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Letters to the Editor  |   August 2008
Osteopathic Approach to Diastolic Heart Failure
Author Affiliations
  • Thomas Michael McCombs, DO
    Touro University College of Osteopathic Medicine–California Vallejo
    Assistant Professor
Article Information
Cardiovascular Disorders
Letters to the Editor   |   August 2008
Osteopathic Approach to Diastolic Heart Failure
The Journal of the American Osteopathic Association, August 2008, Vol. 108, 365-366. doi:10.7556/jaoa.2008.108.8.365
The Journal of the American Osteopathic Association, August 2008, Vol. 108, 365-366. doi:10.7556/jaoa.2008.108.8.365
To the Editor:  
I read with interest the article by Sunil Dhar, MD, and colleagues,1 in the April issue of JAOA—The Journal of the American Osteopathic Association. This article represents an expansion of the medical profession's thinking about cardiac insufficiency. As the article suggests, diastolic heart failure—an inability of the heart to relax, dilate, and fill—may account for half of the cases previously thought to be caused by the heart's inability to contract and eject.2-6 The authors1 credit this deficit in diastole to the following factors: 
  1. increased passive stiffness
  2. abnormal active ventricular relaxation
  3. changes in calcium metabolism and adenosine triphosphate availability
  4. degenerative changes in the myocardium caused by age
  5. myocardial ischemia
  6. changes in the extracellular matrix
  7. negative intrathoracic pressures from chronic obstructive pulmonary disease and obstructive sleep apnea
Treatment, evidence, and prognosis are discussed adequately by Dhar and coauthors,1 and the conclusions they offer are sound. However, what is lacking for me in the article is an insight and approach to this issue based on osteopathic medicine. 
I suggest that osteopathic physicians consider three additional factors in the care of patients with diastolic heart failure: 
Sympathetic hypertonia to the heart driven by somatic dysfunctions of the upper thoracic spine and ribs— An overfunctioning of the sympathetic nervous system could contribute to the problems listed above as numbers 1, 2, and 5. 
Decades of osteopathic medical research have documented the patho-physiologic consequences to the heart from somatic dysfunction in the upper thoracic spine. Most of these ill effects are mediated through hypersympatheticotonia, as noted by Robert C. Ward, DO,7 as well as by Michael L. Kuchera, DO, and William A. Kuchera, DO.8 Louisa Burns, DO, DScO,9 reported on “cardiac changes following certain vertebral lesions,” and Irvin M. Korr, PhD,10,11 provided much excellent research on the relationships between somatic dysfunction, the autonomic nervous system, and endorgan damage. 
It seems a shame to have osteopathic practitioners of cardiology so underinformed about the many decades of osteopathic medical research directly applicable to cardiology. 
The internal contours of the inferior thorax—My observations suggest that if the sternum is “too close” to the spine as a result of kyphosis, pectus excavatum, or internal rotation of each hemithorax, the diastole will be inadequate because of the physical constraints of the available space for the heart to expand its diastolic volume. The heart cannot expand further into diastole when wedged between the anterior thoracic spine and the posterior sternum. This structural constraint could contribute to the problems listed on the previous page as numbers 2 and 4. 
The respiratory diaphragm—The right side of the heart is attached to the superior surface of the diaphragm. As the diaphragm descends during inspiration, the heart is widened while being carried inferiorly. Absent this widening, diastole must be reduced, contributing to the problem listed on the previous page as number 2. 
I have treated several patients in congestive heart failure that responded immediately to improved diaphragm function, with visible reductions in their dyspnea and edema. It is possible that their heart failure was primarily diastolic in nature, and using osteopathic manipulative treatment to enlarge the available space for diastole was sufficient for symptom relief. 
Perhaps heart failure will eventually be understood to result from a continuum of causes, with inadequacies of systolic forces and diastolic spaces both contributing to cardiac insufficiency. Wouldn't it be ideal for the osteopathic medical profession to lead the way in such research, contributing to standards of care by demonstrating our unique approach to medicine? 
I encourage the osteopathic medical profession to explore these suggestions. Research may prove that reduction of upper thoracic somatic dysfunction, expansion of the antero-posterior diameter of the lower thorax, and enhancement of diaphragm mobility—all of which are obtainable through osteopathic manipulative medicine—can provide additional, synergistic clinical benefits to patients with diastolic heart failure. 
Shouldn't osteopathic medicine be about more than back pain? 
Dhar S, Koul D, D'Alonzo GE Jr. Current concepts in diastolic heart failure. J Am Osteopath Assoc. 2008;108:203-209. Available at: http://www.jaoa.org/cgi/content/full/108/4/203. Accessed July 31, 2008.
Senni M, Tribouilloy CM, Rodeheffer RJ, Jacobsen SJ, Evans JM, Bailey KR, et al. Congestive heart failure in the community: a study of all incident cases in Olmsted County, Minnesota, in 1991. Circulation. 1998;98:2282-2289. Available at: http://circ.ahajournals.org/cgi/content/full/98/21/2282. Accessed July 31, 2008.
Kitzman DW, Gardin JM, Gottdiener JS, Arnold A, Boineau R, Aurigemma G, et al. Importance of heart failure with preserved systolic function in patients > or = 65 years of age. CHS Research Group. Cardiovascular Health Study. Am J Cardiol. 2001;87:413-419.
MacCarthy PA, Kearney MT, Nolan J, Lee AJ, Prescott RJ, Shah AM, et al. Prognosis in heart failure with preserved left ventricular systolic function: prospective cohort study. BMJ. 2003;327:78-79. Available at: http://www.bmj.com/cgi/content/full/327/7406/78. Accessed July 31, 2008.
Vasan RS, Larson MG, Benjamin EJ, Evans JC, Reiss CK, Levy D. Congestive heart failure in subjects with normal versus reduced left ventricular ejection fraction: prevalence and mortality in a population-based cohort. J Am Coll Cardiol. 1999;33:1948-1955.
Aurigemma GP, Gottdiener JS, Shemanski L, Gardin J, Kitzman D. Predictive value of systolic and diastolic function for incident congestive heart failure in the elderly: the cardiovascular health study. J Am Coll Cardiol. 2001;37:1042-1048.
Rogers FJ. An osteopathic perspective on cardiology. In: Ward RC, ed. Foundations for Osteopathic Medicine. 2nd ed. Philadelphia, Pa: Lippincott, Williams & Wilkins; 2003:358-363.
Kuchera ML, Kuchera WA. Osteopathic Considerations in Systemic Dysfunction. Kirksville, Mo: KCOM Press;1990 : 53-73.
Burns L. Cardiac changes following certain vertebral lesions [Louisa Burns, DO, Memorial]. In: Beal MC, ed. 1994 AAO Yearbook. Indianapolis, Ind: American Academy of Osteopathy;1994 : 195-204.
Peterson B, ed. The Collected Papers of Irvin M. Korr, Vol 1. Colorado Springs, Colo: American Academy of Osteopathy; 1979.
King H, ed. The Collected Papers of Irvin M. Korr, Vol 2. Indianapolis, Ind: American Academy of Osteopathy;1997 .