1. Lecture 6b 10 Feb. 2014 Congestive heart failure Class activity-what is the best approach to avoiding CHF

2. Pathology Myocardial infarction can lead to chronic or congestive heart failure -a weakened heart does not pump sufficient blood to the kidneys -hence kidneys’ ability to filter blood and produce urine is reduced -decreased urine production results in more water being retained in the blood

3. Pathology Myocardial infarction can lead to chronic or congestive heart failure -weakened heart can not keep up with water load returning to heart and fluid backs up in the extremities and in lungs -heart becomes even more weakened because it tries to pump more fluid -ultimately the heart is overwhelmed by the fluid load and quits

4. CHF and Nutrition status -build up of fluid causes heart and lungs to work harder -when the heart and lungs work harder they require more energy -yet that extra energy is not available because fluid build up impairs cardiac and pulmonary function

5. CHF and Nutrition status - since blood flow and oxygen delivery are critical to the processes of digestion, absorption and transport and energy release the extra energy required for the heart and lungs is not there - therefore heart and lungs cannot keep up and there is heart failure and ultimately flooding of the lungs -all above limits energy and protein intake

6. CHF and Nutrition status -oral intake may be limited by anorexia, taste sensitivity, intolerance to food odours, physical exhaustion, low sodium diet -weight loss may go unnoticed due to oedema since oedema masks weight loss -consequently PEM can occur – in this case PEM is called cardiac cachexia

7. Treatment of CHF -treatment consists of diuretics (reduce fluid load) and glycosides (strengthen cardiac intropy) -with this combination strong chance of potassium deficiency (why?) and constipation constipation can stress heart

8. Nutrition therapy for CHF -increase potassium by eating potassium rich foods if potassium deficient -if overweight –lose weight- why? -aims are to reduce or restore nutrition status and to reduce cardiac work

9. Nutrition therapy for CHF -reduce fluid and sodium intake- remember body in CHF is having trouble keeping up with the water load -sodium increases the water load and ultimately the blood pressure

10. Nutrition therapy for CHF reduce fluid and sodium intake- remember body in CHF is having trouble keeping up with the water load -as blood pressure increases the risk of kidney failure increases -if kidney failure occurs then fluid retention will shut down the body -dialysis is an option but not nearly as good as properly functioning kidneys

11. Nutrition therapy for CHF reduce fluid and sodium intake- remember body in CHF is having trouble keeping up with the water load -patient gets high nutrient density foods-get energy and protein with less fluid -heart healthy diet described in previous lectures is appropriate to ensure that there is a reduced risk of heart attack or subsequent heart attack

12. Nutrition therapy for CHF -a healthier heart is critical to being able to meet the demands of increased water load -max 2000 mg sodium per day -if recurrent or persistent fluid retention then no more than 2 litres of fluid/day -adequate fibre -no alcohol

13. Nutrition therapy for CHF -carbohydrate requirement is dictated by the presence of hyperglycemia- - possible reasons for hyperglycemia -if supplements are required then nutrient dense liquids are the first choice

14. Nutrition therapy for CHF -if patient does not want to eat then duodenal feeding can be initiated -feedings begin slowly (30 ml/hour) and then are increased gradually -fluid and electrolyte status must be carefully monitored why?

15. Nutrition therapy for CHF -if patient does not want to eat then duodenal feeding can be initiated -overly aggressive nutritional support can worsen CHF resulting in pulmonary edema -2 kcal/ml and moderate to low sodium -continuous nasogastric feeding can result in loss of body weight (fluid) loss and lean body mass increase without compromising cardiac status

16. Nutrition therapy for CHF if oral and tube feeding fail then parenteral feeding is instituted -as with nasogastric- therapy begins slowly -1500 ml per day to start -cachetic patient as low as 600 ml/day –why? -central venous pressure, pulse rate, arterial blood pressure and urine output are tracked as fluid input increases

17. Nutrition therapy for CHF -at the first sign of nutritional inadequacy, enteral or parenteral therapy should begin as progression of nutritional inadequacy is slow and nutritional goals take longer to obtain

18. Nutrition therapy for CHF -sodium-4 grams sodium chloride -no sodium added diet-high sodium foods restricted (processed foods- eg hot dogs) -2 grams sodium chloride - mild sodium restriction -1 gram sodium chloride –moderate sodium restriction -500 mg sodium chloride - strict sodium restriction -250 mg sodium chloride -severe sodium restriction -normal intake of other nutrients