NFS 561 Case Study Presentation: Heart Failure. Presented by: Megan Lasko University of Rhode Island MS in Dietetics December 10, 2016

Transcription

1 NFS 561 Case Study Presentation: Heart Failure Presented by: Megan Lasko University of Rhode Island MS in Dietetics December 10, 2016

2 I. Subjective/Objective Data Patient: CC Age: 59 Presenting symptoms: SOB Occasionally productive cough Extreme fatigue Elevated BNP (30,034 pg/ml) and troponin (0.07 ng/ml) Admission Diagnosis: Acute on Chronic Systolic Heart Failure Other Pertinent Medical Dx: Systemic lupus erythematosus HTN HLD Depression w/ anxiety Acute on chronic kidney disease (stage III) Tobacco abuse

3 I. Subjective/Objective Data Anthropometrics: Height: 5 (152 cm) Weight: 83 lbs (37.9 kg) BMI: 16.4 kg/m 2 Weight history: 12% weight loss x 9 months 4 lb. weight gain x <1 month No change in food intake Determined to be from CHF-related fluid retention 20 mg daily IV Lasix (furosemide) initiated 5 lb. (2.3 kg) weight loss during hospital stay Other medications?

4 I. Subjective/Objective Data Initiation of the Nutrition Care Process (NCP) Nutritional Trigger : BMI <17 NCP Steps: 1 Assessment Anthropometric Data (AD) Biochemical Data (BD) Client History (CH) Food/Nutrient-Related History (FH) Nutrition-Focused Physical Findings (PD) Diagnosis Intervention Monitoring and Evaluation

5 I. Subjective/Objective Data NCP Step 1: Assessment Anthropometric Data (AD) Weight (AD-1.1.2): 35.6 kg (post-diuresis) Height (AD-1.1.1): 152 in. (5 ) Recent Weight Changes (AD-1.1.4): Noted previously 4 lb. weight gain x <1 month 5 lb. weight loss x <24 hours w/ diuresis Weight History (AD-1.1.4): Noted previously 12% weight loss x 9 months

6 I. Subjective/Objective Data NCP Step 1: Assessment Biochemical Data (BD) Troponin: 0.07 ng/ml BNP: Not re-taken since admission 30,034 pg/ml Triglycerides: 213 mg/dl Creatinine: 1.39 mg/dl

7 I. Subjective/Objective Data NCP Step 1: Assessment Client History (CH) Already Reviewed: Age (CH-1.1.1) Sex (CH-1.1.3) Nutrition-oriented medical/health history (CH-2.1) Psychological history (CH ) Family History (CH-2.1) Wife left him 2 Children - Deceased

8 I. Subjective/Objective Data NCP Step 1: Assessment Food/Nutrient-Related History (FH) 24-Hour Recall (as Inpatient) Breakfast: Scrambled eggs, Toast, Coffee 75% consumed Lunch: Hamburger, French fries, Coffee 75% consumed Reported Appetite: Fair Usual Intake (at Home) Regularly eats 3 meals/day (FH ) Common Foods Eaten: (FH-1.2.2) B: Eggs, Toast, Coffee L/D: Hamburger, Hot dog, French fries, Fried plantains Drinks: Orange juice, Water Snacks: Chips, Cakes Environment: (FH-2.1.3) Home Eats alone Prepares food for self

9 I. Subjective/Objective Data NCP Step 1: Assessment Nutrition-Focused Physical Findings (PD) Strikingly Underweight (PD-1.1.1) Muscle Wasting: (PD ) Temporal wasting Clavicle protrusion Cardiovascular-Pulmonary Complications (PD ) Cough SOB Body Fat Depletion Hollowed orbitals Triceps

10 I. Subjective/Objective Data NCP Step 1: Assessment WEIGHT HISTORY + NUTRITION-FOCUSED PHYSICAL FINDINGS= Springer et al 2 : Involuntary weight loss of at least 6% non-edematous body weight during a 6-month period. Loss of Lean Body Mass 3

11 I. Subjective/Objective Data NCP Step 1: Assessment Protein Needs: AND EAL for HF: g/kg body weight for clinically stable depleted patient: preserve actual body composition limit the effects of hypercatabolism 1.4 g x 35.6 kg=50 grams protein/day Energy Needs: AND EAL for HF: 4 Predictive Equation w/ Adjustment for Hypercatabolism RMR using MSJ: 1011 kcal Activity Factor: 1.3 Hypercatabolism Factor: 1.2 RMR X 1.2 X 1.3= 1,577 kcal/day Fluid Needs: AND EAL for HF: 4 Restrict between liters/day improve clinical symptoms improve quality of life CC s fluid needs: 1.4 L/day

12 I. Subjective/Objective Data NCP Step 2: Diagnosis but Not So Fast! Excessive sodium intake (NI ) -??? REMINDER: Observed eating hamburger, French fries FOODS COMMONLY EATEN: Chips, Hot dogs, Fried Plantains Before moving on, let s review: Heart Failure pathophysiology as it relates to the diet Changes made in CC s diet prescription during his stay!

13 II. Disease Pathophysiology/Dietary Rationale A Healthy, Non-HF Heart: a Atrial Pressure Release of Atrial Natriuretic Pepetide Tone of Sympathetic Nervous System in the Kidneys Release ADH Renal Na/H2O excretion Glomerular Filtration Rate Vasodilation Renal Water Reabsorption Vasodilation and kidney able to efficiently excrete dilute urine a Information adapted from Urso et al 4

14 II. Disease Pathophysiology/Dietary Rationale Figure 1: Heart Failure Pathophysiology and the Diet a a Figure Adapted with Permission from Urso et al 4 VEC: Extracellular Fluid Volume SNS: Sympathetic Nervous System AVP: Arginine Vasopressin GFR: Glomerular Filtration Rate

15 II. Disease Pathophysiology/Dietary Rationale Fluid-Build Up: Pulmonary congestion Edema Sodium Restriction: Sodium contributes to fluid retention AND Evidence Analysis Library: <2 g Na per day for patients w/ HF 5 Improve clinical symptoms (i.e. edema, fatigue) and quality of life. 5

16 II. Disease Pathophysiology/Dietary Rationale Diet Order History UPON ADMISSION: TLC 2.3 gram Na Diet: <25% total kcal from fat (<7% from saturated fat) <200 mg cholesterol 2 g plant sterols g soluble fiber Meat portions restricted to 2-3 oz. per meal Opinion: Too Restrictive w/ Fat, Not Restrictive Enough w/ Na! AFTER CARDIOLOGY CONSULT: Regular House Diet: ~2000 kcal ~90 g protein NO RESTRICTIONS Initial opinion: Not restrictive enough w/ Na! Cardiology Note: Will liberalize patient s diet more important that a patient this cachectic eat something palatable to him.

17 II. Disease Pathophysiology/Dietary Rationale Na Restriction in HF: The Evidence Atliti et al 6 75 hospitalized HF Patients Na Restriction (800 mg/d) Standard Hospital Diet (Unrestricted) RESULTS: No differences in clinical stability* or 30-day readmission rates between groups *As measured by clinical congestion and weight changes

18 II. Disease Pathophysiology/Dietary Rationale Na Restriction in HF: The Evidence Doukky et al HF Patients: followed for 36 months and classified as: Na Restricted (<2500 mg/d) Na Unrestricted (>2500 mg/d) RESULTS: Na Restricted subjects had a significantly higher: Death risk HF hospitalization risk

19 II. Disease Pathophysiology/Dietary Rationale Na Restriction in HF: The Evidence Colin-Ramirez et al 8 38 adults w/ confirmed HF 6 months Low Na Group (<1500 mg/d) Moderate Na Group (<2300 mg/d) RESULTS: Significantly lowered BNP* and improved quality of life** in the Low Na group *BNP: prognostic marker in HF **As measured by the Kansas City Cardiomyopathy Questionnaire

20 II. Disease Pathophysiology/Dietary Rationale Na Restriction in HF: The Evidence 2013 ACCF/AHA Guidline for the Management of Heart Failure: 9 Insufficient data to endorse any specific level of sodium intake in Stage C and D HF Patients* The widely embraced dictum of sodium restriction in HF is not well supported by current evidence *CC was classified as Stage D HF: w/ Advanced Heart Disease and Symptoms 9

21 NCP Step 2: Diagnosis PES Statement: Inadequate protein-energy intake (NI-5.2) related to increased nutrient needs due to catabolic illness (cachexia) as evidenced by BMI 15.4 kg/m 2 and patient reported food intake indicating <75% of protein and energy needs.

22 NCP Step 3: Intervention In an effort to increase protein-energy intake in this patient with increased nutrient needs related to catabolic disease state (cachexia), the dietetic intern will place an order for an Ensure Enlive vanilla milkshake for the patient to receive and drink twice each day: 1) between breakfast and lunch, and 2)between lunch and dinner (ND-3.1.1). Image Source:

23 NCP Step 4: Monitoring and Evaluation Monitor: Electrolyte lab trends (Na, K, Mg) (BD-1.2.5) Daily weight changes (AD-1.1.2) Evaluation: At the nutrition review, RD to perform another dietary recall to evaluate whether or not CC is meeting/getting closer to meeting his high protein-energy needs (FH , FH ) Daily weight changes (AD-1.1.2)

24 GOALS Short-Term Goals: Increase protein-energy intake by 25% by follow-up (5 days after assessment) Avoid weight loss >0.5 lb (1 kg) by follow-up (5 days after assessment) Long-Term Goals: Quality of Life Maintenance

25 III. Effectiveness of Nutritional Care RD-conducted Review: % protein-energy intake charted Patient satisfied with Ensure delivery bid Electrolytes stable Weight increased by 0.2 kg Outcome?: Nutritional care was effective

26 IV. Discussion/Conclusion Individualization always important! Considerations: *Colleague Opinions Wanted!* What is your take on the research? None with cachectic subjects None with BNP elevations as high as CC Occurred over time/in outpatients None matched CC s clinical profile perfectly Nutrition education would it have been beneficial? Cachexia prognosis is it significant enough? Fluid restriction recommendation?

27 References 1. Nutrition care process: Introduction. Academy of Nutrition and Dietetics Evidence Analysis Library website. Accessed December 10, Springer J, Filippatos G, Akashi YJ, Anker SD. Prognosis and therapy approaches of cardiac cachexia. Cur Opin Cardiol. 2006; 21(3): Raymond JL, Couch SC. L Nutrition Therapy for Cardiovascular Disease. In: Mahan LK, Raymond JL, ed. Krause s Food & the Nutrition Care Process 14 th Edition. St. Louis, MO: Elsevier; 2016: Urso C, Brucculeri S, Caimi G. Acid-base and electrolyte abnormalities in heart failure: pathophysiology and implications. Heart Fail Rev. 2015;20(4): HF: Executive summary of recommendations (2008): Heart failure evidence-based nutrition practice guidelines. Academy of Nutrition and Dietetics Evidence Analysis Library website. Accessed December 10, Atliti GB, Rabelo ER, Clausell N, Rohde LE, Biolo A, Beck-da-Silva L. Aggressive fluid and sodium restriction in acute decompensated heart failure: a randomized clinical trial. JAMA Intern Med. 2013;173(12): Doukky R, Avery E, Mangla A, et al. Impact of dietary sodium restriction on heart failure outcomes. JACC Heart Fail. 2016;4(1): Colin-Ramirez E, McAlister FA, Zheng Y, Sharma S, Armstrong PW, Ezekowitz JA. The long-term effects of dietary sodium restriction on clinical outcomes in patients with heart failure. The SODIUM-HF (Study of Dietary Intervention Under 100 mmol in Heart Failure): a pilot study. Am Heart J. 2015; 169(2): Yancy CW, Jessup M, Bozkurt B, et al ACCF/AHA guideline for the management of heart failure: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;62(16):e