Osteopathic Approach to Diastolic Heart Failure

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:

• increased passive stiffness

• abnormal active ventricular relaxation

• changes in calcium metabolism and adenosine triphosphate availability

• degenerative changes in the myocardium caused by age

• myocardial ischemia

• changes in the extracellular matrix

• 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?