Cardiovascular

Case Study: Cardiovascular Disease

  1. Klosterman had a myocardial infarction. Explain what happened to his heart.

The literal meaning of myocardial infarction (MI) when broken down is “myocardial” meaning the muscles of the heart and “infarction” meaning the death or permanent damage of tissue due to a lack of blood supply. The heart needs a constant supply of blood and oxygen to function properly, and it receives this blood supply from the coronary arteries. However, this process can be compromised if the coronary arteries become blocked – this is called atherosclerosis which literally means the “hardening of the arteries”. This blockage consists of cholesterol, white blood cells, and fatty deposits (plaque) and in turn, the blood flow to the heart is limited. When these specific arteries of the heart become blocked or narrowed, it is called Coronary Artery Disease. Inadequate blood flow results in a lack of oxygen and vital nutrients, starving the muscles of the heart and altering its ability to function properly. If one or more artery becomes completely blocked, the tissues of the cells start to die resulting in myocardial infarction, also known as a heart attack.

There are two types of MIs. One is called an “acute MI” which is sudden and serious. There is also a “silent MI” in which the symptoms are atypical and therefore it is very hard to diagnose which occurs in nearly 64% of myocardial infarctions. Typical symptoms include pain of the chest (angina) which is located behind the sternum or pain of the left arm/neck. Other symptoms are shortness of breath, abnormal heartbeat, sweating, nausea, anxiety.  To determine if someone has had a heart attack, there are a few different tests that are commonly used. The first, used moreso in the case of an acute MI, is an electrocardiogram (ECG) which is used to see where the blockage was. The second is by using serum levels of the blood such as creatine-phosphokinase – MB levels.

Myocardial infarction is the result of a poor diet, inadequate exercise, and other bad habits extending over a long period of time. This is why the average age for the occurrence of an MI is 66 for men and 70 for women. It takes time for cholesterol and fatty deposits to build up. Other risk factors beyond decreased physical activity and obesity/overweight are history of cardiovascular disease, old age, tobacco, smoking, high cholesterol, high blood pressure, and alcoholism or just drinking alcohol in excess. The best way to reduce the risk of MI or any type of cardiovascular disease is to do strenuous activity most days of the week and eat a diet full of fruits, vegetable, and fiber.

Source(s): Nelms, K. Sucher, K. Lacey, S. Roth (2011). Nutrition Therapy and Pathophysiology.

Mendis, K Thygesen, and K Kuulasmaa (2008). World Health Organization definition of myocardial infarction: 2008-2008 revision.

Srinath Reddy and Martijn B Katan (2004). Diet, nutrition and the prevention of hypertension and cardiovascular diseases.

  1. Klosterman’s chest pain resolved after two sublingual NTG at 3-minute intervals and 2 mgm of IV morphine. In the cath lab, he was found to have a totally occluded distal right coronary artery and a 70% occlusion in the left circumflex coronary artery. The left anterior descending was patent. Angioplasty of the distal right coronary artery resulted in a patent infarct-related artery with near-normal flow. A stent was left in place to stabilize the patient and limit infarct size. Left ventricular ejection fraction was normal at 42%, and a postero-basilar scar was present with hypokinesis. Explain angioplasty and stent placement. What is the purpose of this medical procedure?

 

Coronary angioplasty is the procedure used to open clogged arteries after a myocardial infarction. It involves the insertion of a tiny balloon into the artery of the heart where it had become clogged, and then inflating the balloon. This widens the artery, pushing the plaque aside. A stent, a small wire mesh tube, is then permanently inserted to help prop the artery open. These were originally just plain metal called bare-metal stents. However, drug-eluting stents are also an option now. These stents are coated with medication to prevent plaque from building up and to keep the artery open as well. Angioplasty is used during a myocardial infarction not only to open up an artery but it also lessens the amount of damage done to the heart, reduces symptoms such as angina and shortness of breath.

In the case of Mr. Klosterman, the myocardial infarction was caused by the complete closure of his distal right coronary artery. Angioplasty was used to open the artery to obtain a nearly normal flow. A stent was used to prevent future blockage. However, permanent scarring has left limited blood flow (hypokinesis) overall. The 70% occlusion in the left circumflex coronary artery (which runs between the aorta and the main pulmonary artery) and because of this, nutrition and disease prevention management is essential to ensure that this does not cause another heart attack for Mr. Klosterman.

Source(s):

Califf, FE Harrell Jr, KL Lee, et al.(1989). The evolution of medical and surgical therapy for coronaty artery disease: a 15-year perspective.

 

  1. Mr. Klosterman and his wife are concerned about the future of his heart health. What role does cardiac rehabilitation play in his return to normal activities and in determining his future heart health?

Cardiac rehabilitation includes several different parts, and every plan is individualized. However, the main goals are always the same – to regain strength, prevent worsening of cardiovascular disease, improve health, and develop lifelong habits that not only improve health but overall quality of life.  This process usually takes 3 to 6 months but can take longer depending on the progress of the patient.

The first step is to do a medical evaluation. This includes physical abilities, medical limitations, and other conditions or risk factors that relate to cardiovascular disease. Based on abilities physical activity, the second step, is implemented. Patients are taught how to monitor their heart rate while doing physical activity and then they progress at their own pace to cycling, rowing, or even jogging. A physical therapist typically works with patients on proper techniques such as warming up and stretching. The goal is to reach a regimen of working out 3 to 5 times each week.

The last step is lifestyle education. This step is all about setting up a patient for lifetime success. The habits of exercising are reinforced and the patients learns how to continue this exercising regimen even after the rehabilitation has ended. Nutrition education is huge in this step. Patients are taught how to lose weight which will help lower cholesterol. They are taught to make healthier food choices that involve foods low in certain fats, and low in sodium and cholesterol. This step may also include eliminating other risk factors beyond overweight and obesity if a patient smokes or is diabetic.

Source(s): Ross, Insel Turner (2009). Discovering Nutrition.

  1. What risk factors indicated on his medical record can be addressed through nutrition therapy?

The following are all risk factors that can be address through nutrition therapy:

  1. BMI categorized as overweight can be addressed through decreased caloric consumption and increased physical activity.
  2. High total cholesterol levels, high LDL-C levels, low HDL-C levels, and a low LDL/HDL ratio can be addressed by weight loss as well as decreased saturated fat in the diet and possibly by decreased sodium and cholesterol consumption.
  3. High blood pressure can be addressed through increased physical activity.
  4. Smoking can be addressed through education and support.
  1. What are the current recommendation for nutritional intake during a hospitalization following a myocardial infarction?

Immediately following a myocardial infarction, a typical protocol may consist of clear liquids to prevent aspiration and vomiting and the exclusion of caffeine to decrease the risk of arrythmia. Pain, anxiety, fatigue, and shortness of breath may be factors that cause difficulty eating. After the condition starts to stabilize, modified consistency foods are introduced as able. This usually goes from clear liquids, to thicker liquids, to soft foods that are easy to chew. Once able to eat normally again, cardiac rehabilitation will shape the nutritional intake.

Source(s): Nelms, K. Sucher, K. Lacey, S. Roth (2011). Nutrition Therapy and Pathophysiology. p. 319

  1. What is a healthy weight range for an individual of Mr. Klosterman’s height?

Hamwi Method

Men       106lbs + (6lbs for every inch over 5 foot)

106 + (6 X 10)

= 166 lbs

Source(s): Weight – for – Height Tables reference sheet

  1. This patient is a Lutheran minister. He does get some exercise daily. He walks his dog outside for about 15 minutes at a leisurely pace. Calculate his energy and protein requirements.

                        Weight = 185 lbs / 2.2 = 83.9 kg

Height = 5’10” = 70 in = 177.8 cm

Mifflin-St. Jeor

Men     10 X wt (kg) + 6.25 X ht (cm) – 5 X age (yrs) + 5

(10 X 83.9) + (6.25 X 177.8) – (5 X 61) + 5

839 + 1,111 – 305 +5

= 1,650

1,650 X (PAL) 1.5

= 2,475 cal / day

Protein Needs

Weight (kg) X 0.8-1.8 gm/kg

83.91 X 1.4

= 117.4 gm protein/day

Source(s): Resting Energy Expenditure Equation sheet

  1. Using Mr. Klosterman’s 24-hour recall, calculate the total number of calories he consumed as well as the energy distribution of calories for protein, carbohydrate, and fat using the exchange system.

Total number of calories: 2,802 kcal

  • Fat: 464 kcal => 86 g => 22% of daily calories

Sat. Fat:      26 g => 37%

Mono. Fat:   30 g => 37%

Poly. Fat:     22 g => 26%

  • Carbs: 1,138 kcal => 356 g => 54% of daily calories
  • Protein: 432 kcal => 140 g => 20% of daily calories
  • Alcohol: 76 kcal => 11 g => 4% of daily calories
  • Sodium: 6,054 mg

Source(s): Fitday.com (2014). Retrieved from: http://www.fitday.com/app/log/

 

  1. Examine the chemistry results for Mr. Klosterman. Which labs are consistent with the MI diagnosis? Explain. Why were the levels higher on day 2?

Creatine Phosphokinase-MB (CPK-MB) is one of the best indicators known for diagnosing an acute myocardial infarction. Initially ECGs were used to assess MIs but this led to misdiagnoses in the case of an MI with atypical symptoms of a “silent myocardial infarction”, because heart attacks were not assumed to be the cause of symptoms and therefore ECGS were not used. CPK-MB as well as lactate dehydrogenase (LDH) are both released from tissues and into the blood serum during an MI and therefore are now both used as diagnostic tools.

CPK-MB is especially effective because it is only present in the myocardium and is only released during a myocardial infarction. Also, the concentration and the duration of presence of CPK-MB can determine how severe the myocardial infarction was. The reason the levels become higher on day two is because it takes time for CPK-MB to reach the serum. It typically appears within 4 to 6 hours after the onset of symptoms, and is back to normal in 48 to 72 hours.

Source(s): Norris, RM Whitlock, C Barratt-Boyes, CW Small (1985). Clinical measurement of myocardial infarct size. Modification of a method for the estimation of total creatine phosphokinase release after myocardial infarction.

Wagner, CR Roe, LE Limbird, RA Rosati, AG Wallace (1993). The importance of identification of the myocardial-specific isoenzyme of creatine phosphokinase (MB form) in the diagnosis of acute myocardial infarction.

  1. What is abnormal about his lipid profile? Indicate the abnormal values.

Mr. Klosterman has a borderline high total cholesterol of 235 mg/dL while it should be between 120 and 199 mg/dL. He has a low HDL Cholesterol level of 30 mg/dL while it should be greater than 45 mg/dL, and an LDL at a high of 160 mg/dL when it should be less than 130 mg/dL. This makes his LDL/HLD ratio a high of 5.3 when for males, it should be no more than 3.55.

Source(s): Nelms, K. Sucher, K. Lacey, S. Roth (2011). Nutrition Therapy and Pathophysiology.

 

  1. Mr. Klosterman was prescribed the following medications on discharge. What are the food-medication interactions for this list of medications?
Medication Possible Food-Medication Interactions
Lopressor 50 mg daily Alcohol, multivitamins with minerals
Lisinopril 10 mg daily Foods high in potassium (bananas, orange, leafy green, salt substitutes)
Nitro-Bid 9.0 mg twice daily Alcohol
NTG 0.4 mg sl prn chest pain Alcohol
ASA 81 mg daily Caffeine, Alcohol

Source(s): FDA (2014). Avoiding Drug Interactions. Retrieved from: http://www.fda.gov/forconsumers/consumerupdates/ucm096386.htm

  1. You talk with Mr. Klosterman and his wife, a math teacher at the local high school. They are friendly and seem cooperative. They are both anxious to learn what they can do to prevent another heart attack. What questions will you ask them to assess how to best help them?

I would start by giving Mr. and Mrs. Klosterman some basic background information on cardiovascular disease, and the importance of weight management, and cholesterol and fat intake. Then my goal would be to find out how comfortable they are with the idea of change to decide at what pace we could make lifestyle changes. Because they seem cooperative and anxious about preventing further cardiovascular damage, I would assume that somewhat drastic changes would be okay to make. I would ask he following open-ended questions to further evaluate:

  • Can you tell me more about your situation?
  • Where would you like to begin? Exercise, diet alterations?
  • No knowing some of the background information on cardiovascular disease, what changes do you feel comfortable making?
  • What are some struggles that you think you may face altering your caloric intake? Or adding exercise?
  • What steps would you like to take to help you stop smoking? Would you be comfortable going to smokers anonymous? Or perhaps another emotional support system?
  • What will we look for to know that changes are occurring?
  • How often would you like to check in with me? Would you like to e-mail me daily 24-hour recalls to check in and get feedback?
  • Is there other information I should know?
  • Does what I’m saying make sense?
  • What are your thoughts on the plan we have come up with?
  1. What other issues might you consider to support successful lifestyle changes for Mr. Klosterman?

I would offer up suggestions to Mr. Klosterman that would help him make not only short term changes but long term changes. Perhaps utilizing his impact as a minister – offer the idea of him starting a walking group with those that work and attend the church to get physical activity in every day or taking walks with his wife after dinner in the evening. I would offer a psychologist as an option if he felt he needed extra support. Also, I mentioned smokers anonymous to him in an earlier question. There is also the option of joining a gym, taking exercise classes that he is scheduled to go to. Cooking classes or even just cooking with his wife and implementing my advice would also be an option. Asking him what resources he is comfortable with is huge, and he may have some ideas of his own as well.

  1. From the information gathered within the assessment, list possible nutrition problems using the correct diagnostic terms.
  • At risk for developing hypertension with a BP of 118/90, which is at the upper end of the acceptable range for blood pressure.
  • Overweight with a BMI or 26.6 (the range for overweight is 25-29.9).
  • Cholesterol levels: high total cholesterol of 235 mg/dL (normal is 120-199), low HDL-C of 30 mg/dL (normal is >45), low LDL-C of 130 mg/dL (normal is <130), and high LDL/HDL ratio of 5.3 (normal is <3.55).
  • Excessive calorie intake of 2,802.
  • High amount of saturated fats consumed – 37% of total fat, 26.25 g.
  • High sodium consumption of 6,053.9mg compared to recommended 1300mg, 465.7%.

Source(s): Ross, Insel Turner (2009). Discovering Nutrition.

 

 

  1. Select two of the identified nutrition problems and complete the PES statement for each.
  2. Excessive energy intake (problem) related to high fat foods that are calorically dense such as red meats, mayonnaise, butter, margarine, dressings, and pie (etiology) as evidence by a 24 hour recall of 2,802 kcals/day which is excess of daily caloric need of 2,470 kcals/day (signs/symptoms).
  3. High sodium consumption (problem) related to intake of food high in sodium such as canned soup, pickles, pretzels, dressings, and possibly salted butter (etiology) as evidence by a 24 hour recall of 6,054 mg salt which is 465.7% in excess of RDA 1300 mg (signs/symptoms).
  4. Overweight (problem) related to physical inactivity and excessive energy intake (etiology) as evidence by a BMI of 26.54 which is overweight.

(I wanted to do a third. Number 1 and 3 will be combined in #16)

 

  1. For each PES statement you have written, establish an ideal goal (based on the signs and symptoms) and an appropriate intervention (based on etiology).
  2. Average caloric intake will be no more than 110% of estimated needs of between an estimated 1,800 and 2,000 kcal/day which decreases caloric intake by 500 kcal/day to lose 1 pound per week.
  3. Sodium intake will not exceed 1300 mg/day.
  4. Daily physical activity such as walking will occur 3-5 times/week for 30 minutes.
  5. Weight loss will occur by about 1-2 pounds per week until the ideal weight of 166 pounds is reached and a BMI of a normal weight is reached.

 

  1. Mr. Klosterman and his wife ask about supplements. “My roommate here in the hospital told me I should be taking fish oil pills.” What does the research say about omega-3-fatty acid supplementation for this patient?

Omega-3-Fatty Acids are fatty acids that the body needs but cannot produce on its own and therefore must be consumed. According to the University of Rochester Medical Center, Omega-3-Fatty Acids can help prevent coronary heart disease (CHD) in healthy people and can slow progression in those who have already developed some form of CHD. Omega-3s can be added into the diet by consuming not only fish oil pills but also by eating fatty fish like mackerel, tuna, and salmon or by cooking with soy or canola oil. Other sources include flaxseed, walnuts, and other nuts. There is still research to be done, but there is definite evidence that those with higher levels of omega-3-fatty acids have lower rates of CHD.

The American Heart Association (AHA) advises that all people eat some form of fatty fish twice a week. It also states that those with some form of CHD should have 1 gram of fish oil per day while those trying to lower cholesterol and triglyceride levels can take 2-4 grams per day under the supervision of a physician. This should be done not in place of but in addition to lowering saturated fat intake in order to lower cholesterol and triglyceride levels to help prevent the worsening of coronary heart disease.

Source(s): Ross, Insel Turner (2009). Discovering Nutrition.

  1. What would you want to assess in three to four weeks when he and his wife return for additional counseling?

(The following is all based on the assumption that Mr. Klosterman is doing well and progressing. This would look different if he was not doing well.) I would first ask how Mr. Klosterman thinks things are going – what is going well and what can be improved. I would have Mr. Klosterman send me a 24-hour recall several times a week just to check in, analyze his intake, and give him feedback on what small things can be changed to improve his choices. We would then look at his average caloric intake, saturated fat intake, total fat intake, sodium intake and activity levels. We would also talk about how he is doing as far as quitting fully or greatly reducing the frequency of his smoking.

Another aspect would be to look at his clinical outcomes. Mr. Klosterman would be weighed and perhaps even indirect calorimetry would be used. I would also look at his cholesterol levels (HDL, LDL, total cholesterol) blood pressure, and BMI. Lastly, I would help him set new goals and look at how to work through current issues he may be having. I would encourage him by making him feel as though he is on the right track and progressing. We would also look at ways in which he can continue his healthy habits with more autonomy – I may show him fitday.com and have him assess his own intake.

References

Califf, FE Harrell Jr, KL Lee, et al.(1989). The evolution of medical and surgical therapy for

coronaty artery disease: a 15-year perspective.

FDA (2014). Avoiding Drug Interactions. Retrieved from:

http://www.fda.gov/forconsumers/consumerupdates/ucm096386.htm

Fitday.com (2014). Retrieved from: http://www.fitday.com/app/log/

Mendis, K Thygesen, and K Kuulasmaa (2008). World Health Organization definition of

myocardial infarction: 2008-2008 revision.

Nelms, K. Sucher, K. Lacey, S. Roth (2011). Nutrition Therapy and Pathophysiology.

Nelms, S. Roth (2009). Medical Nutrition Therapy: A Case Study Approach.

Norris, RM Whitlock, C Barratt-Boyes, CW Small (1985). Clinical measurement of

myocardial infarct size. Modification of a method for the estimation of total creatine

phosphokinase release after myocardial infarction.

Ross, Insel Turner (2009). Discovering Nutrition.

Srinath Reddy and Martijn B Katan (2004). Diet, nutrition and the prevention of

hypertension and cardiovascular diseases.

Wagner, CR Roe, LE Limbird, RA Rosati, AG Wallace (1993). The importance of

identification of the myocardial-specific isoenzyme of creatine phosphokinase (MB form)

in the diagnosis of acute myocardial infarction.