrine also known as noradrenaline at the neuromuscular junction of the cardiac nerves.

This shortens the repolarization period, thus speeding the rate of depolarization and contraction, which results in an increased heart rate. It opens chemical or ligand-gated sodium and calcium ion channels, allowing an influx of positively charged ions. The heart is the first functional organ to develop and starts to beat and pump blood at about three weeks into embryogenesis. This early start is crucial for subsequent embryonic and prenatal development. The heart derives from splanchnopleuric mesenchyme in the neural plate which forms the cardiogenic region.

Two endocardial tubes form here that fuse to form a primitive heart tube known as the tubular heart. This places the chambers and major vessels into the correct alignment for the developed heart. Further development will include the septa and valves formation and remodelling of the heart chambers. By the end of the fifth week the septa are complete and the heart valves are completed by the ninth week. Before the fifth week, there is an opening in the fetal heart known as the foramen ovale. The foramen ovale allowed blood in the fetal heart to pass directly from the right atrium to the left atrium, allowing some blood to bypass the lungs.

Within seconds after birth, a flap of tissue known as the septum primum that previously acted as a valve closes the foramen ovale and establishes the typical cardiac circulation pattern. A depression in the surface of the right atrium remains where the foramen ovale was, called the fossa ovalis. The embryonic heart begins beating at around 22 days after conception 5 weeks after the last normal menstrual period, LMP. It starts to beat at a rate near to the mother's which is about 75—80 beats per minute bpm. The embryonic heart rate then accelerates and reaches a peak rate of — bpm early in the early 7th week early 9th week after the LMP.

There is no difference in female and male heart rates before birth. The heart functions as a pump in the circulatory system to provide a continuous flow of blood throughout the body. This circulation consists of the systemic circulation to and from the body and the pulmonary circulation to and from the lungs. Blood in the pulmonary circulation exchanges carbon dioxide for oxygen in the lungs through the process of respiration. The systemic circulation then transports oxygen to the body and returns carbon dioxide and relatively deoxygenated blood to the heart for transfer to the lungs.

The right heart collects deoxygenated blood from two large veins, the superior and inferior venae cavae. Blood collects in the right and left atrium continuously. The inferior vena cava drains the blood from below the diaphragm and empties into the back part of the atrium below the opening for the superior vena cava. Immediately above and to the middle of the opening of the inferior vena cava is the opening of the thin-walled coronary sinus. The blood collects in the right atrium. When the right atrium contracts, the blood is pumped through the tricuspid valve into the right ventricle.

As the right ventricle contracts, the tricuspid valve closes and the blood is pumped into the pulmonary trunk through the pulmonary valve. The pulmonary trunk divides into pulmonary arteries and progressively smaller arteries throughout the lungs, until it reaches capillaries. As these pass by alveoli carbon dioxide is exchanged for oxygen. This happens through the passive process of diffusion. In the left heart , oxygenated blood is returned to the left atrium via the pulmonary veins. It is then pumped into the left ventricle through the mitral valve and into the aorta through the aortic valve for systemic circulation.

The aorta is a large artery that branches into many smaller arteries, arterioles , and ultimately capillaries. In the capillaries, oxygen and nutrients from blood are supplied to body cells for metabolism, and exchanged for carbon dioxide and waste products. The cardiac cycle refers to the sequence of events in which the heart contracts and relaxes with every heartbeat.

The atria and ventricles work in concert, so in systole when the ventricles are contracting, the atria are relaxed and collecting blood. When the ventricles are relaxed in diastole, the atria contract to pump blood to the ventricles. This coordination ensures blood is pumped efficiently to the body. At the beginning of the cardiac cycle, the ventricles are relaxing. As they do so, they are filled by blood passing through the open mitral and tricuspid valves. After the ventricles have completed most of their filling, the atria contract, forcing further blood into the ventricles and priming the pump.

Next, the ventricles start to contract. As the pressure rises within the cavities of the ventricles, the mitral and tricuspid valves are forced shut. As the pressure within the ventricles rises further, exceeding the pressure with the aorta and pulmonary arteries, the aortic and pulmonary valves open.

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Blood is ejected from the heart, causing the pressure within the ventricles to fall. Simultaneously, the atria refill as blood flows into the right atrium through the superior and inferior vena cavae , and into the left atrium through the pulmonary veins. Finally, when the pressure within the ventricles falls below the pressure within the aorta and pulmonary arteries, the aortic and pulmonary valves close.

The ventricles start to relax, the mitral and tricuspid valves open, and the cycle begins again. Cardiac output CO is a measurement of the amount of blood pumped by each ventricle stroke volume in one minute. This is calculated by multiplying the stroke volume SV by the beats per minute of the heart rate HR.

The average cardiac output, using an average stroke volume of about 70mL, is 5. Preload refers to the filling pressure of the atria at the end of diastole, when the ventricles are at their fullest. A main factor is how long it takes the ventricles to fill: if the ventricles contract more frequently, then there is less time to fill and the preload will be less.

The force of each contraction of the heart muscle is proportional to the preload, described as the Frank-Starling mechanism. This states that the force of contraction is directly proportional to the initial length of muscle fiber, meaning a ventricle will contract more forcefully, the more it is stretched.

Afterload , or how much pressure the heart must generate to eject blood at systole, is influenced by vascular resistance. It can be influenced by narrowing of the heart valves stenosis or contraction or relaxation of the peripheral blood vessels. The strength of heart muscle contractions controls the stroke volume. This can be influenced positively or negatively by agents termed inotropes.

Inotropes that increase the force of contraction are "positive" inotropes, and include sympathetic agents such as adrenaline , noradrenaline and dopamine. The normal rhythmical heart beat, called sinus rhythm , is established by the sinoatrial node , the heart's pacemaker.

Here an electrical signal is created that travels through the heart, causing the heart muscle to contract. The sinoatrial node is found in the upper part of the right atrium near to the junction with the superior vena cava. It travels to the left atrium via Bachmann's bundle , such that the muscles of the left and right atria contract together. This is found at the bottom of the right atrium in the atrioventricular septum —the boundary between the right atrium and the left ventricle. The septum is part of the cardiac skeleton , tissue within the heart that the electrical signal cannot pass through, which forces the signal to pass through the atrioventricular node only.

In the ventricles the signal is carried by specialized tissue called the Purkinje fibers which then transmit the electric charge to the heart muscle. The normal resting heart rate is called the sinus rhythm , created and sustained by the sinoatrial node , a group of pacemaking cells found in the wall of the right atrium. Cells in the sinoatrial node do this by creating an action potential. The cardiac action potential is created by the movement of specific electrolytes into and out of the pacemaker cells.

The action potential then spreads to nearby cells. When the sinoatrial cells are resting, they have a negative charge on their membranes. However a rapid influx of sodium ions causes the membrane's charge to become positive. This is called depolarisation and occurs spontaneously. All the ions travel through ion channels in the membrane of the sinoatrial cells. The potassium and calcium start to move out of and into the cell only once it has a sufficiently high charge, and so are called voltage-gated.

Shortly after this, the calcium channels close and potassium channels open, allowing potassium to leave the cell. This causes the cell to have a negative resting charge and is called repolarization. The ions move from areas where they are concentrated to where they are not. For this reason sodium moves into the cell from outside, and potassium moves from within the cell to outside the cell. Calcium also plays a critical role.

Their influx through slow channels means that the sinoatrial cells have a prolonged "plateau" phase when they have a positive charge. A part of this is called the absolute refractory period. Calcium ions also combine with the regulatory protein troponin C in the troponin complex to enable contraction of the cardiac muscle, and separate from the protein to allow relaxation. The adult resting heart rate ranges from 60 to bpm.

The resting heart rate of a newborn can be beats per minute bpm and this gradually decreases until maturity. During exercise the rate can be bpm with maximum rates reaching from to bpm. The normal sinus rhythm of the heart, giving the resting heart rate , is influenced a number of factors. The cardiovascular centres in the brainstem that control the sympathetic and parasympathetic influences to the heart through the vagus nerve and sympathetic trunk.

Through a series of reflexes these help regulate and sustain blood flow. Baroreceptors are stretch receptors located in the aortic sinus , carotid bodies , the venae cavae, and other locations, including pulmonary vessels and the right side of the heart itself. Baroreceptors fire at a rate determined by how much they are stretched, [51] which is influenced by blood pressure, level of physical activity, and the relative distribution of blood.

With increased pressure and stretch, the rate of baroreceptor firing increases, and the cardiac centers decrease sympathetic stimulation and increase parasympathetic stimulation. As pressure and stretch decrease, the rate of baroreceptor firing decreases, and the cardiac centers increase sympathetic stimulation and decrease parasympathetic stimulation. Increased venous return stretches the walls of the atria where specialized baroreceptors are located. However, as the atrial baroreceptors increase their rate of firing and as they stretch due to the increased blood pressure, the cardiac center responds by increasing sympathetic stimulation and inhibiting parasympathetic stimulation to increase heart rate.

The opposite is also true. Low oxygen or high carbon dioxide will stimulate firing of the receptors. Exercise and fitness levels, age, body temperature, basal metabolic rate , and even a person's emotional state can all affect the heart rate. High levels of the hormones epinephrine , norepinephrine, and thyroid hormones can increase the heart rate. The levels of electrolytes including calcium, potassium, and sodium can also influence the speed and regularity of the heart rate; low blood oxygen , low blood pressure and dehydration may increase it. Cardiovascular diseases , which include diseases of the heart, are the leading cause of death worldwide.

Many other medical professionals are involved in treating diseases of the heart, including doctors such as general practitioners , cardiothoracic surgeons and intensivists , and allied health practitioners including physiotherapists and dieticians.

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Coronary artery disease , also known as ischaemic heart disease, is caused by atherosclerosis —a build-up of fatty material along the inner walls of the arteries. These fatty deposits known as atherosclerotic plaques narrow the coronary arteries, and if severe may reduce blood flow to the heart. Severe narrowings may cause chest pain angina or breathlessness during exercise or even at rest. The thin covering of an atherosclerotic plaque can rupture, exposing the fatty centre to the circulating blood.

In this case a clot or thrombus can form, blocking the artery, and restricting blood flow to an area of heart muscle causing a myocardial infarction a heart attack or unstable angina. Heart failure is defined as a condition in which the heart is unable to pump enough blood to meet the demands of the body. Heart failure is the end result of many diseases affecting the heart, but is most commonly associated with ischaemic heart disease , valvular heart disease , or high blood pressure.

Less common causes include various cardiomyopathies. Heart failure is frequently associated with weakness of the heart muscle in the ventricles systolic heart failure , but can also be seen in patients with heart muscle that is strong but stiff diastolic heart failure. The condition may affect the left ventricle causing predominantly breathlessness , the right ventricle causing predominantly swelling of the legs and an elevated jugular venous pressure , or both ventricles. Patients with heart failure are at higher risk of developing dangerous heart rhythm disturbances or arrhythmias.

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Cardiomyopathies are diseases affecting the muscle of the heart. Some cause abnormal thickening of the heart muscle hypertrophic cardiomyopathy , some cause the heart to abnormally expand and weaken dilated cardiomyopathy , some cause the heart muscle to become stiff and unable to fully relax between contractions restrictive cardiomyopathy and some make the heart prone to abnormal heart rhythms arrhythmogenic cardiomyopathy.

These conditions are often genetic and can be inherited , but some such as dilated cardiomyopathy may be caused by damage from toxins such as alcohol. Some cardiomyopathies such as hypertrophic cardiomopathy are linked to a higher risk of sudden cardiac death, particularly in athletes.

Healthy heart valves allow blood to flow easily in one direction, but prevent it from flowing in the other direction. Diseased heart valves may have a narrow opening and therefore restrict the flow of blood in the forward direction referred to as a stenotic valve , or may allow blood to leak in the reverse direction referred to as valvular regurgitation. Valvular heart disease may cause breathlessness, blackouts, or chest pain, but may be asymptomatic and only detected on a routine examination by hearing abnormal heart sounds or a heart murmur.

In the developed world, valvular heart disease is most commonly caused by degeneration secondary to old age, but may also be caused by infection of the heart valves endocarditis. In some parts of the world rheumatic heart disease is a major cause of valvular heart disease, typically leading to mitral or aortic stenosis and caused by the body's immune system reacting to a streptococcal throat infection. While in the healthy heart, waves of electrical impulses originate in the sinus node before spreading to the rest of the atria, the atrioventricular node , and finally the ventricles referred to as a normal sinus rhythm , this normal rhythm can be disrupted.

Abnormal heart rhythms or arrhythmias may be asymptomatic or may cause palpitations, blackouts, or breathlessness. Some types of arrhythmia such as atrial fibrillation increase the long term risk of stroke. Some arrhythmias cause the heart to beat abnormally slowly, referred to as a bradycardia or bradyarrhythmia. This may be caused by an abnormally slow sinus node or damage within the cardiac conduction system heart block.

These arrhythmias can take many forms and can originate from different structures within the heart—some arise from the atria e. AV nodal re-entrant tachycardia whilst others arise from the ventricles e. Some tachyarrhythmias are caused by scarring within the heart e. Wolff-Parkinson-White syndrome.

The most dangerous form of heart racing is ventricular fibrillation , in which the ventricles quiver rather than contract, and which if untreated is rapidly fatal. The sack which surrounds the heart, called the pericardium, can become inflamed in a condition known as pericarditis. This condition typically causes chest pain that may spread to the back, and is often caused by a viral infection glandular fever , cytomegalovirus , or coxsackievirus.

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Fluid can build up within the pericardial sack, referred to as a pericardial effusion. Pericardial effusions often occur secondary to pericarditis, kidney failure, or tumours, and frequently do not cause any symptoms. However, large effusions or effusions which accumulate rapidly can compress the heart in a condition known as cardiac tamponade , causing breathlessness and potentially fatal low blood pressure.

Fluid can be removed from the pericardial space for diagnosis or to relieve tamponade using a syringe in a procedure called pericardiocentesis. Some people are born with hearts that are abnormal and these abnormalities are known as congenital heart defects. They may range from the relatively minor e. Common abnormalities include those that affect the heart muscle that separates the two side of the heart a 'hole in the heart' e.

Other defects include those affecting the heart valves e. More complex syndromes are seen that affect more than one part of the heart e. Tetralogy of Fallot. Some congenital heart defects allow blood that is low in oxygen that would normally be returned to the lungs to instead be pumped back to the rest of the body. These are known as cyanotic congenital heart defects and are often more serious.

Major congenital heart defects are often picked up in childhood, shortly after birth, or even before a child is born e. More minor forms of congenital heart disease may remain undetected for many years and only reveal themselves in adult life e. Heart disease is diagnosed by the taking of a medical history , a cardiac examination , and further investigations, including blood tests , echocardiograms , ECGs and imaging.

Other invasive procedures such as cardiac catheterisation can also play a role. The cardiac examination includes inspection, feeling the chest with the hands palpation and listening with a stethoscope auscultation. A person's pulse is taken, usually at the radial artery near the wrist, in order to assess for the rhythm and strength of the pulse.

The blood pressure is taken, using either a manual or automatic sphygmomanometer or using a more invasive measurement from within the artery. Any elevation of the jugular venous pulse is noted. A person's chest is felt for any transmitted vibrations from the heart, and then listened to with a stethoscope. Typically, healthy hearts have only two audible heart sounds , called S1 and S2. The first heart sound S1, is the sound created by the closing of the atrioventricular valves during ventricular contraction and is normally described as "lub".

The second heart sound, S2, is the sound of the semilunar valves closing during ventricular diastole and is described as "dub". A third heart sound , S3 usually indicates an increase in ventricular blood volume. A fourth heart sound S4 is referred to as an atrial gallop and is produced by the sound of blood being forced into a stiff ventricle. The combined presence of S3 and S4 give a quadruple gallop. Heart murmurs are abnormal heart sounds which can be either related to disease or benign, and there are several kinds.

Murmurs are graded by volume, from 1 the quietest , to 6 the loudest , and evaluated by their relationship to the heart sounds, position in the cardiac cycle, and additional features such as their radiation to other sites, changes with a person's position, the frequency of the sound as determined by the side of the stethoscope by which they are heard, and site at which they are heard loudest. A different type of sound, a pericardial friction rub can be heard in cases of pericarditis where the inflamed membranes can rub together.

Blood tests play an important role in the diagnosis and treatment of many cardiovascular conditions. Troponin is a sensitive biomarker for a heart with insufficient blood supply. It is released 4—6 hours after injury, and usually peaks at about 12—24 hours. A test for brain natriuretic peptide BNP can be used to evaluate for the presence of heart failure, and rises when there is increased demand on the left ventricle.

These tests are considered biomarkers because they are highly specific for cardiac disease. Other blood tests are often taken to help understand a person's general health and risk factors that may contribute to heart disease. These often include a full blood count investigating for anaemia , and basic metabolic panel that may reveal any disturbances in electrolytes.

A coagulation screen is often required to ensure that the right level of anticoagulation is given. Fasting lipids and fasting blood glucose or an HbA1c level are often ordered to evaluate a person's cholesterol and diabetes status, respectively. Using surface electrodes on the body, it is possible to record the electrical activity of the heart. An ECG is a bedside test and involves the placement of ten leads on the body.

This produces a "12 lead" ECG three extra leads are calculated mathematically, and one lead is a ground. There are five prominent features on the ECG: the P wave atrial depolarisation , the QRS complex ventricular depolarisation [h] and the T wave ventricular repolarisation. A downward deflection on the ECG implies cells are becoming more positive in charge "depolarising" in the direction of that lead, whereas an upward inflection implies cells are becoming more negative "repolarising" in the direction of the lead.

This depends on the position of the lead, so if a wave of depolarising moved from left to right, a lead on the left would show a negative deflection, and a lead on the right would show a positive deflection. The ECG is a useful tool in detecting rhythm disturbances and in detecting insufficient blood supply to the heart. Testing when exercising can be used to provoke an abnormality, or an ECG can be worn for a longer period such as a hour Holter monitor if a suspected rhythm abnormality is not present at the time of assessment. Several imaging methods can be used to assess the anatomy and function of the heart, including ultrasound echocardiography , angiography , CT scans , MRI and PET.

An echocardiogram is an ultrasound of the heart used to measure the heart's function, assess for valve disease, and look for any abnormalities. Echocardiography can be conducted by a probe on the chest "transthoracic" or by a probe in the esophagus "transoesophageal". A typical echocardiography report will include information about the width of the valves noting any stenosis , whether there is any backflow of blood regurgitation and information about the blood volumes at the end of systole and diastole, including an ejection fraction , which describes how much blood is ejected from the left and right ventricles after systole.

Ejection fraction can then be obtained by dividing the volume ejected by the heart stroke volume by the volume of the filled heart end-diastolic volume. This cardiac stress test involves either direct exercise, or where this is not possible, injection of a drug such as dobutamine. CT scans, chest X-rays and other forms of imaging can help evaluate the heart's size, evaluate for signs of pulmonary oedema , and indicate whether there is fluid around the heart.

They are also useful for evaluating the aorta, the major blood vessel which leaves the heart. Diseases affecting the heart can be treated by a variety of methods including lifestyle modification, drug treatment, and surgery. Narrowings of the coronary arteries ischaemic heart disease are treated to relieve symptoms of chest pain caused by a partially narrowed artery angina pectoris , to minimise heart muscle damage when an artery is completely occluded myocardial infarction , or to prevent a myocardial infarction from occurring.

Medications to improve angina symptoms include nitroglycerin , beta blockers , and calcium channel blockers, while preventative treatments include antiplatelets such as aspirin and statins , lifestyle measures such as stopping smoking and weight loss, and treatment of risk factors such as high blood pressure and diabetes. In addition to using medications, narrowed heart arteries can be treated by expanding the narrowings or redirecting the flow of blood to bypass an obstruction.

This may be performed using a percutaneous coronary intervention , during which narrowings can be expanded by passing small balloon-tipped wires into the coronary arteries, inflating the balloon to expand the narrowing, and sometimes leaving behind a metal scaffold known as a stent to keep the artery open. Sign In. The Heart. Figure 1. The pathway of blood through the chambers and valves of the heart. Two additional passageways are present in the fetal heart: The foramen ovale is an opening across the interatrial septum.

It allows blood to bypass the right ventricle and the pulmonary circuit while the nonfunctional fetal lungs are still developing. The opening, which closes at birth, leaves a shallow depression called the fossa ovalis in the adult heart. The ductus arteriosus is a connection between the pulmonary trunk and the aorta. Blood that enters the right ventricle is pumped out through the pulmonary trunk. Although some blood enters the pulmonary arteries to provide oxygen and nutrients to the fetal lungs , most of the blood moves directly into the aorta through the ductus arteriosus.

The coronary circulation consists of blood vessels that supply oxygen and nutrients to the tissues of the heart. Blood entering the chambers of the heart cannot provide this service because the endocardium is too thick for effective diffusion and only the left side of the heart contains oxygenated blood.

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