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Redefining Concepts of Diastolic Function with term of
Volumetric Interrelationship between Diastolic and Systolic
Functions is for Holistic Re-Recognition of Cardiac Functions
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Journal: Heart
Manuscript ID: Draft

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Article Type: Original research article
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Date Submitted by the Author: n/a
Complete List of Authors: geng, shizhao; Beijing Anzhen Hospital, Ultrasound Imaging Dept.
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CARDIAC FUNCTION, DIASTOLIC DYSFUNCTION < CARDIAC FUNCTION,

Keywords:
SYSTOLIC DYSFUNCTION < CARDIAC FUNCTION
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http://mc.manuscriptcentral.com/heart
Page 1 of 36 Heart
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4 Redefining Concepts of Diastolic Function with term of
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6 Volumetric Interrelationship between Diastolic and
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9 Systolic Functions is for Holistic Re-Recognition of
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11 Cardiac Functions
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Dr. Shizhao Geng
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19 Author Affiliation: Department of ultrasound imaging, Beijing An-zhen Hospital, Capital Medical
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21 University
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24 Correspondence Address: An-Ding Men Wai street, Beijing An-zhen Hospital, P. R. China.
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27 Zip: 100029
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Tel: 13683285831
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32 E-mail: gengshizhao2009@163.com
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The words number: 2984
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4 ABSTRACT
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6 Background The most severe problem in cardiologic domain is neither about Coronary artery disease
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9 (CAD) or Hypertension, and nor the Heart failure (HF) or Sudden cardiac death (SCD), but about
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11 misunderstanding of cardiac function, an inseparably functional wholeness, covering systole and diastole,
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14 which has referenced to all cardiac diseases. All the diseases have their respective causes and
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16 mechanisms, and also have their common substantial something that is cardiac function and its
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19 complicated changes. If no cardiac function reduced the cardiac diseases would not be disorders and
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21 they, such as HF and SCD, would not threaten people’s health and their lives. All the researches about
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24 each cardiac disease should be conducted with its functional states.

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Method and Conclusions Here, the logic analysis and qualitative analysis were employed rather than
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30 statistics method. Because usual measurement method in EF values has obviously overvalued, and has
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disobeyed the biological minimum action principle, the diastolic heart failure actually does not exist.
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35 Cardiac systolic function will represent its ability of providing blood volume, and diastolic function
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represents its compensatory ability of the heart. This is a functionalistic description of the heart function.
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40 As Echo Doppler E and A velocities in mitral inflow in diastole are mainly affected by systolic performance,
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not by the diastolic suction strength, If the term of blood velocity was replaced by blood volume,
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45 observing different relationships between diastolic and systolic functions (D-S) from functionalistic holistic
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48 notions, the diastolic function, systolic function as well as their complicated changes could be correctly
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50 recognized.
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53 Key message: redefining concepts of diastolic function
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Volumetric interrelationship
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56 Logic analysis
57 Compensation
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Page 3 of 36 Heart
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5 Introductions
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For a long time, our researches on cardiac function have dedicated themselves only to the systolic one
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10 without considerations on diastolic function and for more than 2 decades latest, the issue of diastolic
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function has been addressed on , being similarly isolated from the systolic in researches, yet they are
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15 still not able to promote anything to solve heart diseases3,4.
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20 In general, it is understandable that the velocity of E wave ≥ that of A of Echo Doppler profile in normal
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mitral inflow. However, the following viewpoints in current diastolic theory may not be logically correct
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25 about that the velocity of E ＜ that of A would indicate an abnormal diastolic function, and that viewing
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the extension of decelerating time of E as a presentation of diastolic reduction, and that diastolic damage
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30 often occurs previously to that of systolic ones, or when the latter occurs often accompanied by the
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former, and even that the concept of “diastolic HF” has been established in current diastolic theory, all
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35 of which, however, cannot be acceptable in fact.
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40 However, if ventricular systolic function, not diastolic function, has a little reduction, then a subtle blood
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residual will be accumulated in the ventricle, leading to cardiac preload rising and ventricular pressure
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45 elevation, and that enable pressure gradual (PG) between atrium and ventricle goes down. So, the E
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48 velocity in mitral inflow may also be diminished and A will be naturally raised in its velocity. In such
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50 situation, indicator of E velocity ＜ that of A should not be discussed in concept of diastolic abnormality.
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54 Method: Logic Analysis
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A comprehensively logic analysis method will be employed as chief study method in this article and even
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Heart Page 4 of 36
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4 in all cardiologic functionalistic studies.
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9 Diastolic performance may be existing and working immediately for systolic one along chiefly
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11 with a volumetric relationship between D-S
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14 In organism bodies, anything could not be existed isolated from all others. Diastolic and systolic
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16 performances and their interacting relationships comprised a wholeness of cardiac function. First of all,
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19 there is a volumetric relation between them for their working, rather than a velocity relation. In other
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21 words, the concepts and theories of diastolic function has to be established based on the volumetric and
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24 other relations of D-S. The reasons are as following:

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1) Both requirements on blood by body tissues from heart or by systole from diastole refer to the term of
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31 blood volumes. While the requirements are met, the cardiac functions can be regarded normal, in
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34 functional equilibrium status. So, cardiac output and stroke volume and the coronary vascular reserve are
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36 measured with blood volume unit .
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41 2) Ventricular end-diastolic volume is just the initial volume of systole; similarly, the end-systolic volume is
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44 the initial volume of diastole. The diastole must accept and send out usually the same volumes required
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46 by systole without any additional precondition. Responsibility of diastolic performance is to transmit and
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49 receive information from systole through the volumetric relations and to maintain cardiac balanced
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functions of D-S. In fact, heart has to regulate its ventricular cavity by volumes in diastole to adapt to an
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54 enlarged ventricle in systole. “Living organism is an open system, maintaining itself in, or approaching a
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steady state .” ”Once steady state conditions had become re-established, stroke volume was, of course,
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Page 5 of 36 Heart
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4 equal to the volume of blood that had entered the ventricles during diastole.”
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9 3) A balanced cardiac function refers to stroke volume equals to the amount of blood volume in mitral
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11 inflow, not more or not less, which may be a good indicator to show a normal cardiac performance in
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14 wholeness. It is a best status for myocardium to work with less effort and get better effects,
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16 corresponding with biological minimum principle that refers to “one leading to maximum effect with
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19 minimum effort is realized.” . Even in HF, heart is in pursuit of such aim and a living myocardium has
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21 such ability to overcome HF and to restore its normal contraction in lifetime, unlike a saying of “in
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24 congestive heart failure,decreased contractility is eventually self-augmenting” . The most important
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controls of a whole heart function may be “heterometric autoregulation” and “Homeometric

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autoregulation” . They are both volume control.
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34 4) Once diminished a systolic function, showing a lower E velocity, as mentioned above, and reactively
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36 longer its deceleration time, an essential augmentation of end-systolic volume without any exception.
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39 Here, the extension of deceleration time of E is an active process in energy-consuming, and therefore it
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41 has a longer time to allow more volume of E for mitral inflow, which is a manifestation of a strengthened
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44 rather than of an injured diastole.

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49 5）While E velocity is lowering, the A velocity in mitral inflow will certainly become taller reactively to
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51 maintain the inflow volumetric invariable, and atrium is “volume sensor of heart” 10.
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6) According to Frank-Starling mechanism, once was systolic function injured, the ventricle dilated in
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Heart Page 6 of 36
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4 diastole, which in turn to compensate the diminished systole by strengthening cardiac contractility. In
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6 other words, diastolic function could not only provide the same blood volume for a given volume of
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9 normal ejection, but also participate in the compensation to reduced systole for its requirement. “The
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11 Frank-Starling mechanism is the one that is certainly most ideally suited for matching the cardiac output
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14 to the venous return.” “When cardiac compensation involve ventricular dilation, the tension required by
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16 each myocardial fiber to generate a given intra-ventricular systolic pressure must be appreciably greater
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19 than that developed by the fibers in a ventricle of normal size” .
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24 7）As blood volume = flowing velocity × time through a given area of valve orifice, it means that blood
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volume covered two factors in Doppler imagine of its velocity and flowing time. Obviously, defining
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diastolic concept only with term of blood velocity may have ignored the time factor, thereby have lost the
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31 possibility to reveal the volumetric relationship between D-S.
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39 insufficient supplement fluids after cardiac surgical operation, or hypercatharsis can make acute
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41 variations of blood volumes in circulation leading to reduce systolic function and to lose its functional
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44 equilibrium resulting in worsening diseases; then, the diagnosis of them in time and correction of them
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46 promptly by a control of appropriate fluid volume in or out of body will be necessary measures of
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49 treatment.
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54 9) When a reduced systolic functions being progressively relieved, ventricle can eject out of the residual
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blood previously in it and start its compensation; it tends to restore ventricle to its original sizes and
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Page 7 of 36 Heart
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4 shape before myocardial ischemia and ultimately, to arrive at a new volumetric equilibrium of heart
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6 performances; and ischemic symptoms may be dismissed. This is also due to the role of Frank-Starling
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9 law. “The increased diastolic fiber length somehow facilitates ventricular contraction and enables the
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11 ventricles to pump a greater stroke volume, so that, at equilibrium, cardiac output exactly matches the
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14 augmented venous return.” 8
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19 10) ‘’It is the Frank-Starling mechanism that maintains a precise balance between the outputs of the
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21 right and left ventricles.it is apparent that even a small, but maintained imbalance in the outputs of the
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24 two ventricles would have catastrophic consequences.” The volumetric relationship in equilibrium is
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also a condition of other cardiac functional balances, such as that between right and left ventricles and
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that between atrial and ventricular performances.
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34 11) This is a discussion from falsification. “Many philosophers still argue that the failure to obtain at least
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36 a probabilistic solution of the problem of induction means that we ‘throw over almost everything that is
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39 regarded as knowledge by science and common sense.’” “The falsificationist demands that once a
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41 proposition is disproves, there must be no prevarication: the proposition must be unconditionally

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44 rejected.”
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46 Notice：in a long term observations, there is no such phenomenon at all: while E velocity＞A velocity,
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49 being accompanied with E integral＜A integral. So, it may deduce a coupling of lower E and extension
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of its acceleration. Both of them together revealed an accumulation of ventricular volume and
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54 atrioventricular PG is gradually decreasing. This is a manifestation of ventricular functional decreased
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could be conceived whenever ischemia persistent.
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6 12) The analysis above is not all of medical argumentation for volumetric relationship of D-S. Medical
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9 verification may be much more complicated than statistical methods. If the inferences above could
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in a potentially cardiologic model, the more
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14 rigorous verification for it would have been logically completed as it could explain the possible causes of
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16 HF and SCD and even promote to resolve them. If it does, the verification of it will be powerfully
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19 convinced.
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24 The suggestions on some other interrelationships between D-S:

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1) Energy relationship
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31 Ventricular energy-consuming in systole is constantly more than that in diastolic one, and much more
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34 than that in E wave. Logically, once blood supplying is insufficient for myocardium, even slightly, the
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36 earliest phase in circulation being affected must be the systolic one, never the diastolic one. It will never
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39 produce so-called “diastolic function seems impaired as a relatively early event.” . A piece of spread
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41 medical knowledge is that all of dead hearts would always stop their beats at end-diastole, rather than
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44 their systole without any exception. It means that myocardium, capable of doing its diastolic performance
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46 successfully, may not certainly be able to accomplish its systolic one, resulting in the death. Therefore, it
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49 is certainly impossible that “diastolic failure may occur on its own and often precedes systolic failure,
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2) Mechanical relationship
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4 As myocardial relaxation may produce a suction strength . Now, the problem is: whether or not the
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6 reduced suction could diminish the E velocity as diastolic dysfunction? The answer is no, the suction from
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9 diastole may have not main effects on E of the inflow. The reasons are as following:
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14 ①If reduced ventricular suction in abnormal diastolic function could diminish the E velocity, which would
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16 correspondingly accompanied by a form of extension of acceleration time of E, rather than its
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19 deceleration time, namely, the peak velocity of E occurs later within E period. However, it is not the facts
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24 diastole, whatever the diastolic functional stases are. But in my observation, in so called “abnormal
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diastolic function (E≤A )", there is only extension of deceleration of E, or even the disappearance of it as
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E being covered by A waves, a fused state of E and A, rather than an extension of acceleration time. It
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31 suggests that the construction of E is only concerning with natural PG between atrium and ventricle, and
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34 ventricular actively energy-consuming process is chiefly to maintain a longer diastolic phase and the
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36 original inflow volume in E. It may be a process for enhancement of diastole to compensate to the
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39 reduced systolic function.
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44 ② Another phenomenon: in comparison of a group of consecutive mitral E waves and that of their
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46 corresponding aortic waves in any identical patient with atrium fibrillation, all the mitral E waves have a
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49 roughly equal velocity, appearing about an even altitude of it, without A waves; whereas the aortic
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velocities are displaying in their absolutely different tallness. In statistical observation, the dispersion
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54 degree of E velocities is significantly lower than that of aortic velocities.
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4 In atrium fibrillation, absolutely irregular ventricular contractions are naturally accompanied with their
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6 irregular relaxations. The irregular contraction has produced absolutely uneven aortic ejections, but
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9 irregular diastolic relaxations did not produce the absolutely irregular E velocities; in other words, the
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11 absolutely irregular ventricular suctions did not participate itself in E velocity changes.
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16 ③ The pathophysiologic cause of this phenomenon may be simple: There is an isovolumic contraction or
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19 an isovolumic relaxation respectively before ventricular contraction and its relaxation. The former could
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24 originally and potentially irregular E’s suction, appearing a roughly same tallness of E in a form of similar
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E velocities.
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31 3) Time relationship
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34 Diastole must exists before systole to complete a cardiac cycle, which can only explain that Diastolic
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36 function does not participate immediately in supplying blood to whole body, then it would be impossible to
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39 produce so-called term of “diastolic dysfunction or diastolic heart failure with normal systolic function,”
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41 because the term of HF has involved in the issue of whether or not body’s requirement for blood volumes
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44 was met, not only limited in cardiac status alone. The normal systolic function implies that the body’s
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46 requirement has been met, and then, so-called the term of diastolic HF with normal ejection fraction (EF)
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53 Furthermore, there is another overestimation derived from index of Ejection Fraction (EF) for the systolic
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55 function, even to lead to such wrong terms on HF. The immediate reasons of wrong term of diastolic HF
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Page 11 of 36 Heart
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4 the biggest ventricular diastolic Echo section was determined, another section chose for end-systole has
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6 always a significant shift from the main section, is no longer the biggest systolic section, making the
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9 ventricular systolic measurement value is smaller than its reality, and the EF values get larger and
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14 biological principle of minimum work, and reflect real systolic function for a heart failure. On the other
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16 hand, incompressible blood has provided the more sensitive index to show “diastolic dysfunction” with
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19 symptoms of HF. This is a wrong way to conduct medical research in using two different measuring
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24 that leading to a wrong concepts on diastolic HF.

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Conclusions
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Here, the logic analysis and qualitative analysis were employed to observe different relationships
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35 between diastolic and systolic functions (D-S) from functional holistic notion, which has proved that the
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changes of E and A mainly reflect a systolic functional reduction. Because Echo measurement of EF
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40 values has obviously overvalued system function, and has disobeyed the biological minimum action
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principle, the diastolic heart failure actually does not exist. Cardiac systolic function will represent its
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45 ability of providing blood volume for body, and diastolic function represents its compensatory ability of the
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48 heart to reduced systolic function. This is a functionalistic description of the heart function.
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Discussion
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55 In epistemology, the cardiac functions should play the leading and fundamental roles in anatomic
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58 evolutions, and anatomy may be a specific form of some functions and obey the total demand of
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4 evolutions. Such views have been supported by Lamarck in his research of evolutionary biology. “The
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6 evolution of animals was impelled by their recognition of new needs. This in turn provoked behavior
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9 appropriate to the satisfaction of these needs, and behavioral change caused structural change which
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“Physiology is the logic of life.” The causes of various diseases are only exists in their logical
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19 relationship. So, logical analysis would be efficient study method to understand diseases and cardiac
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functions. Darwin’s practice in research of biological evolution has offered us a best way about how to
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24 analyze logically biologic phenomena. For example, Darwin confirmed his core idea: “natural selection is
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27 the mechanism of evolutionary change“, which “is not readily observable, but is inferred by argument
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29 from other kinds of observation. The argument is constructed from three apparently independent
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32 generalizations about the properties of organisms. These three generalizations then serve as premises
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34 or axioms for a formal syllogism whose conclusion is a further generalization about the properties of
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37 organisms. If the three axiomatic generalizations are valid, and if there is no other relevant valid
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39 generalization that has not been considered, then the conclusion must also be true and should be
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42 observable.” 16
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Of many relationships of D-S, the most important one may be volumetric relationship, around which heart
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49 is working; and other relationships have to be subject to it. In fact, heart in its performances is often
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52 encountering different troubles, such as myocardial ischemia or peripheral resistance increase,

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54 expressing a form of imbalanced volumetric relation of D-S, i.e. a reduction of systole of the heart. With
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57 imbalanced volumetric relations were frequently overcame, the heart performances can get another new
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Page 13 of 36 Heart
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4 equilibrium state, during which the heart performances were considered as relatively healthy states. Then,
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6 to keep a heart health, it will be necessary to maintain its functional equilibrium states, for which the best
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9 index may be a relative and dynamic index for different persons, rather than an absolute index, unlike
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11 that of hypertensive criterion by statistics from population.
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16 In such discussion and inferences, some presumptions and a coherent medical model are useful and
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19 necessary steps for a solution to cardiologic problems. Furthermore, according to the holistic and
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21 functionalistic views in general system theory18, so-called conception of cardiac diseases is simply about
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24 how long the distance is from present cardiac functional states to its equilibrium and how the present
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heart states deviate from a healthy equilibrium, which is also a relative concept for different individuals.
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Different heart diseases, even other non-cardiac diseases, should be defined based on the functional
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31 equilibrium, which can provide a relative inner steady environment of organisms. “The living organism is
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34 an open system, maintaining itself in, or approaching a steady state.” “There is the phenomena of
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36 so-called homeostasis, or maintain of balance in the living organism.Similar homeostatic mechanisms
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39 exist in the body for maintaining the constancy of great number of physiochemical variables.”7 In
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41 particular, a equilibrium volumetric relationship may indicate not only a balanced relation between D-S,
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44 and even include that of A-V, also that of right and left (R-L) ventricular functions. The clinical
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46 significance of evaluating D-S functions with Doppler has been far beyond the D-S functions themselves.
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54 Reference
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1. Sanderson J E. Diastolic heart failure: fact or fiction? Heart 2003, 89:1281-1282. [FREE Full text]
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Heart Page 14 of 36
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4 2. Petric M C, Caruana L, Berry C, J J V Mc Murray. ”Diastolic heart failure” or heart failure by subtle
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6 left ventricular systolic dysfunction? Heart, 2002, 87:29-31. [FREE Fill text]
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9 3. Michael RZ; Dirk LB. New concepts in diastolic dysfunction and diastolic heart failure: partⅠ,
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11 Diagnosis, prognosis, and measurements of diastolic function. Circulation, 2002;105:1387-1393
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14 4. Michael RZ; Dirk LB. New concepts in diastolic dysfunction and diastolic heart failure: partⅡ, Causal
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16 mechanism and treatment. Circulation, 2002; 105:1503-1508.
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19 5. Ramachandran SV; Daniel L. Defining diastolic heart failure, a call for standardized diagnostic
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21 criteria. Circulation, 2000;101: 2118-2121.
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24 6. Lionel HO. 10 Oxygen supply: coronary flow. See in: The heart physiology from cell to circulation.
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Lippincott-Raven, New York, 3ed Edition, 1998: 267-293.

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7. Lidwig vB. 2 The meaning of general system theory. See in: General System Theory. Foundations,
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31 Development, Application. George Braziller, Inc. New York, 1973: 30-53.
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34 8. Robert MB, Matthew NL. 8 Control of the heart. See in: Cardiovascular Physiology. C. V. Mosby,
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New York, 4 Edition, 1981:145-181.
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39 9. Lidwig v.B. 3 Some system concepts in elementary mathematical consideration. See in: General
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41 System Theory, foundations, development, applications. George Braziller, New York. 1973:54-86
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44 10. Lionel HO. 12 Ventricular function. See in: The heart physiology from cell to circulation.
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46 Lippincott-Raven, New York, 3ed Edition, 1998: 343-389.
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49 11. Imre L.: Falsification and the methodology of scientific research programmes. In: The methodology
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of scientific research programmes: philosophic papers Vol 1. First Paperback Edition 1980.
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54 Cambridge University Pub. New York: 8-48.
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12. Lionel HO. 13 Overload hyperytophy and its molecular biology. See in: The heart physiology from
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4 cell to circulation. Lippincott-Raven, New York, 3 Edition, 1998: 391
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6 13. Lionel HO. 16 Heart failure and neurohumoral responses. See in: The heart physiology from cell to
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9 circulation. Lippincott-Raven, New York, 3ed Edition, 1998:475-511
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11 14. Jonathan H. 2 Chapter The foundations of Darwinism in: Darwin, A very short introduction. Oxford
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14 University Press, London,1982:13-24.
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16 15. Lionel HO. 2 Control of the circulation. See in: The heart physiology from cell to circulation.
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19 Lippincott-Raven, New York, 3 Edition, 1998: 17-42..
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21 16. Jonathan H. 3 Chapter Natural selection and the origin of species. in: Darwin, A very short
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24 introduction. Oxford University Press, London,1982:25-37.

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26
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17. D. J. P. Barker. A new model for the origins of chronic disease. Medicine, Health Care and
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Philosophy, 2001, 4:31-35.
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31 18. Neil B: Foucault’s new functionalism. Theory and Society. 1994,12: 679-709
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40 Competing interests
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42 none
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4 Dear Editors
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6 I am pleased to send my manuscript to you for publication, titled as Redefining Concept of
7 Diastolic Function with term of Volumetric Interrelationship between Diastolic and Systolic
8 Functions is for Holistic Re-Recognition of Cardiac Functions
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11 Since I read an article: Diastolic heart failure: fact or fiction? In Heart 2003, 89:1281-1282
12 by Sanderson J E, and other articles, their opining is right, but they had not clearly
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13 elucidated questions of what it is wrong and of why it is wrong about concepts and theory
14 of cardiac diastolic function. In my remember, there were less then 7% of articles holding
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opposing opining to current diastolic functions in an European heart annual meeting of the
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17 assembly （ in 2002? ） , but now they have disappeared at all. This is a woeful
18 phenomenon of a minority subject to majority without sufficient discussions of logical
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19 analysis, and it will certainly depress or restrain some rational ideas.
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22 After that, I started my logical thinking on diastolic function and its relations with systolic
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23 function. Several years later, I believe I could clearly illustrate the insights of heart
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performances. Because current Cardiology ignored the relationships of interactions
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26 among many physiological actors, emphasizing just the pathological anatomic changes as
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27 foundations of clinical diagnosis, it may be the causes to mislead clinical theory, such as
28 diastolic heart failure. Modern General System Theory is one leading-edge theory
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specially applying to biological complex problems. It told us that any biological system has
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31 its 3 elements, the necessary factors, among which existing various relations, and
32 boundary conditions to distinguish inner and outer organism body. The substantial of the
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33 functions mainly refer to relations interacting among actors, such as between diastolic and
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systolic functions. Current cardiologic research about heart functions primarily dependent
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36 on changes in anatomic changes, such as Ejection Fraction, which even in normal value
37 could not be demonstrated as a valid proposition to prove diastolic heart failure existing;
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38 and even statistics may be less capacity to study functions and naturally leading a series
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of wrong point of views in diastolic theory.
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42 After a further study, when I understood that functionalism may be more advanced basic
43 theory to imply the functional study as a potential way to save Sudden Cardiac Death and
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Heart Failure and so on, I identified that the theory of diastolic function has to be
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46 explicated again from its preliminary concept and its volume relation to systolic
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47 performance for no more cardiac sudden death occurring since now on. Strictly,
48 functionalistic study should include structuralized study but not reverse, so, the former
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50 might be the direction for the later development.
51
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52 For all these, I started thinking of statistical clinical values. And then I try to make a logical
53 analyzing and to manage to build a solution to cardiologic problems. When I find a very
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55 wide and new horizon front of me I know a Systemic Cardiology should be more
56 interesting than current Anatomic Cardiology. The strength of logical analysis must be
57 stronger than that of statistics. I hope my manuscript could be published in Heart, I need
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3 your help. If it could be done I will return you a surprising.
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6 Well, I am a Chinese doctor, mainly engaged in Echo diagnosis, though the operator of
7 Echo is often acted as by technicians in western countries. My daily work is first materials
8 for my observations and thinking of. Echo as equipment through which all cardiac
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9 structure and details of its functions, and blood flow could be watched, measured and
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11 analyzed. So, Echo would be a determinant tool to provide information for clinicians. It has
12 actually become my hands to touch and feel, and my mind to analyze and conceive all
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13 things. If we could get many different conclusions with logical analysis from that based on
14 same Echo data with statistics, and even could reach a solution to prevent efficiently
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cardiologic problems, I believe that the logical analysis would be hopeful and useful.
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17 Someone said Medicine is Experimental discipline, whose development mainly dependent
18 on animal experiments. Besides that I believe there is a logically theoretical cardiology,
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19 which would unify all of conclusions from valid medical studies into an integrated
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21 theoretical wholeness; in this process all incorrect concepts and recognition will be
22 screened out and corrected, just like soil is best purifier or cleaner for climate water. Some
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23 the editorials, for instance, may be the pieces of theoretical medicine, and each
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experiment has to be raised up to a theoretical level to merge logically into a wholeness
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26 and be logically valid.
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27 Especially, when diastolic function could be verified to bear a role of compensation to

28 systolic functional ischemia, the volumetric relationship between diastolic and systolic
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functions would be further confirmed, from which diastolic functional theory could find its
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31 more profound clinical significances, it could further be discussed along with CAD studies.
32 And diastolic role, serving immediately systolic function, cannot be denied. Before such
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33 relationship are clarified or integrated, relevant discussion has to be inevitably conducted

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again.
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37 Thank you for your considerations
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Sincerely Yours
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42 Dr. Shizhao Geng
43 February 23, 2014
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4 Editorial (Reference 1)
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6 Diastolic Heart failure: fact or fiction?
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8 J E Sanderson
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9 ………………………………………………………………………………………………………
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11 Heart 2003; 89:1281-1282
12 The concept of “diastolic” heart failure grew out of the observation that many patients who
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13 had the symptoms and signs of heart failure had an apparently normal left ventricular (LV)
14 ejection fraction ( >0.45). Thus it was assumed that since systolic function was “preserved” the
15
problem must lie in diastole, although it is not clear by whom or when this assumption was made.
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17 Nevertheless, many guidelines followed on how to diagnose “diastolic” heart failure backed up by
18 indicators of diastolic dysfunction derived from Doppler echocardiography,1-3 and it was found to
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19 be common.4 This edifice is, however, built on a number of assumptions that are looking
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21 increasingly shaky. For example, is the ejection fraction a good index of LV systolic function? Can
22 diastolic function or dysfunction be measured accurately? And in any case can systole be
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23 separated so neatly from diastole?

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26 EJECTION FRACTION
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27 The ejection fraction has proved to be a robust measurement for epidemiological purposes but in
28 individuals it is highly unsatisfactory---it is dependent on many variables including most
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importantly afterload. Furthermore it tends to reflect mainly circumferential fibre shortening and
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31 takes little account of long axis function. In fact, studies of long axis shortening using the mitral
32 valve ring have shown that maximal systolic excursion by M mode echocardiography or peak
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33 systolic velocity by tissue Doppler imaging are remarkably sensitive indicators of systolic
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performance.5 We,6 and others,7 have used these techniques in patients with diastolic heart
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36 failure diagnosed according to the European guidelines, and shown conclusively that mean
37 systolic mitral annular amplitude and peak velocity were significantly lower than normal age
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38 matched controls, although higher than those with “systolic” heart failure.6 Recently end systolic
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elastance (stiffness) was also shown to be higher in patients with heart failure with “preserved
40
ejection fraction”.8 Thus, if a sensitive enough tool is used it can be shown that systolic function is
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42 not normal in those with diastolic heart failure despite a so-called normal LV ejection fraction.
43 The majority (95%) of our patients had LV hypertrophy suggesting that most of these patients
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with diastolic heart failure probably have hypertensive heart failure. Frequently the heart failure
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46 is precipitated either by some degree of ischemia or an arrhythmia.
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47 The question of whether we have the tools or the concepts to adequately describe and define
48 diastolic function or its abnormalities has recently been lucidly covered in this journal by Gibson
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50 and Francis.9 As these authors state “no simple definition of diastolic disease has emerged”.
51 Notwithstanding the lack of a theoretical framework, standard Doppler echocardiography indices
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52 derived from mitral inflow have been widely used for a crude or rough assessment of diastolic
53 function. Although a restrictive filling pattern is clearly abnormal and related to high atrial
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55 pressure and natriuretic peptide concentrations,10 the so called abnormal filling pattern is
56 strongly affected by heart rate and age, and is virtually universal in elderly subjects.11 Of course,
57 age related changes are not normal and increasing ventricular stiffness is part of the aging
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3 process. However, the presence of an abnormal relaxation pattern cannot be taken as more
4 abnormal than “normal” aging. Even if pressure----volume loops are derived at cardiac
5
6 catheterization, the measurement of a ventricular stiffness constant by applying an exponential
7 equation is not measuring stiffness but the extent that stiffness varies with volume changes, as
8 pointed out by Gibson and Francis.9 Even a perfectly normal heart will become abnormally stiff if
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9 the volume is increased enough. Therefore, there is no gold standard for diastolic dysfunction and
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11 we do not have the tools to accurately measure diastolic function; however, the early diastolic
12 velocity of the mitral annulus is a very sensitive measure of impaired overall ventricular function,
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13 indicating the value of assessing ventricular long axis function.12
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15
SYSTILIC FUNCTION
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17 It is often overlooked that the major determinant of diastolic filling is systolic function.
18 Incoordination during contraction leads to a notable delay in mitral opening and curtailment of
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19 the time for filling, and impaired contractility will reduce ventricular suction. This latter process is
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21 vital for rapid early ventricular filling and is likely to be the first process affected by declining
22 systolic function. In fact, it is theoretical nonsense to try to artificially separate systole from
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23 diastole----they are both part of a single contraction---relaxation cycle and a continuous

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process.13,14 It is likely and logical therefore to expect to find some abnormalities of systolic
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26 function in those with “diastolic” heart failure, just as it is well established that diastolic
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27 dysfunction is an integral part of systolic heart failure.11 In fact, the diastolic abnormalities in
28 those with “systolic” heart failure are more powerful predictors of outcome and mortality than
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the systolic abnormalities.15,16
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31 It is time therefore to abandon this artificial and increasingly meaningless distinction between
32 systolic and diastolic heart failure. This taxonomy has run its course and is no longer useful.
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33 Patients present with what appears to be heart failure clinically and it is better to try to
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determine the precise cause and treat appropriately. Each patient will have a mixture of systolic
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36 and diastolic abnormalities with some degree of incoordination. Most with so-called “diastolic”
37 heart failure will be elderly ladies who have hypertensive heart failure in disguise, and those with
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38 “systolic” heart failure will have severe ischemic heart disease or cardiomyopathy with
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pronounced ventricular remodeling. The consequence of using the LV ejection fraction in the past
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to classify patients has meant that almost half of our heart failure patients have been excluded
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42 from, all the previous heart failure treatment trials, and these studies will now have to be done
43 again in a more representative cohort. As throughout history, plausible but incorrect theories can
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4 Cardiovascular Medicine (Reference 2)
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6 “Diastolic heart failure” or heart failure caused by subtle left
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9 ventricular systolic dysfunction?
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11 M C Petrie, L Caruana, C Berry, J J V McMurray
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………………………………………………………………………………………………………………..
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14 Patients with the signs and symptoms of heart failure nut apparently normal left ventricular
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systolic function (and no other obvious cause of heart failure) present a puzzle. Accumulating
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17 reports suggest that up to one third, or even one half, of all patients with a clinical diagnosis of
18 heart failure are of this type.1-5 Resent studies suggest that these patients have a prognosis that is
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19 nearly as bad as that for patients with heart failure and reduced left ventricular systolic
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21 function.6,7 Despite this, we do not really understand what is wrong with patients who seem to
22 have heart failure and apparently preserved systolic function. Perhaps more important, we do not
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Though it has become popular to describe these patients as having” diastolic heart failure”
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26 caused by “diastolic dysfunction”, it is also possible that unrecognized, subtle left ventricular
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27 systolic function way be present. Diastolic dysfunction is usually assumed because some measure
28 of left ventricular systolic function is found to be within a normal range. Typically, this is left
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ventricular ejection fraction, left ventricular fraction shortening, or, more commonly, an ”eyeball”
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31 assessment. Recently, what is thought to be a better measurement of predominantly systolic
32 function has been described. Left ventricular systolic atrioventricular (AV) plane displacement,
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33 principally a measure of left ventricular systolic function, may be more sensitive than
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conventional indices.8-15 This technique measures longitudinal rather than circumferential
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36 shortening of the left ventricle.
37
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38 METHODS
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Patients
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The cohort of patients studied was that referred by general practitioners to a direct access
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42 echocardiography service at the department of cardiology at the Western Infirmary, Glasgow. The
43 indication for referral for all patients was suspected heart failure. The focus of this analysis was
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patients with preserved left ventricular systolic function (defined by conventional methods as
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46 described below). Patients with significant valve disease or atrial fibrillation were not studied
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47 further.
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50 Transthoracic echocardiography
51 All examinations were performed by a single operator (LC) on an Acuson 128XP10c (Acuson
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52 Corporation; Mountain View, California, USA). With the patient resting in the lateral decubitus
53 position M mode, two dimensional, and Doppler ultrasound examinations were carried out.
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56 Conventional measurements of left ventricular systolic function
57 Left ventricular systolic function was quantified using M mode fractional shortening (< 25% was
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3 considered impaired) and ejection fraction was measured using Simpson’s biplane method, as
4 described previously.16 Qualitative “eyeball” assessment of the two dimensional images
5
6 (categorizing all as impaired or preserved) was also carried out.16-18
7
8 Measurement of systolic AV plane displacement
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9 Systolic AV plane displacement was measured according to the methods of Willenheimer and
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11 colleagues.14 Briefly, this index was evaluated using two dimensionally guided M mode
12 echocardiography in the two and four chamber views. The regional displacement (in millimetres)
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13 was the distance covered by the AV plane between the position most remote from the apex
14 (corresponding to the onset of contraction) and the position closest to the apex (corresponding
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to the end of contraction, including any postejection shortening)------that is, the full extent of the
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17 displacement. This was measured in the septal, lateral, posterior, and anterior regions, and was
18 calculated from an average of four measurements. The mean of the systolic AV plane
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19 displacement in the four regions was then calculated.
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21 Table 1 Patient characteristics and medication
22 All (n=131) ≥10 (n=76)
AVPD≥ AVPD<10 (n=40)
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23 Patient characteristics
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Age (years) 72 (11) 70 (11) 73 (10)
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26 Male Sex (n, %) 46 (35) 27 (36) 15 (38)
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27 Systolic BP (mmHg) 149 (23) 152 (21) 145 (23)

28 Diastolic BP (mmHg) 84 (11) 83 (11) 82 (10)
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Heart rate (beats/min) 76 (18) 73 (18) 78 (19)
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31 Fractional shortening (%) 28 (8) 30 (7) 24 (9)
32 Ejection fraction (M mode) (%) 52 (13) 56 (11) 48 (14)
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33 Ejection fraction (Simpson’s biplane) (%) 42 (11) 48 (10) 34 (9)

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Hypertension (n, %) 55 (42) 38 (50) 13 (32)
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36 Myocardial infarction (n, %) 14 (11) 5 (7) 6 (15)
37 Coronary artery bypass grafting (n,%) 9 (7) 5 (7) 3 (7)
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38 Pulmonary disease ( n,%) 29 (22) 16 (21) 9 (22)

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Medication
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Diuretics (n, %) 90 (69) 48 (63) 32 (80)
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42 B blockers (n, %) 21 (16) 10 (13) 8 (20)
43 Nitrates (n, %) 29 (22) 15 (20) 11 (28)
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Calcium Channel blockers (n, %) 22 (17) 16 (21) 4 (10)
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46 ACE inhibitors (n,%) 17 (13) 4 (5) 11 (28)
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47 Aspiring (n,%) 36 (27) 20 (26) 11 (28)

48 Inhaled β2 agonists (n, %) 25 (19) 10 (13) 10 (25)
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Inhaled corticosteroids (n, %) 11 (8) 5(7) 4 (10)
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51 Oral hypoglycaemic agents (n, %) 6 (5) 4 (5) 2 (5)
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52 Lipid Lowering drugs (n, %) 4 (3) 3 (4) 1 (3)

53 Non steroidal anti-inflammatory drugs (n, %) 11 (8) 7 (9) 2 (5)
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Digoxin (n, %) 9 (7) 1 (11) 7 (18)
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56 Data are mean (SD) unless otherwise indicated. ACE, angiotension covering enzyme; AVPD,
57 atrioventricular plane displacement; BP, blood pressure
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3 RESULTS
4 Patients
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6 One hundred and forty seven patients with suspected heart failure were referred. Ten patients
7 had atrial fibrillation alone, two patients had valve disease alone, and four patients had both
8 atrial fibrillation and valve disease. The remaining 131 patients with suspected heart failure in the
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9 absence of valve disease or atrial fibrillation were the focus of the study. Table 1 summarises
10
11 characteristics of these patients. In keeping with epidemiological studies, the patients were
12 elderly and frequently women.
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14 Prevalence of abnormalities of systolic AV plne displacement in patients with preserved left
15
ventricular systolic function
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17 Between 21% and 33% of patients with “normal” left ventricular systolic function as determined
18 by conventional methods (fractional shorting, ejection fraction (by Simpson’s biplane method),
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19 qualitative “eyeball” assessment) were found to have abnormal systolic AV plane displacement
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21 (table 2)
22 Measurement of fraction shortening, ejection fraction by Simpson’s biplane method, and
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23 systolic AV plane displacement was not possible in 49 (37%), 36(27%), and 15 (11%) patients,
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respectively. An “eyeball” assessment was possible in each case.
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26
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27 DISCUSSION
28 The principal finding of this study is that a substantial proportion of patients with suspected heart
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failure and apparently preserved systolic function, as assessed by conventional measures, may
30
31 have an unrecognized reduction in left ventricular contractility. Depending on which measure of
32 systolic function and “upper limit of normal” is considered, between 21-33% of the cohort
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33 studied were found to have abnormally low systolic AV plane displacement. This finding raises the
34
possibility that many patients thought to have “diastolic dysfunction” may, in fact, have systolic
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36 dysfunction undetected by the measurements usually made when patients with suspected heart
37 failure undergo echocardiographic assessment. Before accepting this point of view, one must ask
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38 what exactly does systolic AV plane displacement measure and why should this index identify
39
abnormalities apparently missed by conventional indices such as fractional shortening and left
40
ventricular ejection fraction?
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42 Systolic AV plane displacement is quite different from left ventricular ejection fraction and
43 other conventional measurements of left ventricular systolic function. Whereas the latter assess
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45 Table 2 Systolic atrioventricular AV plane displacement (AVPD) in patients with preserved LV systolic function
46 Preserved fractional shortening Preserved LV ejection fraction by Simpson’s Preserved LV systolic function
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47 biplane method by “eyeball” assessment

48 Systolic AVPD (mm) ≥25% (55 / 82) ≥30% (34 / 82) ≥35% (68/95) ≥40% (57/95) (109 / 131)
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≥10 (n, %) 38 (70) 25 (74) 44 (65) 40 (70) 74 (68)
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51 8.2-9.9 (n, %) 13 (24) 9 (26) 20（29) 16（28） 25（19）
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52 6.4 -8.1(n, %) 3 (5) 0 (0) 3 (4) 0（0） 3（2）

53 <6.4 (n, %) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)
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Not measurable 1 (2) 0 (0) 1 (1) 1 (2) 7 (6)
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56 Total number of patients referred with suspected heart failure was 147. Two had valve disease alone, 10 had atrial fibrillation alone,
57 and four had valve disease and atrial fibrillation. The total number of patients studied was 131. Forty nine had no measurable
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3 fractional shortening (therefore, n=82 for fractional shortening (82+49=131). Thirty six had no ejection fraction measurable by
4 Simpson’s biplane method (therefore n=95 for ejection fraction by Simpson’s biplane method (95+36=131)). Fifteen had no
5
measureable AVPD. LV, left ventricular.
6
7 Mainly contraction of circumferentially orientated fibres, systolic AV plane displacement is
8 replaced more to contraction of longitudinal fibres.8-15 Systolic AV plane displacement assesses
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global left ventricular function as it is measured in four separate regions of the left ventricle
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11 (septal, lateral, posterior, and anterior) and, consequently, describes total shortening along the
12 left ventricular long axis.8-15 Though different from ejection fraction, AV plane displacement does
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13 correlate with the former measure.14 More important, reduced systolic AV plane displacement is
14
a powerful predictor of poor prognosis.14,19 Indeed, it is worth noting that patients with an AV
15
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16 plane displacement of < 10mm (that is, below our upper limit of normal) have a 25% mortality
17 rate at one year. This may be one explanation for the hitherto surprising observation that patients
18 with heart failure and abnormal left ventricular ejection fraction, around 25% of whom we would
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suggest have reduced systolic AV plane displacement, have a poor outcome.6 This is often not
20
21 much better than that of patients with a depressed ejection fraction. The high mortality in this
22 group of patients may also reflect the likely alternative diagnosis found in patients with suspected
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23 heart failure but preserved left ventricular systolic function.16 Patients with obesity, chronic
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obstructive pulmonary disease, and myocardial ischemia all have well recognized increased
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26 mortality.
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27 Systolic AV plane displacement may have one other important advantage over conventional
28 measures of systolic function. We were able to measure it in 89% of our population in contrast to
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fractional shortening, which could be measured in only 63% of patients, and ejection fraction
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31 (Simpson’s biplane method), measurable in 73%.
32 One limitation of our analysis and interpretation is that AV plane displacement may also give
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33 some measure of diastolic function as well as systolic function. However, the correlation between
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35 AV plane displacement and reliable indices of left ventricular systolic function is very strong (r
36 values > 0.8).9,10 That between AV plane displacement and indices of diastolic dysfunction is
37 much weaker.20,21 It is also difficult to know how to interpret correlations with indices that are
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38 themselves thought to be of uncertain value----for example, E:A ratio.

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40 Our findings add further to the emerging debate about what has been called “diastolic heart
failure”. Many suspected of having this syndrome have alternative explanations for their
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42 symptoms (such as chronic lung disease, myocardial ischemia, obesity) and may not have heart
43 failure at all.16 Even among those who do, there is difficulty in deciding whether “diastolic
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45 dysfunction” is present because there are few agreed upon no-invasive indices and those that
46 have been suggested show very poor concordance (resulting in vastly differing prevalences of
“diastolic dysfunction”).22 For this reason the term “heart failure with normal (or preserved)
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48 systolic function” has become ,ore popular and patients described in this way are now being
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50 recruited into two large placebo controlled outcome trials, one with an angiotension covering
51 enzyme inhibitor and the other with an angiotension receptor blocker.23,24 Our findings, however,
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52 suggest that even these terms may be imprecise. It may be more accurate to describe such
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patients as those with the syndrome of heart failure and a normal ejection fraction, or whatever
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55 conventional and a normal ejection fraction, or whatever conventional index is used. It may also
56 be time to start using AV plane displacement, a very readily obtainable and reproducible
57 measurement.
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3 (My opinion 1)
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5 Diastolic function research value is far from cardiac function
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8 itself
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9 Dr. Shi-Zhao Geng
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1. The diastolic function of current theory study is very casual, in the case of no according to is
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12 established according to the velocity of mitral valve E and A peak define the concept of diastolic
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13 dysfunction. Basic concept of error led to the theoretical system. To unify the concept of diastolic
14 heart failure and systolic heart failure.
15
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2. At this point, both of statistical and evidence-based medicine don't have the strength to rectify such
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17 misleading error, which showing that they also don't have enough ability to study cardiac function;
18 Logical analysis as method, like all other natural science, is a pathway to establish a real Theoretical
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19 Medicine. Without Systematic Theoretical Medicine, there would be no so-called Experimental
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Medicine and will not be able to understand the causes of all kinds of heart diseases.
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22 3. Heart functionalistic research will make up for the shortcomings of the structuralism study, and can
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23 realize actually the early diagnosis and early prevention of diseases and become the key to solve the
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24 problem of heart disease. The severe problem of current cardiologic research in structuralism may
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26 be ignoring that human body is a living system, and rejecting system method and functionalism for
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27 research, which have become the theoretical source for increasing Heart Failures and Cardiac Heart
28 death.
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4. Now, it is time to try to establish an effective Cardiovascular Preventive Medicine. To do this, it has
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31 to start our work from clarifying the concepts of diastolic function and its theory system.
32
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(My opinion 2)
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43 Alert to a statistical
statistical trap in its improper application and its medical
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45 misleading
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47 Dr. Shi-Zhao Geng

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49
50 Introduction
51 For a long time, the majority of clinically cardiologic research is often discussed a
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52 1, 2, 3
special, or a given problem of diseases And they all used the statistics as their
53 common method in their researches. But most of the researches without statistics
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55 would be restricted, or even rejected. Especially, after the birth of epidemiology that
56 had contributed to establish a wide expectation to the statistics in medical research.
57 All of the researches, since then, were taking place under the guidance of the
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3 statistical methods without any exception. Clinicians expect to solve all the
4 cardiovascular diseases with help of statistics like its overcoming tuberculosis
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6 completely, yet far from achieving this goal.
7 As issue of causations in most cardiovascular diseases has not been solved, such a
8 widely used statistics must bear the corresponding responsibility: the excessive or
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9 improper applications of statistics have been misleading our study.
10
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12 The success for statistics to be applied to epidemics may not be equally
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13 successful in solution to the cardiovascular disease
14 Significant cardiovascular diseases, including coronary heart disease, hypertension,
15
diabetes, high cholesterol, and heart failure, sudden cardiac death, etc, including
id
16
17 their etiology, pathogenesis, pathological changes, and their treatment are all
18 different from that of epidemics of infectious diseases and microorganisms, which
en
19
had the real epidemic process, pathogenic organisms, and some specific medicine
20
21 for their treatment, then the most of first class of infectious diseases are now
22 eliminated. The fundamental reason is that the essence of pathogenic
t
23 microorganisms came from outside the human body and by chance invaded the
ia
24
human body and caused the disease. Various lesions and processes of the diseases
25
26 cannot integrate both metabolisms of pathogenic microorganisms and of the body
l:
27 into harmonic union of body. At any link of epidemic process in individual, the
28 special clues related to the pathogen can easily be found by statistics, and thus the
Fo
29
cause of disease can be determined and eliminated from body. The statistically
30
31 Indirect demonstration was almost supporting with clinically direct verification for
32 the causes, and soon will invent the specific remedy for these potent infections.
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33
34
Relatively speaking, the etiology of a variety of viral diseases, although very clear,
35
36 the metabolism of such pathogens are often peacefully associated with the body's
37 normal cell metabolism and hard to separate both of them, therefore, it is difficult to
ev
38 produce therapeutic cure. This kind of infectious disease is almost impossible to

39
eradicate from body, the Hepatitis B virus, HIV are like this.
40
ie
41
42 So far, any major independent cause in most cardiovascular diseases could not be
43 found just because these diseases are not caused by the foreign pathogens, but by
w
44
the body's own metabolic processes that deviated from the physiologically healthy
45
46 function, and no clear demarcation line between physiologic and pathologic
On
47 conditions for us to distinguish or diagnose the diseases. Over the years, for
48 instance, we have taken 140/90mmHg as a bottom line for diagnosis of
49
50 hypertension, and another bottom line of the ejection fraction of 50% for diagnostic
51 criterion of systolic function normal or abnormal. Such quantitative standards make
ly
52 each patient or doctor readily compare the changes of disease, because people had
53 accustomed to simple thinking 4, but which, in fact, is just contrary to the actual
54
55 situations of complex cardiac metabolic diseases. Such diagnostic standards may be
56 derived through the statistics dealing with populations. Why, then, statistics has
57 also been so widely used?
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Heart Page 26 of 36
1
2
3
4 It is reductionist thinking has selected Medical Statistics, and, in return,
5
6 Statistics concealed the disadvantage of reductionism in medical research
7 The contents of medical research is extensive and complex, and branch of medicine
8 is more and more fine, and their philosophical basis may be reductionism 5, which is
Co
9 leading the research; but this kind of thinking is not suitable to use for such complex
10
11 living systems of body. The reductionist thinking pursues discoveries in the
12 microcosm world, and hopes to solve clinical problems later. Such thinking manner
nf
13 belongs to a "bottom-up" strategy; but another kind of study is a "top-down"
14 strategy 5, which is focusing on the holistic research of body, and starting the
15
research from whole of body, adhere to the overall point of view, and gradually
id
16
17 going into the microcosm world. It is a systematical research. Though modern
18 system theory has now been very mature, its concepts, methods and principles are
en
19
seldom applied to clinical research.
20
21
22 It is reductionist thinking that selects the statistical method as common and
t
23 fundamental method for all medical research. Because the mathematical basis of
ia
24
statistical methods in line with the expectations of many researchers for
25
26 quantitatively theoretical research and empirical argument; and statistics upholds
l:
27 the figures showing of a randomized, controlled study, or probability of study 6,7 in

28 line with the simple thinking of people for the subjective understanding of complex
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29
medical procedures and medical proof. The emergence and development of
30
31 evidence-based medicine and Meta-analysis 8, at least proved a defect of statistics
32 alone as common method in studies, and showed the concern and expectation of
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33 researchers for new methods of medical argument.

34
35
36 On the other hand, statistics, in return, mask disadvantages of reductionism. The
37 reductionist thinking ignored the integrity and wholeness of the human body, and
ev
38 expected to find something in microworld, a lower level in a system, to favour of

39
dealing with anything in body. The reductionism had made significant contributions
40
to modern science and society in history. Newton’s achievement is still results with
ie
41
42 simple thinking. He had fully simplified the natural phenomena that are originally
43 not very complex in a close system to formulate his generalizations. However, a
w
44
human phenomenon cannot be arbitrarily divided in study; especially,
45
46 cardiovascular diseases cannot be based on subjective design to develop pilot
On
47 programs, “animal models, none of which successfully duplicate the human

48 condition.” 9
In beginning of human study, we may lack understanding of some
49
50 phenomena, if interactions among various factors in vivo that could be casually cut
51 off, physiological and pathological functions in forms of various logical relations
ly
52 were inevitably given up, falling into a one-sided look at the issue, which would
53 certainly lead to error. For example, unaware of the relationship between
54
55 hypertension and coronary heart disease (CHD) would be impossible to understand
56 their causes, because the two are inseparable. But the statistics was just used to
57 support both of them in isolated researches. This is a wrong way to put a scientific
58
59
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Page 27 of 36 Heart
1
2
3 method in an inappropriate place. “A system can be defined as a set of elements
4 standing in interrelations”, “They could become problematic and lead to confused
5
6 conceptions in biology, psychology and sociology only because of …the tendency
7 being towards resolution of phenomena into independent elements and causal
8 chains, while interrelations were bypassed ”10 General Systems- theory was born
Co
9 just to solve the complex problems, and its holistic notion is just to keep all those
10
11 relevant relationships not to be ignored or distorted. This is a prerequisite to gain
12 the correct recognitions from medical research.
nf
13
14 Improper application of statistics in medical study seems not to be able to
15
solve the complex problems
id
16
17 Before our discussion on specific issues of statistics, there is another instance very
18 interesting: every morning the Sun rises from the east, and falls down to the west.
en
19
No doubt, this probability is 100%, but it cannot prove that the sun revolves round
20
21 the earth. It is in the wider solar system Galileo solved this problem through logical
22 analysis. From this case, many suggestion may possibly be gained:
t
23
ia
24
1) First of all, this is an issue of probability. The statistical probability is one of main
25
26 research contents, but it is essentially a principle of minority subject to majority.
l:
27 This principle can be applied to the administrative elections, but not be suitable to
28 scientific research, or otherwise it will stifle all germ of scientific innovation and curb
Fo
29
the development of medical science. “Living systems maintain themselves in a state
30
31 of high order and improbability”.11
32
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33 2) Second, the case involved 2 kinds of logic relationships, a statistical and another
34
intrinsic relationship of celestial mechanics, professional relations. The former are
35
36 not capable of replacing the later to reveal the truth of things. Statistical reasoning
37 is no more than an incomplete inductive inference in logic, cannot explain the direct
ev
38 causes of diseases. Statistical conclusions obtained for causations can only suggest
39
the "risk factors". If the logical reasoning on the human body were actually
40
abandoned, just because of excessive application of statistics, the study would have
ie
41
42 been far away from the causation research, because the causes only exist in body’s
43 inherent relations. The different scientific method must be used dependent on
w
44
different objects. There is no panacea to solve all problems in the world. The
45
46 complexity of human science is mainly reflected in that of their functional
On
47 relationship, to which it demands logical analysis. Statistical relationship is only one

48 kind of various logical relationships, not manifesting as personal logical character in
49
50 diseases development. "Physiology is the logic of life" 12.The real causes of acquired
51 heart disease have never been discussed by taking heart physiology as a starting
ly
52 point of the disease development, Ignoring the root causes stay only in physiological
53 state.
54
55
56 3) The pathological process or phenomena in cardiovascular diseases are all
57 consequences of the interaction among multifactor, and manifested throughout the
58
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Heart Page 28 of 36
1
2
3 circulatory system.” When we appraise arguments, we can do so from several points
4 of view.” 13
Such examples are a variety of syndrome: as "nephrotic syndrome”,
5
6 “coronary syndrome" and “metabolic syndrome," and so on. In fact, the complex
7 human phenomena are almost all the consequences by multiple factors
8 interactions.
Co
9
10
11 But, reductionism described human system from different aspects of pathologic and
12 anatomic status, which is easy to establish statistical diagnostic criteria for each
nf
13
single disease in population. In order to explain correctly cardiac phenomena,
14
15 however, an appropriate system level must be correctly chosen, make all elements
id
16 and their relationship are included in consideration because any system is organized
17 a hierarchy structure following system principles by multiple factors and their
18
en
interacted relations. “The mechanistic concept…emphasized…the reduction of
19
20 biological processes to laws known from inanimate nature. In contrast to this, in the
21 theory of open system, principles of multivariable interaction become apparent.”11
22
t
According to the logic of celestial mechanics analysis must be the sun and the earth
23
ia
as a larger system, considering the interaction between them. Although the earth
24
25 also is a system, but cannot contain the right relationship, so can't properly explain
26
l:
this phenomenon. In order to solve the problem, the Sun and the Earth and their
27 relationships have to be taken in consideration. This is an important system
28
principle: high level theory can help to solve the problem in lower level.
Fo
29
30 “Centralization and hierarchic order are achieved by stratification, i.e., by
31 14
superimposition of higher ‘layer’ that take the role of leading parts” , which has
32 become one of effectively way to manage to solve the cardiovascular problems. But
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33
34 statistical random principle would reject system concept, which may be the reason
35 of “correct statistics” and “non-correct consequences”. In fact, the relationship
36 between hypertension and CAD is as that between the Earth and the Sun
37
ev
inseparable, independent study of them would never get their logical causes.
38
39
40 4) When we fully understand the movement of the Sun and the Earth, about which
ie
41
any debate no longer exist theoretically. Now we have more understood of the
42
43 human body or diseases in their anatomical structures, and less understood their
w
44 changes in their body functions. These are enough to lead our research to
45 disorientation. The biggest deficiency of modern medicine lies in the lack of the
46
research of functionalism.
On
47
48
49 The primary purpose of reductionism of pursuit of something in micro-world is
50 kindness: it seeks the smallest physical unit which will represent the whole
51
ly
organism, and to be used as substantial basis to explain various biological

52
53 phenomena. But looking from the functionalism, the smallest unit, corresponding to
54 complexity of the human body, should be some functional relationship, rather than
55 some anatomic structures. So, corresponding to cardiovascular disease, the unit
56
57 should be a special functional relationship between myocardial ischemia and its
58 compensation, which will act as an integrated concept, a most basic unit to explain
59
60
Page 29 of 36 Heart
1
2
3 all of cardiovascular diseases, and the center content of the medical model, from
4 which we seem to be able to manage to make an overall solution to cardiovascular
5
6 diseases, just like the action and reaction both of which can explain most of the
15
7 mechanical phenomena as the chief principle of new functionalism. The
8 functionalism and method of system theory will make up for the deficiency.
Co
9
10
11 Modern medicine emphasizes that anatomical structure is functional carrier, and
12 pathological anatomy is previous to pathological function. The clinically diagnostic
nf
13 criteria, thereby, are mainly based on pathological anatomy, not benefit to the heart
14 functional, especially early functional studies and to causations. For example, the
15
issue being now confirmed is that myocardial ischemia can occur after coronary
id
16
17 artery obstructed, but avoided meeting the problem of ischemia before coronary
18 blocking. We cannot blame the statistical unscientific, but statistical data in study
en
19
are often come from the observations of morphology and anatomy, and it is not
20
21 good at functional observations. When the evidence of pathological anatomy was
22 emphasized, it has lost the chances of early diagnosis and prevention of the
t
23 diseases, and it may also not be able to realize understanding of true functionalism,
ia
24
because the statistical study is not primarily adapted to that of functional relations,
25
26 which may be more suitable to take logical reasoning.
l:
27
28 From the biological evolution, biologic functionalism could be overwhelmingly
Fo
29
accepted. Individual of organisms is just the smallest unit of the overall process of
30
31 the evolution, which merely reflects an epitome or a moment in overall functional
32 evolution. Functionalist views can fully and integrally explain various cardiovascular
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33 diseases and further interpret them with mechanisms, involving relevant changes in
34
various pathological anatomy; whereas from notions of pathological anatomy alone,
35
36 it seems not be able to explain the complex etiology and mechanisms of
37 cardiovascular disease.”Natural selection is the mechanism of evolutionary
ev
38 change…it is not readily observable, but is inferred by argument from other kinds of
39
observation….If the three axiomatic generalizations are valid, and if there is no
40
other relevant valid generalizations that has not been considered, then the
ie
41
42 conclusion must also be true and should be observable” 16 Darwin's work has proved
43 that the importance of logical analysis in biological study.
w
44
45
46 In short, functionalism argued that functional change is a thread to dominate the
On
47 biological evolution, but we have to speculate it only through their anatomical

48 changes, and in turn, the correct speculation of functional changes will promote the
49
50 understanding of the anatomical changes. If awareness of the logical relationships
51 between diastolic and systolic functions by logical analysis, it would be proved that
ly
52 the current concept of diastolic function may be invalid; If awareness of the

53 relationship between hypertension and coronary heart disease, we would find what
54
55 was their real causes!
56 In order to solve cardiac problems, even all medical problems, a new system
57 medicine or functionalistic medicine should be developed, a new biomedicine theory,
58
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60
Heart Page 30 of 36
1
2
3 in which functional changes will lead its theory or paradigm 5. At that time, the lack
4 of statistics will be more obvious. “The new paradigm does cover new problems,
5 17
6 especially those previously rejected as ‘metaphysical” .
7 In facing of the open living system of human body, the properties of reductionism
8 and statistics may also bring many potential difficulties to our research, which could
Co
9 be realized only with system theory.
10
11
12 5) The medical research is developing gradually into the microcosm under
nf
13 reductionism, it will continue to increase comprehensive dimensions of research,
14 whose information will increase geometrically. Generally speaking, in medical
15
research, there is only one relationship between two elements, three relationships
id
16
17 among the three, and the six relationships among the four, and ten elations from
18 the five elements, and so on, for each additional one element in the group of
en
19
information more than one relationship will be occurred. Statistics supported the
20
21 microscopic study of the world, and its consequences may hard to be integrated into
22 their wholeness, or even further away from the overall reality of the complex
t
23 information. In a system, the whole is not the same as the sun of its parts. “Things
ia
24
(phenomena) should be studied as transcendental wholes and not as mere
25
26 aggregates of parts.”18 Adhere to the quantitative study in microscopic world, under
l:
27 the guidance of reductionism that will encounter insurmountable difficulties in

28 integration of all information and relations. General system theory has a concept of
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29
three elements: the necessary factors, the relationships among the factors and their
30
31 boundary conditions that would be supporting a biological holistic study.19 Facing
32 the complexity of human body, it is necessary first to establish the correct direction
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33 of the holistic study, so as to avoid losing its way in details of the study.
34
35
36 6) Statistics needs quantitative data; and a quantitative research has been seen as
37 a high level of aspiration by medicine researchers, while qualitative research seen
ev
38 as a low level of it. This may have confused the relationship between qualitative and
39
quantitative studies. Qualitative research is not shoddy, but should be the basis of
40
quantitative research. Although all of the phenomena interacting by factors in vivo
ie
41
42 are with strict quantifiable indicators, which are all the results of biological evolution.
43 Our research of the human body cannot re-take this way of evolutionary process,
w
44
except for an approach from the outside to inside, from the brief to fine, from the
45
46 overall to partial and from qualitative to quantitative research, which is also in line
4
On
47 with further cognitive process of human “There are, however, many aspects of
48 organizations which do not easily lend themselves to qualitative interpretation….So
49
50 we have to content ourselves with an ‘explanation in principle,’ a qualitative
51 argument which, however, may lead to interesting consequences” 20. It would be at
ly
52 least impossible in quantitative description of the common nature of complex

53 systems.
54
55
56 7) Statistical application often requires the repeatability of biological phenomena or
57 biological data to prove something. Complex biological phenomena involving
58
59
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Page 31 of 36 Heart
1
2
3 various effects from each objective and subjective factors, like a philosophical
4 maxim: it is impossible to step twice into the identical one river.”Because
5
6 consciousness is always changing, we can never experience the same thought or
7 sensation more than once.”18, 21
Any biological data cannot be simply repeated,
8 whereas the repeatable things are only some qualitatively common causes or
Co
9 mechanism and the centre content, based on which those data have been produced,
10
11 which are not fit to be quantified in early study.
12 All the medical data or information processed by statistics may be homogeneous
nf
13 material and uniform single monomers, which can even be considered as a rigid
14 body without changes in their internal structure and function. Their groups can form
15
a complex situation in unorganized status. “the disorganized situations with which
id
16
17 statistics can cope”22 For instance, the Statistical Mechanics is an independent
18 discipline just as the statistical objects are uniformed gas molecules, whose
en
19
structure and properties are relatively unchanged. The various patho-physiological
20
21 phenomena in body are all highly organized complex issues. The same clinical
22 manifestations in different patients or phases of diseases may have different causes,
t
23 and different presentations may have the same cause. Changeability of clinical data
ia
24
processed by statistics would surely alter the statistical results at any time; yet,
25
26 increase the statistical samples can remain much a stable statistical result, but far
l:
27 away from the personalized differences, not finely to reflect the subtle changes of
28 individual diseases.
Fo
29
30
31 8) All of the mentioned situations above are due to the departure from the logical
32 relationships inherent in development of the disease. These relationships only exist
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33 in each individual, because of the occurrence and changed of the disease are based
34
on individual units, rather than changing according to the statistical logic in
35
36 population; “the phenomena of life are found only in individual entities called
37 organisms”23 namely, the individual differences and their common property in
ev
38 crowd of physiology and disease must be simultaneously respected. Statistical

39
methods and purpose should apply only to the crowd, a part of the crowd, do not
40
apply to individuals, and has made disorder in medical theory and practice. Thus
ie
41
42 chaos theory has not only been encouraging different patients to use the same
43 diagnostic criteria for same diseases, but also encouraging them to take same
w
44
treatment programs, not meeting with the individual logic of diseases. Even if taking
45
46 medicine lifelong, it will not cure the disease.
On
47
48 The diagnostic criteria of personalized medicine should fully reflect the
49
50 characteristics of human body system. Facing changing human functions, many
51 statistical standards in clinical application have become fixed ones forever in
ly
52 quantification that basically did not reflect the dynamic function of individual organs,
53 such as the diagnostic criteria of hypertension. Therefore, the criteria are unfit, as a
54
55 gold standard, to each individual patient. So-called gold standard should have rigid
56 principles that are not readily to vary, and joined by multiple flexible indicators, all
57 of which are all integrated in a group of information to guide diagnosis of disease in
58
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Heart Page 32 of 36
1
2
3 individuals. Personalized medicine should be hence developing direction.
4 Personalized medicine will suggest that medical research have accepted the system
5
6 characteristics of human body.
7
8 9）Personalized medicine is not equal only to consider the individual features. More
Co
9 important is to find their commonness. "How then is it possible to get knowledge of
10
11 the infinite individuals? For all things that we come to know, we come to know in so
12 far as they have some unity and identity, and in so far as some attribute belong to
nf
13 them universally." 18
To get such common features needs to maximize
14 summarization of all the commonness of heart diseases,-----which may do nothing
15
with size of clinical samples in observations; and such features of different diseases
id
16
17 will be a basis on which various diseases could be derived. For normal human body,
18 their commonness is in physiology and anatomy, for clinical disease is still the
en
19
content, just with different levels and forms. Specific to cardiovascular disease,
20
21 their commonness is about ischemia and its compensation, such a concept is
22 impossible to quantify, but it can sum up all of heart diseases and their individuals.
t
23 That is to say, the description of the disease should include the unchanged “hard
ia
24
core” theory and a “protective belt”. 24 So, our disease diagnostic criteria should also
25
26 be consisted of the two aspects.
l:
27
28 10) Typical statistical approach is to take observations from partial individuals
Fo
29
(sampling) as replacement of the understanding from all individuals, and then to
30
31 put the statistical conclusions to guide the diagnosis and treatment of every
32 individual.
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33 Theoretically, the former process belongs to inductive inference in Format logic,

34
whose conclusion may be probable, because it is impossible to observe all
35
36 individuals; and the later process may be a mandatory action to apply a statistical
37 conclusion or a criterion from population on the different individual diagnosis or
ev
38 functional evaluations that has confused 2 kinds of conceptions of general concept

39
and collective concept.
40
The collective concepts could represent the aggregate traits only in part of all
ie
41
42 individuals, not represent the common properties, or illness, in all individuals, such
43 as statistical results. Whereas personal property could be represented by general
w
44
concept, because the results by logical analysis have ability on behalf of the
45
46 common characteristics of all individuals; its conclusion is just a general concept in
On
47 logic, which fully summarizes the common properties for all people, namely, for
48 each individual25; Particularly, under the guidance of holistic notion the logical
49
50 analysis can constitute a complete inductive reasoning, its conclusion is considered
51 to be necessarily valid, which, therefore, have the argumentative authorities in
ly
52 clinical medical research.

53
54
55 Conclusion
56 We insisted that statistics is a scientific method, which can describe a complex
57 phenomenon from many aspects in population. But these respective descriptions of
58
59
60
Page 33 of 36 Heart
1
2
3 the human body cannot become an excuse to sever intrinsically complex links of
4 individual disease. Psychological data including emotions, thinking, mental stress;
5
6 laboratory information, such as blood pressure, blood lipids, blood glucose, and
7 other clinical data in anatomical and functional changes must come from a unitary
8 26
medical model to explain human behavior, and then to illustrate disease . The
Co
9 most of natural and social disciplines are built on the basis of the inference of logical
10
11 relationships in discipline itself, not simply on the basis of the statistical analysis.
12 Here, it is said that medical problems could not be resolved by statistics alone.
nf
13
14
Discussion
15
Of the 12 items above, each of them alone is not an absolutely right or wrong
id
16
17 principle that must be considered in medical research. Reductionism is in such a way,
18 through statistics, to reject the system theory.
en
19
As an opened and complex living system, human body is highly organized structure
20 26
21 in form of hierarchy . Cardiac anatomy and its functions in body system are
22 absolutely indivisible. It is the reason that we have to discuss something in body
t
23 under a comprehensively understanding of the 10 items above, and we can find that
ia
24
the reductionism and the system theory cannot be reconciled with each other. This
25
26 is the issue of the Sun and the earth could not be solved simply by statistics.
l:
27 Fortunately, systems theory and its methodology have been mature, and it has now
28 been the time to consider solving cardiac problems, because of what we need may
Fo
29
not be more medical knowledge, but the system thinking and system methods. “The
30
31 systems approach was introduced as an antithetical approach whose very essence
32 lies in opposing reductionism (both in science and in design) due to its incapacity to
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33 deal with the holistic transcendental character of phenomena.”18 Notice: we need

34
now to manage to identify some solutions to the cardiac problems as our overall
35
36 goal to avoid meaningless discussion and hopeless research.
37
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38
39
40 References
1．K.M. John C, Prakash P. P, Marcus F, Riccardo W, Karen S, Isabelle R, Shelley R.H,
ie
41
42 Dudley J. P, Philip J. K, Gilles D. D, John R. P. Coronary artery bypass with or
43 without mitral annuloplasty in moderate functional ischemic mitral regurgitation,
w
44
final results of the Randomized Ischemic Mitral Evaluation (RIME) Trial. Circulation
45
46 2012; 126:
126 2502-2510.
On
47 2. Seema P, Frederick K, Ravindra G, Pushkar K, Newry C, Richard E. S, Sripal B.

48 Percutaneous coronary intervention versus optimal medical therapy in stable
49
50 coronary artery disease. Circulation: Cardio Inter, 2012;5
5: 476-490.
51 3. Yurong Z, Jaakko T, Pekka L, Yujie W, Riitta A, Gang H. Lifestyle factors and
ly
52 antihypertensive treatment on the risks of ischemic and hemorrhagic stroke.

53 Hypertension: 2012; 60:
60 909-912.
54
55 4. Nicholas R. 3 Cognitive progress in a complex world: destabilization and
56 complexification. In: Complexity, a philosophical overview. Transaction Pub.
57 London.1998:55-74.
58
59
60
Heart Page 34 of 36
1
2
3 5. Hans M. S. The holistic claims of the biopsychosocial conception of WHO’s
4 international classification of functioning, disability, and health (ICF): A conceptual
5
6 analysis on the basis of a pluralistic-holistic ontology and multidimensional view of
7 the human being. J Med and Philo. 2012, 0: 1-18.
8 6. Marsteller J. A., Sexton, J. B.P, Hsu Y.-J., Hsiao, C-J., Holzmueller, C. G., Pronovost, P.
Co
9 J., Thompson, David A. A multicenter, phased, cluster-randomized controlled trial to
10
11 reduce central line-associated bloodstream infections in intensive care units. Crit
12 care Med. 2012, 40 (11):2933-2939.
(11)
nf
13 7. Omar W.-P., Stavros G. D., Abdallah G. K., Jose N. N., Edward M. G., Melanie E., Rami
14 A., Kim Bz., Feras M. B., Dean Y. L., Craig H. S., Josef S. Morbidity and Mortality in
15
Heart Transplant Candidates Supported With Mechanical Circulatory Support: Is
id
16
17 Reappraisal of the Current United Network for Organ Sharing Thoracic Organ
18 Allocation Policy Justified? Circulation, 2013:127
127:452-462.
127
en
19
8. Martin B, Janet P. Statistical questions in evidence-based medicine. Oxford Uni. First
20
21 Ed. New York, 2000.
22 9. Opie LH. 19 Myocardial reperfusion: new ischemia syndromes. In: The heart:
t
23 physiology, from cell to circulation. 3rd. Edition. Philadelphia, Lippincott-Raven,

ia
24
1998: 563-588.
25
26 10. Ludwig von Bertalanffy. 3 Some system concepts in elementary mathematical
l:
27 consideration. In: General System Theory: Foundation, development, applications.

28 George Braziller, New York. 1973: 54-86.
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29
11 Bertalanffy Lv. 6 The Model of Open System. In: General System Theory: Foundation,
30
31 development, applications. George Braziller, New York. 1973: 139-154.
32 12. Opie LH. 2 Control of the Circulation. In: The heart: physiology, from cell to
rR
33 circulation. 3rd. Edition. Philadelphia, Lippincott-Raven, 1998: 17-42.

34
13. Hans V. H. Argument, inference and dialectic: Collected papers on informal logic
35
36 with an introduction. First Ed.by Robert C.P. Kluwer Academic Pub. London. 2001:
37 32-45.
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38 14. Bertalanffy Lv. Chapter 9. General System Theory in Psychology and Psychiatry. In:
39
General System Theory: Foundation, development, applications. George Braziller,
40
New York. 1973: 201-221.
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41
42 15. Brenner N. Foucault’s new functionalism. Theory and society. 1994, 23:
23 679-709.
43 16. Jonathan Howard. Chapter 3. Natural selection and the origin of species. In: Darwin
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44
45 A very short introduction. Oxford University Press. 1982, First, 25-37.
46 17. Bertalanffy Lv. 1. Introduction. In: General System Theory: Foundation,
On
47 development, applications. George Braziller, New York. 1973: 201-221.

48 18. Fuenmayor R. 43 The roots of reductionism: A counter-ontoepistemology for a
49
system approach. In: Systems Thinking Vol. Ⅲ. Edited by Gerald Midgley. First
50
51 edition. SAGE Pub. London, 2003: 80-104.
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52 19. Bunge M. 6 General systems and holism. In: Systems Thinking Vol.Ⅰ.Edited by
53 Gerald Midgley. First Edition, SAGE Pub. London, 2003: 103-109.
54
55 20. Bertalanffy L. v. 2 The meaning of general system theory. In: General System
56 Theory: Foundation, development, applications. George Braziller, New York.
57 1973:30-53
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Page 35 of 36 Heart
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3 21. Duane P. Schuktz, Sydney Ellen Schuktz. William James (1842-1910): anticipator of
4 functional psychology. In: Chapter 7 Functionalism: development and founding. In:
5
6 A history of modern psychology. WADSWORTH Cengage Learning, USA. 10th Edition:
7 131-140.
8 22. Weaver W. 16 Science and Complexity In:Systems Thinking. Vol.Ⅰ. Edited by
Co
9 Gerald Midgley. First Edition, SAGE Pub. London, 2003: 377-385.
10
11 23. Bertalanffy L. v. 9. General System theory in psychology and psychiatry. In: General
12 System Theory: Foundation, development, applications. George Braziller, New York.
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13 1973: 205-221.
14 24. Lakatos I. 3 A methodology of scientific research programmes. In: The
15
methodology of scientific research programmes, Philosophical Papers Vol.ⅠEd. by
id
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17 John Worrall and Gregory Currie. Cambridge press. 1978: 47-89
18 25. Quanji J, Weidong C. 2 Conception In: Logic. Super-Education Pub. 3ed. Edition, (in
en
19
Chinese) Beijing, 2004:16-58.
20
21 26. Herbert G. Towards a unity of the human behavioral sciences. In: Logic,
22 Epistemology, and the Unity of science. First Ed. by Shahid R., John S., Dov M. G.
t
23 and Jean P. von B., Kluwer Academic Pub, London 2004:25-40.

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Heart Page 36 of 36
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4 My opinion 3
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6 Research value on diastolic function is far from cardiac function
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8
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9 itself
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1. The current cardiac theory study on diastolic function is very casual to established diastolic theory
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12 based on the concept of diastolic dysfunction, which was only according to the changes of mitral E
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13 and A peak velocities to define. Basic wrong concept will certainly lead to the theoretical errors and
14 even failed to unify the concepts of diastolic heart failure and systolic heart failure.
15
id
2. At this point, both of statistical and evidence-based medicine may not have the strength to rectify
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17 such misleading error; Logical analysis as method, like all other natural sciences, may be a potential
18 pathway to establish a real Theoretical Medicine. Without Systematic Theoretical Medicine, there
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19 would be no so-called Experimental Medicine and will not be able to understand the causes of all
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kinds of heart diseases.
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22 3. Heart functionalistic research will make up for the shortcomings of the structuralism study, and can
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23 realize actually the early diagnosis and early prevention of diseases and become the key to solve the
ia
24 problem of heart disease. The severe problem of current cardiologic research by structuralism may
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26 be ignoring that human body is a living system, and rejecting system method, which have its inherent
l:
27 reason to interference with effective prevention of Heart Failures and Cardiac Sudden Death.
28 4. Now, it is time to try to establish an effective Cardiovascular Prevention Medicine. To do this, it has
Fo
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to start our work from clarifying the concepts of diastolic function and its theory system.
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CARDIAC FUNCTION, DIASTOLIC DYSFUNCTION < CARDIAC FUNCTION,

24 each cardiac disease should be conducted with its functional states.

24 other relations of D-S. The reasons are as following:

controls of a whole heart function may be “heterometric autoregulation” and “Homeometric

44 rather than of an injured diastole.

41 proposition is disproves, there must be no prevarication: the proposition must be unconditionally

24 The suggestions on some other interrelationships between D-S:

24 that leading to a wrong concepts on diastolic HF.

52 encountering different troubles, such as myocardial ischemia or peripheral resistance increase,

Lippincott-Raven, New York, 3ed Edition, 1998: 267-293.

24 introduction. Oxford University Press, London,1982:25-37.

27 Especially, when diastolic function could be verified to bear a role of compensation to

33 relationship are clarified or integrated, relevant discussion has to be inevitably conducted

23 separated so neatly from diastole?

23 diastole----they are both part of a single contraction---relaxation cycle and a continuous

23 know how to treat them.

27 Systolic BP (mmHg) 149 (23) 152 (21) 145 (23)

33 Ejection fraction (Simpson’s biplane) (%) 42 (11) 48 (10) 34 (9)

38 Pulmonary disease ( n,%) 29 (22) 16 (21) 9 (22)

47 Aspiring (n,%) 36 (27) 20 (26) 11 (28)

52 Lipid Lowering drugs (n, %) 4 (3) 3 (4) 1 (3)

47 biplane method by “eyeball” assessment

52 6.4 -8.1(n, %) 3 (5) 0 (0) 3 (4) 0（0） 3（2）

38 themselves thought to be of uncertain value----for example, E:A ratio.

47 Dr. Shi-Zhao Geng

38 produce therapeutic cure. This kind of infectious disease is almost impossible to

27 the figures showing of a randomized, controlled study, or probability of study 6,7 in

33 researchers for new methods of medical argument.

38 expected to find something in microworld, a lower level in a system, to favour of

47 programs, “animal models, none of which successfully duplicate the human

47 relationship, to which it demands logical analysis. Statistical relationship is only one

organism, and to be used as substantial basis to explain various biological

47 biological evolution, but we have to speculate it only through their anatomical

52 the current concept of diastolic function may be invalid; If awareness of the

27 the guidance of reductionism that will encounter insurmountable difficulties in

52 least impossible in quantitative description of the common nature of complex

38 crowd of physiology and disease must be simultaneously respected. Statistical

33 Theoretically, the former process belongs to inductive inference in Format logic,

38 functional evaluations that has confused 2 kinds of conceptions of general concept

52 clinical medical research.

33 deal with the holistic transcendental character of phenomena.”18 Notice: we need

47 2. Seema P, Frederick K, Ravindra G, Pushkar K, Newry C, Richard E. S, Sripal B.

52 antihypertensive treatment on the risks of ischemic and hemorrhagic stroke.

23 physiology, from cell to circulation. 3rd. Edition. Philadelphia, Lippincott-Raven,

27 consideration. In: General System Theory: Foundation, development, applications.

33 circulation. 3rd. Edition. Philadelphia, Lippincott-Raven, 1998: 17-42.

47 development, applications. George Braziller, New York. 1973: 201-221.

23 and Jean P. von B., Kluwer Academic Pub, London 2004:25-40.

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