OMM: Cardiology Considerations

00:00 Osteopathic Considerations in Cardiology. So, the osteopathic approach to patients with cardiac complaints starts with gathering a thorough history and formulation of your differential diagnosis.

00:14 Our physical exam and structural examination including an osteopathic structural exam helps to narrow down our differential. We want to eliminate any potential life-threatening events first.

00:25 Consider indicated special tests or studies and then plan a course of treatment which includes osteopathic manipulation if indicated. So, our differential diagnosis starts with ruling out the most potentially life-threatening causes. So when patients come in with chest pain, there is a mnemonic eye use to try to rule out things that are most severe and so the things I think about are 2 things with the chest, 2 items with the lungs and 2 tubes. So, the 2 things to the chest that we have to exclude include myocardial infarction and pericardial infarction. The 2 things with the lungs, you have to rule out include pneumothorax and possible pulmonary embolism and the 2 tubes include an esophageal rupture and an abdominal aortic aneurysm. And so, those are things that I always make sure no matter how small the likelihood of the presentation. Being one of those things, I make sure that it's not one of those things that my patient is suffering from. So, make sure you rule out any potential life threatening issues, consider the anatomy and physiology and region of pain. That will tell you what the pain might more likely be due to and make sure you ask pertinent questions in the history and to perform a thorough examination to help rule things in or out. So, the integration of OMM could help in evaluating and diagnosing and treating patients with cardiac presentations. By using the osteopathic models, we could try to formulate an approach into treating the patients with osteopathic manipulation. So, certain presentations that osteopathic manipulation could be indicated for include postmyocardial infarction treatment, trying to help with arrhythmias, congestive heart failure, hypertension and peripheral artery disease. So, when we think about our 5 models, one of the most fitting one when treating cardiac presentations starts with the neurologic approach. So, post myocardial infarction and arrhythmia pretty much are associated with a hypersympathetic state. So, in addition to medical management, utilizing osteopathic diagnosis and treatment could be indicated to treat these conditions. When a patient is stable, utilizing gentle techniques could help to balance autonomic tone. So, remember that inflammation is a real powerful stimulator for nociceptors. So, if we have a visceral input from the heart, remember that the sensitivity of the visceral input is not as specific and so signals from the heart bombard the spinal cord and potentially the cross innervation can cause referred pain and also lead to segmental facilitation and changes to the musculature along that segment. So, sympathetic innervation of the heart comes from the sympathetic chain which runs along the levels about T1 to T5. Remember that outflow nerves could relay not only to T1 to T5 somatically but also up into the stellate ganglion and the cervical ganglion. So, what happens when we have segmental facilitation? So, when we have segmental facilitation, it increases the amount of pain in the region and also decreases the amount needed to fire and so this is a vicious cycle that will increase heart rate, contractility, increasing oxygen demand, it also could potentially reduce coronary blood flow, reducing oxygen supply and also reduce functional reserve in patients with ischemic heart disease. So, overall segmental facilitation is bad for our patients with heart disease. So, getting a better understanding of post MI. Pretty much after an MI, the number one cause of death is ventricular arrhythmia and so pretty much segmental facilitation could potentially predispose the patient to post ventricular arrhythmias. Also more post MI angina, decreased blood flow, decreased oxygenation to the area will prolong healing time and also reduces formation of collateral circulation. So when applying osteopathic manipulation to treat segmental facilitation, what we want to try to do is to prevent the patient from having more pain. So, we don't want to use any techniques that might be painful. So, we want to try to address the osseous tissue of the bone to treat the region. You want to try to stick to more indirect or gentle techniques. Also, try to address the areas around the rib head. Remember we talked about sympathetics running from T1 to T5. That sympathetic chain lies right anterior to the rib heads and so if you treat the tissues around the rib head, that might decrease any sort of restrictions that might be contributing to segmental facilitation. You always want to treat the facilitated areas first and sometimes in the acute state you may want to treat more frequently to try to decrease the somatic dysfunction in the area and try to alleviate that facilitation.