Case study 1: acute myocardial infarction Megan Fuchs Good Sam Dietetic Intern January 5, 2012

Patient Profile Personal Information 46 year old white male Lives in Cincinnati, OH with wife, daughter, and grandson Leads a physically active lifestyle Works in maintenance – constant movement Lifts weights and swims regularly No ethnic or religious considerations

Patient Profile Admission JD presented to the Western Ridge ER with complaints of chest pain, N/V, and diaphoresis Found to be having an acute inferior myocardial infarction (MI) Immediately transferred to GSH ER At GSH, doctors confirmed the diagnosis of an acute inferior MI based on EKG results consistent with MI Noted sinus arrhythmia Rate of 89 Marked segment elevation in inferior leads

Patient profile Past medical History Splenectomy (as a child, unknown reason for removal) Surgical removal of the spleen due to rupture, enlargement, certain blood disorders, cancer, infections, or non-cancerous tumors Spleen is an important part of fighting infection – filters damaged red blood cells Complications may include hemorrhage, blood clots, infection, or injury to other organs Hypertension (HTN) High blood pressure Diagnosed when ones blood pressure is 140/80 mmHg Factors affecting BP include amount of water and salt in the body; function of the kidneys, nervous system, and blood vessels Increased risk of developing HTN if one is obese, stressed/anxious, high salt diet, family history, diabetes, smoker, or African American

Patient Profile Family History Very strong history of heart failure

Patient profile Health History Generally sleeps well, 6-8 hours a night Physically Active Lifestyle Maintenance worker – uses stairs, walks to and from buildings Lifts weights and swims 3-4 times/week Non-smoker Occasionally drinks alcohol No substance abuse

Patient Profile Health History Height: 5’9” Weight: 267.7 lb Weight history: 5 lb weight gain/loss throughout the year No large amount of weight loss or gain Appetite Prior to admission – very good appetite, enjoys all foods but eats very little vegetables JD and his wife enjoy shopping and cooking together During hospital stay – appetite improved but was initially very poor

Patient profile health history No dental problems No chewing or swallowing problems Normal digestion Elimination – regular bowel movements

Disease Background Acute Inferior Myocardial infarction Myocardial Infarction or Heart Attack Occurs when blood flow to part of the heart is blocked resulting in damage or death to the muscle Usually caused by a blood clot or plaque formation blocking the coronary artery, which supplies the heart with oxygen and blood

Disease Background Pathophysiology/etiology Most common etiologic factor: presence of atherosclerotic plaque blocking the coronary arteries Plaque leads to the disruption of blood flow through the coronary arteries to the heart Size of the thrombus determines the percent of blockage, ultimately determining the extent of damage Decreased blood flow for an amount of time can trigger a process known as ischemic cascade Causing the heart muscle to die and potentially resulting in cardiac arrhythmia

Disease Background Symptoms Most often characterized by Chest pain Tightness in chest Feeling of heaviness in the chest area Nausea Vomiting SOB Sweating Often mistaken for heart burn or indigestion during initial onset Usually chest pain or tightness will last longer than 20 minutes and increase in intensity

Medical Diagnosis Treatment Initial Treatment Nitroglycerin or morphine to numb chest pain Angioplasty for stent placement to unclog artery – most common emergency treatment Drug therapy to break apart clots – thrombolytic therapy Open heart surgery – most severe cases After initial treatment Medication to help protect the heart from future cardiovascular events – blood thinner, beta-blocker, or ACE inhibitor Lifestyle changes Slowly incorporating exercise Changing dietary habits Maintaining control of BP, blood sugar, and cholesterol levels

Disease Background Nutritional Intervention Low sodium, low fat, low cholesterol ≤ 30% total kcal from fat – less than 1/3 of those kcal should be saturated 200 mg/day cholesterol Sodium Weigh loss if overweight should be stressed

Disease Background Evidenced Based Research The New England Journal of Medicine Goal: to determine if salt reduction in diet would decrease cardiovascular disease The effects of salt reduction in association with CVD was compared Decrease in cost of HTN medication was determined Results Reducing dietary salt to 3gm a day would reduce new cases of CHD by 60,000-120,000 MI by 54,000-99,000 Stroke by 32,000-66,000 Medical costs related to CVD would decrease by 10 billion to 24 billion dollars annually

Disease Background Prognosis Usually, patients without complications can return to normal activity – slowly! The prognosis is dependent on how much of the heart muscle was damaged Amount of damage will determine how fast one returns to normal activities Level of damage may cause arrhythmia, valve problems, or heart rupture If the heart is no longer able to pump blood as well as it used to, heart failure may be a concern

Application to patient Initial Diagnosis: Acute Inferior Myocardial Infarction November 20, 2011 Symptoms: Chest pain (7 out of 10), nausea, vomiting, and diaphoresis Sinus arrhythmia, marked segment elevation of inferior leads Symptoms lasting 2 hr total JD had a very good understanding of his diagnosis Although discouraged because he lead an active lifestyle Unaware of unhealthy eating habits in relation to diagnosis Connection to strong family history of heart disease

Current Admission Diagnosis Diagnostic procedures Acute Inferior Myocardial Infarction Diagnostic procedures Metabolic panel, chest panel, and complete blood count Echocardiogram showed mild decrease in the left atrium, left ventricular function decreased, ejection factor of 45- 50%, and trace mitral regurgitation Chest x-ray found the trachea, heart, and mediastinal structures to be normal, along with clear lungs and pleural spaces

Current admission Diagnostic procedures cont. Coronary angiography summary noted dominant right system single vessel disease left ventriculography demonstrated severe inferior hypokinesis The right coronary artery was proximally occluded and enlarged with no collateralization Initially JD’s cardiac enzymes were CK: 252 MB: 4.4 Troponin: 0.01

Current Admission Treatment Stent placement to the right coronary artery occlusion JD was started on the beta-blocker Carvedilol to control his hypertension and treat his valve dysfunction in combination with a statin JD was also prescribed plavix and advised to take an aspirin to help avoid future cardiovascular events

Current Admission Medications Chewable Aspirin Colace Coreg Heparin Lipitor Maalox Morphine Nitroglycerin Plavix Prinivil Tylenol Xanax Zofran

Nutrition Care Process Nutrition Assessment Current Diet Order Cardiac: low fat/cholesterol, 3 gram Na, 0 caffeine Diet History Prior to admission JD did not follow any specific diet restrictions; 3 meals a day with an evening snack Fast food (White Castle, Skyline), Sit down restaurants (Applebee’s 1-2 times/week), and home cooked meals (~4 times/week) Ate very little vegetables; liked apples, oranges, and grapes; drank 2% milk Both JD and his wife cook and grocery shop together JD expressed interest in learning new recipes and substituting items to make each meal more heart healthy

Nutrition Care Process Nutrition Assessment 24 hour recall 25% po intake at breakfast – couple bites of low sodium scrambled eggs and whole wheat english muffin with a small amount of jelly, few sips of orange juice 100% po intake at lunch – meatloaf, red skin mashed potatoes, vegetable medley (corn, red peppers, green beans), dinner roll, and 4 oz apple juice 100% po intake at dinner – oven baked chicken, sliced potatoes, vegetables (yellow squash, carrots, and peppers), and 8 oz skim milk JD avoided his deserts because he is not big on sweets

Nutrition Care Process Nutrition Assessment JD had no prior MNT Prior to admission JD clearly stated he ate few, if any vegetables and likes some fruits. Also, most of his meals during the week consist of fast food. JD’s diet is mainly high fat, high sodium foods While in the hospital, JD received well balanced meals, and surprisingly he ate the vegetables! Level of nutritional risk: moderate risk due to high-risk diagnosis and obesity (167% IBW)

Nutrition Care Process Nutrition Assessment Anthropometrics Biochemical Labs Height: 5’9” Weight: 267.7 lb (122 kg) IBW: 160 lb ± 10% %IBW: 167% ABW: 187 lb (85 kg) Usual wt: 250 lb (114 kg) % weight change: +7% BMI: 39.45 kg/m2 Lab Result Na 139 Alb 3.6 K 4.3 Mg 1.7 Glucose 113 Chol 261 BUN 12 HDL 33 Creat 0.90 HA1C 6.2 Osmo 274 Trigly 432 Ca 8.9 BNP 149 Phos 3.2 Troponin I > 50,000 CK-MB index 19 CPK 2200

Nutrition care process nutrition assessment Macronutrient Needs Calories: 2125 kcal (25 kcal/kg ABW) Protein: 68-85 gm (0.8-1.0 gm/kg ABW) Carbohydrates: 292 gm/day (55% total kcal) Fat: 71 gm/day (30% total kcal) *16.5 gm saturated fat/day (7% total fat)

Nutrition Care Process Nutrition Diagnosis NC-3.3 Overweight/obesity PES Statement Overweight/obesity related to excessive kcal intake as evidenced by 167% IBW and a BMI of 39.45 kg/m2 Goals included appropriate weight loss, appropriate oral intake, and appropriate kcal intake Recommendation A critical aspect of JD’s recovery is a decrease in weight and a more restrictive diet than he was used to – diet education is key in preventing future cardiac events

Nutrition Care Process Nutrition Intervention Plan Limit foods high in fat, cholesterol, and sodium Cholesterol intake should be < 200 mg/day Total percent of fat from kcal should be ≤ 30% Increase MUFA and decrease saturated fats (7% of kcal/day) Decreasing total kcal intake to obtain appropriate weight loss Implement Provided JD with a list of heart healthy foods Explained what foods were high in fat, cholesterol, and sodium Reviewed sources of saturated fat and MUFA Explained how to read a nutrition fact label Provided tips eating out Diet education – low sodium, low fat, low cholesterol – and weight loss are the most important nutrition interventions for JD.

Nutrition Care Process Monitoring and Evaluation While in the hospital JD was receiving a cardiac diet per MD order Extensive diet education was provided JD expressed great intentions to follow a low fat, low cholesterol, low sodium diet at home Monitoring JD’s progress Keeping track of his daily sodium, cholesterol, and fat intake – comparing day to day Writing down times a week he eats out and what he ate

Summary 46 year old male living a moderately active lifestyle PMH: hypertension and splenectomy Current medical diagnosis: acute inferior myocardial infarction Stent placement, EF 45-50% Medications: carvedilol, aspirin, plavix, statin Cardiac diet per MD Educated on importance of low sodium, low fat, low cholesterol diet, along with weight loss Encouraged to keep records of fat, cholesterol, and sodium for self monitoring

References Mayo Foundation for Medical Education and Research. Splenectomy. Available at http://www.mayoclinic.com/health/splenectomy/MY01271. Accessed 11/30/2011. Dugdale, DC. PubMed Health. Hypertension. Available at http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001502/. Accessed 11/30/2011. Chen, MA. PubMed Health. Heart Attack. Available at http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001246/. Accessed 11/30/2011. Khera, AV. Cuchel, M. de la Llera-Moya, M. Rodrigues, A. Burke, MF. Jafri, K. French, BC. Phillips, JA. Muchsavage, ML. Wilensky, RL. Mohler, ER. Rothblat, GH. Rader, DJ. Cholesterol Efflux Capacity, High-Density Lipoprotein Function, and Atherosclerosis. N Engl J Med 2011; 364:127-35. Siri-Tarino, PW. Sun, Q. Hu, FB. Krauss, RM. Meta-analysis of prospective cohort studies evaluating the association of saturated fat with cardiovascular disease. Am J Clin Nutr 2010; 91:535-46.

References Bibbins-Domingo, K. Chertow, GM. Coxson, PG. Moran, A. Lightwood, JM. Pletcher, MJ. Goldman, L. Projected Effect of Dietary Salt Reductions on Future Cardiovascular Disease. N Engl J Med 2010; 362:590-9. TriHealth, Inc. Eating with your Hearts Consent. The Heart and Vascular Center. Lee, CD. Jacobs, DR. Schreiner, PJ. Iribarren, C. Hankinson, A. Abdominal Obesity and Coronary Artery Calcification in Young Adults: the Coronary Artery Risk Development in Young Adults (CARDIA) Study. Am J Clin Nutr 2007; 86:48-54. Martin, T. The Normal Range for Creatine Kinase Blood Test. Available at http://www.brighthub.com/science/medical/articles/75706.aspx. Accessed 11/30/2011. The American Association for Clinical Chemistry. CK-MD, The Test. Available at http://labtestsonline.org/understanding/analytes/ckmb/tab/test. Accessed 11/30/2011. Pronsky, ZM. Crowe, SR JP. Food Medication Interactions, 16th edition. 2010; p. 3-339. Khan, S. Myocardial Infarction Pathophysiology. Available at http://www.buzzle.com/articles/myocardial-infarction-pathophysiology.html. Accessed 12/30/11.