[MYOCARDIAL INFARCTION]

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1 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

2 1. Mr. Klosterman had a myocardial infarction. Explain what happened to his heart. Myocardial infarctions, also known as a heart attack, occur when there is a blockage and blood cannot be delivered to the heart. The blockage is normally caused by a blood clot in the coronary artery. 2. Mr. Klosterman was treated with an angioplasty and stent placement. Explain this medical procedure and its purpose. An angioplasty is a procedure that opens arteries that are blocked or that are too narrow. The procedure involves inserting a small balloon that is inflated once inside the artery to remove the blockage. A stent, a small mesh tube, is then placed in the artery to keep it from being blocked again. 3. What risk factors indicated in his medical record can be addressed through nutrition therapy? Mr. Klosterman has high total cholesterol, with low levels of HDL and high levels of LDL. Also, in his 24-hour recall it seems he is taking in too many Calories and he is also getting a lot of sodium and saturated fat from items such as roast beef, cream cheese, canned soup and mayonnaise. He should also be informed of the effects of smoking on the body because he has been smoking a pack of cigarettes a day for 40 years. 4. 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 is designed to help patients recover from a heart attack. It includes nutrition counseling, exercise, and education about proper lifestyle changes. Cardiac rehabilitation help the patient regain strength and prevent another heart attack from happening in the future. 5. Are there any current recommendations for nutritional intake during a hospitalization following a myocardial infarction? Immediately following a myocardial infarction, the patient will be NPO, nothing per oral. After they have their surgical procedure and are recovering, it is recommended that they do not get more than the recommended 2400 mg of sodium a day. Also, only 25% of daily Calories from fat and 7% of daily Calories from saturated fat. The patient should not be getting excess Calories either. 6. What is the healthy weight range for an individual of Mr. Klosterman s height?

3 Using the Hamwi Formula: 106 lbs for first 5 feet + 6 lbs for each inch over 5 feet (10) = 166 lbs Mr. Klosterman s ideal body weight would be 166 pounds. 7. 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. A. Using the Mifflon St-Jeor Formula: 10W+6.25H-5A-5}*SF W=185lbs/2.2kg= 84.1 kg H=70in*2.54cm=177.8 cm (10(84.1)+6.25(177.8)-5(61)-5)= *1.4*1.0=2, kcal I multiplied by 1.4 because of his inactive lifestyle and 1.0 because he had minor surgery. B. 84.1kg*1.1g PRO= 92.51gPRO/day I used 1.1 g of protein because of Mr. Klosterman s surgery. 8. 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. Kcal: 2,496/d CHO (55%): (.55 *2,496)= /4= g/d PRO (15%): (.15*2,496)= 374.4/4= 93.6 g/d FAT (30%): (.30*2,496)= 748.8/9= 83.2 g/d 9. From the information gathered within the intake domain, list the possible nutrition problems using the diagnostic term. NI-1.5 Excessive Energy Intake NI Inappropriate Intake of Fats NI Inadequate Mineral Intake (Calcium) NI Excessive Mineral Intake (Sodium) NI Excessive Protein Intake 10. Examine the chemistry results for Mr. Klosterman. Which labs are consistent with the MI diagnosis? Explain.

4 Total cholesterol and LDL cholesterol are high while HDL cholesterol is low which are consistent with the MI diagnosis. High levels of LDL can cause build up of plaque in the arteries which can lead to a heart attack. 11. Why were the levels higher on day 2? Mr. Klosterman s CPK, creatine phosphokinase, levels were extremely high on day two this indicates that there was damage to the cells due to lack of oxygen, which can indicate a heart attack. 12. What is abnormal about his lipid profile? Indicate the abnormal levels. Lipid Normal Value Patient s Value Total Cholesterol (high) LDL Cholesterol < (high) HDL Cholesterol <45 30(low) Apo A (low) Apo B Triglycerides Mr. Klosterman was prescribed the following medications on discharge. What are the foodmedication interactions for this list of medications? Medication Lopressor 50mg daily Lisinopril 10mg daily Nitro-Bid 9.0mg twice daily NTG 0.4mg sl prn chest pain ASA 81mg daily Possible Food-Nutrient Interactions Nausea, diarrhea Don t eat high Potassium foods Nausea, vomiting None Nausea, vomiting, cramping 14. From the information gathered within the clinical domain, list possible nutrition problems using the diagnostic term. NC- 3.3 Overweight/obesity NC-2.4 Predicted Food/ Medication Interaction 15. 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? - Do you know which foods can be high in cholesterol?

5 - Do you have time to be more physically active? - Do you know how to prepare foods that are low in fat, cholesterol and sodium? - Are you willing to do a nutrition intervention? What other issues might you consider to support the success of his lifestyle change? The first thing I would consider would be Mr. Klosterman s smoking habit. This can have such a horrible effect on his health, I would recommend cutting back on smoking and then eventually quitting. I would also recommend he exercise more and eat a more balanced diet that is low in fat and sodium. 17. From the information gathered within the behavioral-environmental domain, list possible nutrition problems using the diagnostic term. NB-1.4 Self-Monitoring Deficit NB-2.2 Physical Inactivity NB-1.1 Food and Nutrition Knowledge Deficit 18. Select two high-priority nutrition problems and complete PES statements for each. -Physical inactivity related to short duration of exercise as evidenced by being overweight. Excessive energy intake related to unhealthy lifestyle as evidenced by high BMI. 19. For each of the PES statements that you have written, establish an ideal goal (based on the signs and symptoms) and an appropriate intervention (based on etiology). Goal 1: increase physical activity by increasing duration or frequency of walking the dog. Goal 2: Decrease calories the patient is eating by providing nutrition education. 20. Mr. Klosterman and his wife ask about supplements. My roommate here in the hospital told me told me I should be taking vitamin E and I think it was folate along with omega-3 fatty acid supplements. What does the research say about vitamin E, folate, and omega-3 fatty acid supplementation for this patient? It is important to get the recommended amounts of Vitamin E, folate and omega-3 fatty acids. However, it is better to get these nutrients from a well balanced diet. Supplementation is used as an alternative if you cannot get proper amounts of a certain nutrient in the diet. 21. What would you want to assess in 3 to 4 weeks when he and his wife return for additional counseling?

6 The main assessment I would do when Mr. Klosterman returned would be lab values of his cholesterol to see if it had improved. I would also check to see if he had been losing weight and improving his physical activity.

7 Comparison of Harris Benedict and Mifflin-ST Jeor equations with indirect calorimetry in evaluating resting energy expenditure. Amirkalali B, Hosseini S, Heshmat R, Larijani B. Source The Endocrinology and Metabolism Research Centre (EMRC) of the Tehran University of Medical Sciences (TUMS), Shariati Hospital, North Kargar St., Tehran , Iran. Abstract BACKGROUND: An understanding of energy expenditure in hospitalized patients is necessary to determine optimal energy supply. The metabolic rate can be measured or estimated by equations, but estimation is by far the most common method. AIM: This study tests the degree of agreement between measured resting energy expenditure by indirect calorimetry and predicted resting energy expenditure by Harris Benedict and Mifflin-St Jeor equations. Patients were categorized according to sex and diagnosis. SETTINGS AND DESIGN: Cross-sectional study. MATERIALS AND METHODS: In 60 randomly selected patients, aged between 18 and 83 years, resting energy expenditure (REE) was measured by indirect calorimetry and compared with the predicted equations of Harris Benedict and Mifflin-St Jeor. STATISTICAL ANALYSIS: Statistical analysis was performed by using the method of Bland-Altman, one sample t-test and Pearson's correlation. RESULTS: There was no statistically significant difference between measured and predicted resting energy expenditure by both equations, in all cases as a whole and each group. The only statistically significant difference was seen between measured resting energy expenditure and its predicted equivalent by Mifflin-St equation when patients were categorized according to their sex. Limits of agreements were wide for both equations in all cases and each category so clinical significance was considerable. CONCLUSIONS: At a group level Harris-Benedict equation is suitable for predicting REE but at an individual level, both equations have wide limits of agreement and clinically important differences in REE would be obtained.

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

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