9-3 Cardiovascular cases lab Flashcards
Where does the sympathetic innervation of the heart have its origins?
Cord segments T1-5(6)
Synapses occur in the upper thoracic and/or cervical chain ganglia
Sympathetic fibers to the heart do have a right- and left-sided distribution
Right sided fibers pass to the right deep cardiac plexus - innervate the right heart and sinoatrial (SA) node
Left sided fibers pass to left deep cardiac plexus – innervate left heart and atrioventricular (AV node)
What is the result of hypersympathetic activity (tone) to the right side of the heart (SA node)?
Supraventricular tachyarrhythmias
Sinus tachycardia
Paroxysmal supraventricular tachycardia (PSVT)
What is the result of hypersympathetic activity (tone) to the left side of the heart (AV node)?
Ectopic foci
Ventricular tachycardia
Ventricular fibrillation
What type of somatic dysfunction can increase sympathetic activity (tone) to the heart?
Upper thoracic dysfunction (especially extended segments)
Upper rib dysfunction, many times associated with upper thoracic dysfunction
Cervical dysfunction – affecting the superior, middle and inferior cervical ganglia
Where does the parasympathetic innervation of the heart have its origins?
Vagus nerves (cranial nerve 10)
Also have ipsilateral distribution:
Right vagus – innervates the sinoatrial (SA) node
Left vagus – innervates atrioventricular (AV) node
What is the result of hyperparasympathetic activity (tone) to the right side of the heart (SA node)?
Sinus Bradycardia
What is the result of hyperparasympathetic activity (tone) to the left side of the heart (AV node)?
AV Blocks
What is the course of the vagus nerve (cranial nerve 10)?
Originates on the medulla
Exits the skull via the jugular foramen between the occipital and temporal bones
Has connections with the first 2 cervical somatic nerves
Enters the chest via the thoracic inlet
What types of somatic dysfunction can affect the vagus nerves?
Occipitomastoid compression affecting the jugular foramen
Occiput, atlas and axis (upper cervical spine)
Thoracic inlet
Upper thoracics
Upper ribs
Clavicles
Lower cervicals
Cervical fascia
ECT.
What is the path of lymph back to the heart? What drives it?
Lymphatic drainage from heart and lungs primarily carried back to the heart via the right lymphatic duct (1/3 of body)
Courses through the thoracic inlet on the way back into the heart
Driven by synchronized diaphragmatic function and muscle activity – overall body movement
What improves lymphatic flow?
OMM, in dog studies, can improve lymphatic flow by 4-5 times
Exercise can improve lymphatic flow by 30+ times
We can combine both for the benefit of the patient
What are some areas of somatic dysfunction that can negatively affect lymphatic flow?
Thoracic inlet
Respiratory diaphragm
Lower thoracics
Lower ribs
Upper lumbars (psoas major muscle)
Sympathetics
How are Chapman’s reflexes good for CV cases?
They probably are not. Here’s what Ramey says:
Chapman’s Reflexes
A viscerosomatic reflex mechanism
Associated with palpable nodules deep to skin and subcutaneous tissue
Can be used for diagnosis and treatment
Can be used to affect heart, renal and adrenal function
What are some palpatory changes associated with cardiac problems?
Larson, Beal and Nicholas have reported palpatory changes at T2-T4 on the left with cardiac problems
Can any situations mask a patient from developing palpable reflexes (tissue texture changes) with cardiac problems?
How does allostatic load cause disease?
Somatic dysfunction anywhere affects the individual locally and globally (entirely)
Stressors/imbalance that takes them closer to the threshold of symptoms and disease-activates SNS-HPA couple
Increased allostatic load may contribute to breakdown of the cardiovascular, immune, renal, gastrointestinal and central nervous systems
What activity is SD frequently associated with?
Somatic dysfunction is frequently associated with hypersympathetic activity
Example – upper thoracic dysfunction may be associated with local hypersympathetic tone to innervated structures but also a global increase in sympathetic tone throughout the body
Overall, the entire individual is closer to their threshold for firing , more susceptible to imbalance and closer to the threshold for symptoms and disease
What should we do to correct SD?
Our job – to work knowingly with the system to allow health to manifest itself
As a result, multiple layers of dysfunction are removed to allow the underlying health to shine through
It is not a sequence of wresting holds to mindlessly apply to disease conditions
Osteopathy is art and science integrated into one
The overall result of a competently applied Osteopathic treatment is to improve the health, function and motion of the individual
Epigenetics - do our genes (DNA) just randomly think for themselves?
Probably not! Epigenetics look at the genes as responding to multiple environmental signals that go into them
Positive signals may produce positive epigenetic expression and vice versa
Epigenetic abnormalities may be passed on for multiple generations unless the environmental signals are altered
What are some negative environmental signals that may have a negative impact on gene expression?
Poor nutrition
Toxic thoughts/mental stress
Physical stress
Environmental toxins
Somatic dysfunction
Others???
What is the most common cause of hypertension?
Essential
We don’t know what causes it
Harrison’s Principles of Internal Medicine describes multiple contributing factors including increased sympathetic activity
Some antihypertensive medications work by reducing sympathetic effects
Renin-angiotensin-aldosterone system – involved in the regulation of arterial pressure via:
Angiotensin II (vasoconstrictor)
Aldosterone (sodium retention)
What does renin do? Where is it made?
Renin is synthesized by the juxtaglomerular cells of the kidney in response to:
Decreased pressure or stretch within the renal afferent arteriole (baroreceptor mechanism)
Sympathetic nervous system stimulation of renin-secreting cells
How can somatic dysfunction contribute to elevated blood pressure and hypertension?
Upper thoracic dysfunction can facilitate increased sympathetic tone to the heart
Increased heart rate
Increased stroke volume
What can increase sympathetic tone to adrenal gland and kidney?
Somatic dysfunction in the thoracic and lumbar regions (especially T6-L2) can facilitate increased sympathetic tone to the adrenal gland and kidney
What can HTN and SD do hormonally?
Will facilitate catecholamine release from adrenal – resulting in increased cardiac output and peripheral resistance
Will activate renin-angiotensin-aldosterone system – resulting in vasoconstriction (increased vascular resistance) and sodium and fluid retention via aldosterone
How can SD of the cranium alter BP?
Somatic dysfunction affecting the cranium (SBS compression, occipitomastoid compression affecting jugular foramen), occiput, atlas and remainder of cervical spine may alter carotid receptor function and contribute to alterations in blood pressure
What should you do when treating CV cases with OMM?
Treat the entire patient Osteopathically to overall reduce the allostatic load
Pay special attention to the cranial mechanism, cervicals, upper thoracics and thoracolumbar junction
Don’t forget Chapman’s reflexes
A 30 year old male presents for an initial routine physical. He has not seen a physician for 12 years and has no complaints.
Review of systems negative
Medical histories noncontributory
Vitals Temp 99.0F, BP 145/95, Pulse 70, Respirations 14
Physical exam – normal
What is the diagnosis?
How will you manage it?
What is it? MI
Many demonstrate autonomic imbalance
Dysfunction at T2-3 on left in patients with anterior wall MI
Dysfunction at C2 and cranial base (vagus) with inferior wall MI
Most common cause of death within the 1st 24 hours is ventricular fibrillation (50% occur within 1st hour)
Treat them sooner versus later
What is a goal of OMM treatment of CV cases?
Goals
Bring autonomic balance back to the cardiovascular system
Prevent ventricular fibrillation
Reducing sympathetic tone will cause dilation of the coronary arteries – improved myocardial perfusion
Improve arterial supply and venous and lymphatic drainage to heart
Should you use HVLA with CV cases?
Avoid HVLA technique (especially to the upper thoracics) during the initial management. Why?
HVLA can cause a short-term increase in sympathetic activity
May result in vasoconstriction of coronary arteries and extend infarct
What should you pay special attention to when treating CV cases with OMM?
Again, treat the whole patient Osteopathically to improve function and motion but pay special attention to the:
Cranial mechanism (CV 4 helps balance autonomics)
Cervical spine (Vagus)
Upper thoracic spine and upper ribs
Thoracolumbar junction
Chapman’s reflexes affecting heart, adrenals and kidneys
Gentler techniques are initially a better option!
A 48-year-old male is brought to your emergency department via ambulance with chest pain of 45 minutes duration. A 12-lead EKG is suggestive of an inferior wall MI
What do you do?
don’t know yet
What are the symptoms and associations with CHF?
Clinical syndrome associated with:
Intravascular and interstitial volume overload
Inadequate tissue perfusion
Symptoms
Fatigue and SOB most common
Also see anorexia, nausea, early satiety associated with abdominal pain/fullness, confusion, disorientation, sleep/mood disturbances and nocturia
What is the pathogenesis of CHF?
Pathogenesis – progressive disorder
Something damages the heart muscle or reduces its ability to generate force (contract)
Many causes including coronary artery disease, MI, hypertension, toxic damage (excessive alcohol), viral infection, etc.
Regardless of cause, result is overall decline in pumping capacity of heart
Vicious downward spiral develops due to activation of neurohormonal systems
What is the spiral associated with CHF?
Decreased CO – unloading of high-pressure baroreceptors in left ventricle, carotid sinus and aortic arch
Afferent signals to CNS – releases ADH (antidiuretic hormone)
Reabsorption of free water
Activation of sympathetic efferents to heart, kidney, peripheral vasculature and skeletal muscles
Sympathetic stimulation of kidney associated with
Release of renin and activation of renin-angiotensin-aldosterone pathway
Salt and water retention
Vasoconstriction and increased vascular resistance
Myocyte hypertrophy
Myocyte death
Myocardial fibrosis
What is the goal of OMM when treating CHF?
Goal is to break into the downward spiral
Reduce intravascular and interstitial volume overload (improve renal function)
Improve tissue perfusion
Optimize cardiac function
How should patients with CHF be treated with OMM?
Treat entire patient Osteopathically but especially pay attention to:
Cranial mechanism
Cervical spine
Upper thoracics
Thoracolumbar junction (kidneys and adrenals)
Lymphatics (thoracic inlet, respiratory and other diaphragms)
Proceed slowly - these patients can be very fragile!
What are important elements of treatment other than OMM? Other than the obvious medicine/surgery/science?
Exercise is a key and improves:
Autonomic nervous system function
Regional blood flow
Endothelial function
Skeletal muscle function
Quality of life
Exercise training can improve exercise duration as much as pharmaceutical agents (digoxin and ACE inhibitors)
We combine exercise, pharmacologic management and OMM for best possible outcomes
Manage other comorbid conditions including hypertension, diabetes, thyroid disease, etc.
