1. Mr. Garcia had a myocardial infarction. Explain what happened to his heart muscle

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1 Jamie Berray & Jess Bolton Professor Matuszak KNH 411 December 6, 2016 Case Study #5 Understanding the Disease and Pathophysiology 1. Mr. Garcia had a myocardial infarction. Explain what happened to his heart muscle and vascular system. (Nelms 2016, p. 284, 285, 315) Mr. Garcia suffered from a myocardial infarction, which is otherwise known as a heart attack. Myocardial infarctions (MI) are caused by the death of the myocardial cells due to the lack of blood flow and oxygen deprivation of the cells. Often times this oxygen restriction is caused by the development of plaque, or atherosclerosis. When plaque builds up within the vascular wall, oxygen flow is restricted and the myocardial cells die (Nelms 2016, p. 293, 307). 2. Mr. Garcia s chest pain resolved after two sublingual NTG at 3-minute intervals and 2 mg of IV morphine. In the cardiac catheterization 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 posterobasilar scar was present with hypokinesis. Explain angioplasty and stent placement. What is the purpose of this medical procedure? Angioplasty is a method used to combat severe atherosclerosis that involves surgically placing a catheter with a laser that removes the plaque from the artery. During this process, enough plaque is removed to allow a balloon to be inflated so that the stenosis can be dilated. This procedure is often accompanied by the placement of a metal stent. A stent is a wire mesh tube that is placed to prop open arteries after an angioplasty procedure so that the artery no longer gets clogged by the buildup of plaque (Nelms 2016, p. 315). 3. Mr. Garcia 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?

2 Cardiac rehabilitation is designed to improve functional capacity while controlling risk factors in order to improve outcomes (Nelms 2016, p. 317). This will help Mr. Garcia return back to his normal daily life and help to maintain a level of health so that he will avoid suffering another myocardial infarction. The rehab process will include nutrition therapy, an exercise program, and stress management therapy. The goals of the cardiac rehabilitation process include to lose weight, normalize lipid profile, decrease blood pressure, reduce stress levels, and decrease any other risk factors that the patient presents with. Mr. Garcia will be given an individualized plan to help him meet these goals on his path to recovery (Nelms 2016, p. 317, 325). Understanding the Nutrition Therapy 4. What are the current recommendations for nutritional intake during a hospitalization following a myocardial infarction? Because of pain, anxiety, fatigue, and shortness of breath, oral intake may be low immediately after a Myocardial Infarction. The recommendations for nutritional intake during the post-mi period include a progressive diet from liquids to soft foods. The diet should initially consist of clear liquids without any caffeine in the diet. As the patient progresses to a normal intake, the Therapeutic Lifestyle Changes (TLC) diet should be introduced. This consists of a diet which is low in saturated fat and cholesterol, but high fruits, vegetables, whole grains and soluble fiber (Nelms 2016, p. 317) 5. List the risk factors indicated in his medical record that can be addressed through nutrition therapy. Mr. Garcia has a genetic predisposition for developing heart disease. He indicated that his father also suffered from a myocardial infarction at the age of 59. Because this is not a risk factor that can be controlled, we must address the issues that can be improved nutritionally to reduce Mr. Garcia s risk of further incidents. Mr. Garcia s BMI was calculated using the formula BMI=kg/m2. His BMI was found to be 30.9 kg/m2, which places him in the obesity category. This is a factor that puts him at high risk for cardiovascular complications, and it can be addressed through nutrition therapy by developing a weight loss plan through diet and exercise. Dyslipidemia, or elevated lipid levels, are another risk factor that Mr. Garcia presents with that can be addressed using nutrition therapy by improving diet (Nelms 2016, p. 309, 310).

3 6. The RDN plans to talk about the Mediterranean diet with Mr. Garcia and his wife. What are the basic principles of the Mediterranean diet? What does the literature say in regards to the relationship between Mediterranean dietary principles and future heart health? The Mediterranean diet is a type of diet traditionally eaten in Mediterranean countries, which is thought to improve heart health. The diet is characterized by high consumption of vegetables, whole grains, legumes and olive oil and moderate consumption of protein. Due to its high fiber and healthy fat content, this diet would be beneficial in helping Mr. Garcia decrease his risk for developing more cardiovascular disorders. However, because of his current diet choices, this may be a difficult transition for Mr. Garcia. Culturally, this diet does not coincide with the average Western diet, so Mr. Garcia would have to actively make choices to stick to this diet, especially when eating out. I would suggest that he start implementing components of this diet into his daily intake so he can slowly transition and hopefully stick with the diet in the future to see long term results ( Nelms 2016, p. 305, 319). Nutrition Assessment 7. What is the healthy weight range for an individual of Mr. Garcia s height? Mr. Garcia s ideal body weight was calculated using the Hamwi method: (6 x 10) = 166 lbs. We calculated that his IBW is 166 lbs, or 75.5 kg. When calculating the BMI for his IBW, the formula BMI=wt(kg)/m2 was used. If he were to achieve this ideal body weight, his BMI would be This would BMI of less than 24.9 would put him in the normal range for BMI status. 8. Mr. Garcia works in a sedentary job, but he does get some exercise daily. He walks his dog outside for about 15 minutes at a leisurely pace each day and plays with his grandchildren. Calculate his energy and protein requirements Because Mr. Garcia is considered overweight, with a BMI of 30.9 kg/m2, we used his adjusted body weight to determine his calorie and protein needs. Adjusted body weight is found using the formula: ABW = IBW (UBW - IBW). His adjusted body weight was found to be lbs, or 69.9 kg. We used this value in the formula for calculating EER: EER = 10 x wt(kg) x ht (cm) - 5 x age Using the PAL multiplication factor of 1.5, we found that his calorie needs were 2026 kcal, for a range of kcal/day. For his protein needs, we used the recommended 0.8 g/kg per day. This yielded a g of protein/day. To give him an adequate range for protein, we also took into consideration the TLC diet guideline of 15% of kcal from

4 protein/day. This would provide Mr. Garcia with 79 g/day, giving him an ultimate range of g of protein/day. 9. Using Mr. Garcia s 24-hour recall, estimate the total number of kilocalories he consumed as well as the energy distribution of kilocalories for protein, carbohydrate. Using Supertracker.com, Mr. Garcia s 24-hour recall was analyzed to estimate the total number of kilocalories and the macronutrient distribution of his diet. The total kilocalories consumed throughout his day was about 2211 kcal. He consumed 88 grams of protein, 66 grams of fat, and 273 grams of carbohydrates. 10. Examine the laboratory results for Mr. Garcia. Which labs are consistent with the MI diagnosis? Explain. Why were the levels higher on 12/2? Cardiac Troponin is the protein released from myocardial cells when the heart is damaged or placed under severe stress. This level is often elevated after a cardiac injury. In fact, as stated in Nelms, Troponin levels are now considered to be the standard for diagnosing myocardial infarction. Mr. Garcia s value for troponin was 2.4 ng/dl on 12/1, 2.8 ng/dl on 12/2, and 3.1 on 12/3. This is much greater than the reference range of <0.2 ng/dl. Similarly, Troponin T levels should be less than 0.03 ng/dl, and Mr. Garcia s values were 2.1 ng/dl on 12/1, 2.7 ng/dl on 12/2, and 3.2 on 12/3. These values were most likely higher on day two and three, because, depending on the severity of the MI, troponin levels can take up to two weeks to decrease. The troponin levels are also higher due to the angioplasty procedure, which puts additional stress on the heart muscle, causing troponin levels to be elevated. The normal troponin levels will be return to normal when the heart function reaches a normal level and the stress on the heart is reduced (Nelms 2016, p. 324, 325). In addition to the high levels of troponin in his blood, Mr. Garcia s elevated levels of his lipid profile are responsible for the onset of his cardiovascular issues. The following are the elevated levels upon admission on 12/1, with the associated reference range in parentheses: Cholesterol 235mg (<200 mg), HDL 30 mg/dl (>50mg/dL), LDL 160 mg/dl (<130 mg/dl), LDL/HDL 5.3 (<3.55), Apo A 72 mg/dl ( mg/dl), and Triglycerides 220 mg/dl ( mg/dl). 11. Mr. Garcia may be at risk for metabolic syndrome. What is this? Does he have any laboratory values that would support this diagnosis?

5 Metabolic syndrome is the name for a combination of risk factors that occur together. The risk factors for metabolic syndrome are abdominal obesity, triglyceride levels greater than 150 mg/dl, HDL cholesterol less than 40 mg/dl, blood pressure greater than or equal to 130/greater than or equal to 85 mmhg, and insulin resistance with a fasting plasma glucose greater than 100 mg/dl. Mr. Garcia does have laboratory values that support this diagnosis. His triglyceride levels have been in the low to mid 200 s ( mg/dl), his HDL cholesterol has been in the low thirties (30-33 mg/dl), and his glucose levels are elevated as well ( mg/dl) (Nelms 2016, p. 312). 12. List the abnormal values that are found in his lipid profile. What are the long-term implications? What are the possible treatment options for these abnormalities? Mr. Garcia s total cholesterol was elevated at 214 mg/dl. His HDL values were less than recommended at 33 mg/dl, LDL levels elevated at 141 mg/dl as well as his triglyceride levels at 257 mg/dl. The long term implications of these levels are increased risk for cardiovascular disease. Mr. Garcia already presents with myocardial infarction so it will be imperative for him to get these levels under control. Possible treatment options for these abnormalities include weight and diet management, as well as possible addition of medications (Nelms 2016, p. 314). 13. Mr. Garcia was prescribed the following medications on discharge. What are the rationale and the food-medication interactions for each of these medications? a. Lopressor 50 mg daily Lopressor is a Beta-1-blocker to decrease heart rate and cardiac output. Possible food-medication interactions include nausea, diarrhea, and possible interference with calcium absorption. b. Linsinopril 10 mg daily Lisinopril is an ACE inhibitor that reduces blood pressure. Hypertension can occur, can worsen renal function, hyperkalemia, and dysgeusia. Avoid licorice and salt substitutions. c. Nitro-bid 9.0 mg twice daily Nitro-bid is a nitrate that helps with vasodilation. It can cause abdominal pain and dry mouth. d. NTG 0.4 mg sl prn chest pain Nitroglycerin, NTG, is a nitrate like nitro-bid. Helps with vasodilation, but can cause abdominal pain and/or dry mouth.

6 e. ASA 81 mg daily Aspirin, ASA, reduces the recurrence of heart attack. However, excessive use can cause cramping, nausea, and/or vomiting (Nelms 2016, p. 301). 14. You talk with Mr. Garcia and his wife. They are friendly and appear interested in your information. They are both anxious to learn what they can do to prevent another heart attack. What are examples of questions that you can ask them to assess how to best help them? Are you willing to incorporate more physical activity into your daily life? Would you be willing to keep a food journal? Do you know how to properly read nutrition labels? What changes have you been trying to make in your diet? Are you willing to change more? For Mrs. Garcia, are you willing to purchase/prepare a more heart healthy diet? 15. Are there other issues besides diet that should be addressed to support successful lifestyle changes for Mr. Garcia? If yes, please list them. Yes. Mr. Garcia admits to smoking a pack a day for the past forty years or so which is considered to be a major risk factor for cardiovascular disease. Mr. Garcia is on bed rest now, however after he is cleared to be physically active he should increase his activeness in order to reduce weight. Mr. Garcia also admitted to drinking about a glass of wine a day, which is not above the recommendation however alcohol consumption should be in moderation (Nelms 2016, p. 302). 16. From the information gathered within the assessment, list possible nutrition problems using the correct diagnostic terms. Food and nutrition-related knowledge deficit (NB-1.1) Excessive energy intake (NI-1.5) Overweight/obesity (NC-3.3) Altered nutrition-related laboratory values for lipid profile levels (NC-2.2) Physical inactivity (NB-2.1) Nutrition Diagnosis 17. Select two of the identified nutrition problems and complete the PES statement for each.

7 Excessive intake of saturated fat, sodium, and cholesterol related to food and nutrition-related knowledge deficit as evidence by 24-hour diet recall. Physical inactivity related to sedentary job as evidence by BMI, lipid profile, and patient discussion. Nutrition Intervention 18. For each of the PES statements you have written, establish an ideal goal (based on the signs and symptoms) and an appropriate intervention (based on the etiology). An ideal goal would be to decrease calorie consumption by 500 kcal/day, limit saturated fat to less than 7% of total kcal, limit sodium to less than 2400 mg/day, and reduce cholesterol to under 200 mg/day. The intervention strategy would be to implement nutrition education about Therapeutic Lifestyle Changes (TLC) diet as well as some components of the DASH diet. In regards to his physical inactivity, an ideal goal for Mr. Garcia is to decrease weight by 10% in the first 6 months. He can do this by following the TLC diet as mentioned above, and by increasing physical activity to 30 min of moderate activity a day. He can work up to walking 10,000 steps a day. Interventions could include the purchase of a fitness tracker, such as a FitBit, or setting up contact with a personal trainer, or cardiac rehabilitation exercise program at a gym. 19. Mr. Garcia 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? I would inform Mr. Garcia that fish oil pills are beneficial for their omega-3-fatty acids. Current research indicates that omega-3-fatty acids reduce mortality and the incidence of cardiovascular disease. It has been found that omega-3-fatty acids help to not only decrease the incidence of cardiovascular disease, but also protect the heart. The American Heart Association currently recommends that individuals with coronary heart disease consume 1 gram of supplemented omega-3-fatty acids daily (Nelms 2016, p. 319). Nutrition Monitoring and Evaluation 20. What would you want to assess in three to four weeks when he and his wife return for additional counseling? (Hint: your follow-up assessment should be based on signs and symptoms in your PES statements.)

8 In three to four weeks at our follow up appointment, I would want to assess the changes the Garcia s have been implementing as related to the dietary changes: following a TLC diet and consuming less calories, cholesterol, sodium, and saturated fat. Additionally, I would assess how he is doing with his physical activity levels, and if he is reaching the goal of 1 lb of weight loss per week. I would want to identify any challenges that he may be experiencing and help come up with strategies and new ways to combat these things. I would want to assess Mr. Garcia s confidence in making these changes in his lifestyle, as well as answer any questions the Garcia s may have at this time. References Krause, M. V., Mahan, L. K., Escott-Stump, S., & Raymond, J. L. (2012). Krause's Food & the Nutrition Care Process (14th ed.). St. Louis, MO: Elsevier/Saunders. Nelms, M., Sucher, K. P., & K. L. (2016). Nutrition Therapy and Pathophysiology (3rd ed.). Belmonte, CA: Thompson Brooks/Cole.

[MYOCARDIAL INFARCTION]

Case 7 By: Emily Lancaster October 19, 2012 Medical Nutrition Therapy Case Study #3 [MYOCARDIAL INFARCTION] I HAVE NOT GIVEN, RECIVED OR USED ANY UNAUTHORIZED ASSISTANCE ON THIS ASSIGNMENT. X 1. Mr. Klosterman