Cardiac Case Study Nd

Cardiac Case Study Kristine Myers Dietetic Intern

Introduction: Patient’s initials- SA Primary problem- CAD Height- 170 cm (67 in) Weight- 87 kg (191 lbs) Age- 53 Sex- Male Reason patient was chosen for study- CAD and CABG procedure Date of study- 01/05/16 - 01/14/16 Focus of this study- s/p CABG patient, heart healthy cardiac diet Social History: Occupation- unemployed Marital status- Single Health insurance- Medicare Children and ages- N/A Religion- Seventh Day Adventist Normal anatomy and physiology of body function: The primary use of the heart is to pump blood throughout the body to supply oxygen and nutrients to the body’s tissues. Veins connected to the heart are the channels blood uses to reach the tissues . Like the other parts of the body, the heart tissue also requires oxygen and nutrients to function . When blood is passing through the heart’s chambers it is not supplying oxygen and nutrients . The heart receives its oxygen and nutrients from the left and right coronary arteries. 1,2 Plaque can harden in the coronary arteries over time . As plaque build up in the arteries occurs, oxygenated blood has a harder time getting to the heart tissue. As this happens the heart has to work harder to pump . The lack of oxygen weakens the heart and blood is not pumped to the rest of the body’s tissues efficiently. This commonly causes chest pain or angina. If left untreated a heart attack can occur. 1

Past Medical History:

Coronary artery disease (CAD) Hyperlipidemia (HL) Asperger’s syndrome

Previous Admissions 

SA was admitted on October 11th 2015 and underwent cardiac catheterization as well as having a stent placed in his mid LAD due to a non-ST segment elevation myocardial infraction (NSTEMI) . The patient was sent home and doctors were hopeful the stent placement would be adequate treatment.

•

Patient SA was admitted for chest pain on November 13 th – 14th 2015 for an observation stay.

Present Medical Status and Treatment: Theoretical discussion of disease condition CAD is the most common type of heart disease and is the leading cause of death among men and women in the United States . CAD occurs when plaque build up accumulates on the inner walls of the arteries . Blood uses these arteries to get to the heart. The build up of plaque is known as atherosclerosis . The greater the build up the less blood passes through, resulting in the heart not receiving the blood or oxygen it needs to continue working . This will cause chest pain and likely a heart attack if a blood clot forms completely cutting off circulation to the heart. The longer CAD remains the weaker the heart becomes, which leads to heart failure.2,3 There are many different diagnostic tools or tests to identify CAD and a person’s risk of heart attack. Some of these include a lipid profile, cardiac MRI, echocardiography, and coronary angiography. Depending on the test(s) chosen by the doctor and the results of the tests, the treatment route will be determined accordingly. Regardless of the treatment plan, exercise and healthy nutrition are always key factors in the health of the heart.3 Usual treatment of the condition There are two common procedures used to treat Coronary Artery Disease (CAD). Both make a clearer path for blood to travel through on its way to the heart. One uses a balloon to open up a semi-blocked blood vessel and the other reroutes the blood by connecting a new blood vessel around the blocked one .4,5

Percutaneous Coronary Intervention is a procedure also referred to as coronary angioplasty. It is a non-surgical method used to open the arteries for blood to pass through. A catheter is inserted into either the upper thigh or upper arm through the artery. Inserting a catheter opens the narrowing pathway for blood to better reach the heart.4 Coronary Artery Bypass Grafting (CABG) is a surgical procedure used when arteries become blocked. The plaque build up, which prevents blood from getting to the heart, causes a need to bypass the narrowing vein . When this happens, surgery is required to help avoid a heart attack from occurring . The CABG procedure is a form of surgery where a blood vessel from a different area of the body is used to bypass the blocked artery. This blood vessel may be a vein taken from the leg or another artery in the chest . One end of the blood vessel is attached above the blocked artery and the other is attached below the blocked artery. Bypassing the blocked vessel creates a new path for oxygenated blood to reach the heart. 2,4,5 Originally this procedure was always done as an open-heart surgery, breaking the sternum in half, spreading it apart and temporarily stopping the heart. Tubes were hooked up to the heart and a machine was used to pump the body with blood. Though this traditional form of CABG surgery is still used, there have been new discoveries of less invasive CABG surgeries . New developments like the “off-pump” CABG procedure do not require the heart to be stopped . Robotic procedures have become an increasingly popular way to perform CABG surgeries as well.4,5 Other developments in the way CABG surgeries are performed include the way in which the graft is taken. Traditionally a long incision is cut down the inner thigh or calf. Now endoscopic vein harvesting and endoscopic radial artery harvesting are used as a less invasive way to locate a blood vessel for the use of grafting. These two improvements have provided patients with less leg pain after surgery and shorter hospital stays.4 Patient’s symptoms upon admission leading to present diagnosis and explain etiology 

Chest pain: related to plaque build up in the arteries, preventing proper blood flow to the heart. The lack of sufficient blood flow likely causes chest pain.

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Shortness of breath (SOB): related to the organs of the body, specifically lungs, not receiving adequate oxygenated blood . When the blood has difficulty passing through the arteries the rest of the organs in the body are affected.

Lab findings and interpretation Date 1/5/16

Lab A1c

Value 6.0

Range 4-6%

1/6/16

Sodium Potassium Glucose BUN Creatinine GFR/Cl Magnesium Cholesterol HDL LDL Triglycerides

140 4.1 221 (H) 10 0.62 (L) >110/129 2.5 103 41 33 147

132-143 3.5-5.0 70-100 6-20 0.7-1.2 >110 1.7-2.6 <180 40-60 70-189 <200

1/13/16

Sodium Potassium Glucose BUN Creatinine GFR/Cl

138 4.9 93 13 0.60 (L) >110/134

132-143 3.5-5.0 70-100 6-20 0.7-1.2 >110

SA’s laboratory values above upon admission were mostly in range . SA had high glucose levels and low creatinine, but other than that, looked satisfactory. The patient’s sodium value was in range at 140 . Before discharge, patient SA continued to have relatively in-rage lab values . His glucose was down to 93 and sodium dropped slightly to 138. His creatinine was still marginally low at 0.60. Surprisingly, the patient’s lipid values were all in range, aside from LDL cholesterol, which was lower than the normal range . His total cholesterol and triglycerides observed were at adequate levels . Medications  

Aspirin 81 mg/day o Prescribed for chest pain o No known interactions with food Atorvastatin 80 mg/day

o Prescribed for maintenance of adequate cholesterol and triglyceride

    

levels o Grapefruit is not advised while taking Atorvastatin Pepcid 20 mg BID o Prescribed for heartburn o No known interactions with food Heparin 250 mL while at the hospital o Prescribed as a blood thinner for the prevention of blood clots o No known interactions with food Metoprolol 50 mg BID o Prescribed for high blood pressure and chest pain o No known interactions with food Xanax 0.25 mg TID o Prescribed for anxiety o Grapefruit is not advised while taking Xanax Clopidogrel 75 mg/day taken at home o Prescribed as a blood thinner to prevent heart attacks o No known interactions with food Treatment

Treatment options include:    

Surgeries Procedures Healthy nutrition Exercise

The treatment used for patient SA was CABG x 4 . Following this openheart procedure, nutrition is vital. Adequate nutrition with adherence to a heart healthy cardiac diet will provide the best nourishment during recovery . As new procedures and techniques come out for treatment of CAD, the CABG surgery remains prominent. The balloon angioplasty and stents, which were both discovered after CABG, have lost their appeal as their unpredictability has been uncovered. According to a study published in 2015, bypass surgery is one treatment that despite the pain and discomfort it causes patients, has not lost credibility or attraction. It is a very common treatment option with pleasing results.6

Medical Nutrition Therapy:

Nutrition history Patient reports eating three meals a day with snacks in between . He prepares his own meals in his kitchen. SA stated he uses mostly canned fruits and vegetables, but is going to start buying frozen or fresh when able . He is a vegetarian who eats dairy products, but not fish . He gets most of his protein from nuts and soy. SA is allergic to eggs, but stated he eats yogurt occasionally. He likes peanut butter and soy butter sandwiches . He told me during a visit that he likes vegetarian burgers. Patient SA likes to buy black bean or tofu burgers when he can afford them. SA acknowledged he eats many prepackaged snacks such as potato chips and Twinkies. He knows these are not healthy snack choices and wants to try eliminating them from his diet when he leaves the hospital . Another change he is looking to make to his diet is switching from whole and 2% milk to skim milk. Prior to admission SA stated he was not aware he should be buying skim milk. Analysis of previous 24 hour recall Time: 9:00 am

Food: Oatmeal Banana Orange juice

Portion: ½ cup 1 medium 8 oz

11:00 am

Hostess snack

1 pkg

1:00 pm

Wheat bread Peanut butter Canned mandarin oranges Canned green beans Apple juice

2 slices 2 tablespoons 1/2 cup 1/3 cup 8 oz

3:00 pm

Potato chips

1 oz

6:00 pm

Wheat bread Soy butter Pudding Canned peaches Orange juice

2 slices 2 tablespoons ½ cup 1/3 cup 8 oz

According to SA’s 24-hour dietary recall, he is consuming adequate amounts of grains and fruit, but is lacking in vegetables and dairy. His protein intake is also below the recommended amount . Protein intake is important for wound healing. A man of his statue should be consuming 80-100 grams of protein to facilitate healing. As a vegetarian, it is important the patient is eating

adequate non-meat protein sources and though his protein intake from the recall does not appear sufficient, he named many protein sources that he enjoys . His calorie intake status post surgery should be between 2,010-2,345 kcals. The dietary recall provided falls just short of this range . SA greatly exceeded the recommended amount of added sugar per day. He was advised during his hospital stay about cutting back items such as his pre-packaged hostess snacks . He may also benefit from cutting back his juice intake, because of the high sugar content in fruit juice. SA was greatly lacking in Calcium intake. This is not surprising as his recall shows a deficit in dairy consumption. A glass of skim milk at breakfast and low-fat yogurt for a snack could improve his dairy consumption, therefore his Calcium intake. The recall also made apparent his lack of water-soluble vitamins and vitamin B12. An increase in vegetables consumed will benefit his vitamin status. Though the patient’s diet is not perfect, he seemed motivated to make any necessary changes. Current prescribed diet The patient was prescribed a 2-gram sodium, heart healthy cardiac diet at the hospital. The heart healthy cardiac diet includes low fat and low cholesterol . SA was put on this diet following his open-heart surgery. Adequate oral intake abiding by this diet is essential following surgery to facilitate healing of the chest incision. Rationale for diet or changes Sodium and fat are the key nutritional players involved in causing a heart attack. The more sodium consumed by an individual the harder their heart has to work. Sodium and water attract and settle near the heart . The more sodium and water the more pressure there is near the heart . This makes the heart work harder to pump blood. By limiting the sodium to 2 grams (2,000 mg), there is less pressure surrounding the heart muscle. Fat is the other important player. Unhealthy fats, such as saturated fat and trans fat, cause the build up of plaque in the arteries. The more saturated and trans fat eaten by an individual the more plaque builds up. A build up of plaque causes the arteries to harden and prevents the blood from passing through. When patient SA is discharged, he should continue monitoring his sodium and fat intake. Following a 2,000 mg sodium diet and watching his fat intake will be beneficial for his recovery. SA’s current prescribed diet will hopefully prevent him from visiting the hospital in the future for further severe heart issues . Patient’s physiological response to diet

The diet SA is on currently should help improve his chest pain and heart problems. It should prevent the feeling of shortness of breath . In theory a patient prescribed the same diet as SA will have improvement in laboratory values . Although in this patient’s case he already had satisfactory values . Before discharge SA was feeling much better and was not experiencing SOB . Evaluation of present nutritional status Prior to discharge the patient was stable and appeared adequately nourished. His laboratory values were in range and he was eating well . The patient was following a 2-gram sodium diet as well as one low in fat and cholesterol. With an excellent lipid profile and avoidance of high fat/high sodium items, SA should experience a more healthy life . He stated he is an avid walker, as he does not own a car, so he gets plenty of exercise daily. Prognosis: Following the CABG surgery, SA should do very well . The surgery has been shown to improve or completely eliminate symptoms of angina or chest pain. SA was very open to listening to nutrition education . Though the conversation had to be redirected often during the teaching, SA seemed receptive. The patient was able to repeat back nutrition knowledge he had previously been taught. If SA applies the nutritional information he learned in the hospital to his daily life, he should do very well . Summary and conclusion: With SA’s retention of knowledge, motivation to change his diet and frequent daily walking, I believe he will do a wonderful job maintaining great health. He was admitted to the hospital for chest pain and SOB . After receiving CABG x4 he experienced a great deal of pain . Once recovered and upon discharge he stated he was feeling much better . I provided SA with diet education and stressed the importance of healthy nutrition accompanied by exercise. SA is an avid walker and stated he will continue to exercise daily. Though he regularly consumes pre-packaged desserts and canned vegetables, he is going to work on cutting those back . In place of those, he agreed to substitute the canned goods for fresh or frozen vegetables . He also agreed to replace his whole and 2% milk with skim milk . He understands that the high fat milk is unnecessary for him to consume and that he can get all the beneficial vitamins and minerals from non-fat milk . This patient was a very interesting case for me . I was interested in learning more about the CABG procedure, because it was not something I was very familiar with. This patient had an added challenge with his Asperger’s

Syndrome. He seemed very receptive and intelligent during the education I provided him, but often became side tracked. I frequently had to redirect our conversation to stay on topic and get through all the material . I found that short frequent conversations worked better than one long education session . I visited SA’s room on a few occasions to talk about nutritional needs . I learned so much about the heart and heart healthy nutrition during this case study. I also became very familiar with the CABG procedure and how it is performed. The patient challenged me to provide the most up to date and relevant information. He challenged me to provide explanation behind why certain recommendations are in place. I’m very grateful for the learning experience SA was able to provide me.

Bibliography 1. Coronary Artery Bypass Grafting Surgery. Johns Hopkins Medicine Website. http://www.hopkinsmedicine.org/healthlibrary/test_procedures/cardiovascular/cor onary_artery_bypass_graft_surgery_cabg_92,P07967 . Accessed January 9, 2016. 2. Nutrition Therapy & Pathophysiology, 2nd edition; Authors, Marcia Nelms, Kathryn Pucher, Karen Lacey (2011)

3. Coronary Artery Disease. National Institute of Health website. https://www.nlm.nih.gov/medlineplus/coronaryarterydisease.html. Accessed January 11, 2016. 4. Angioplasty. National Institute of Health website. http://www.nhlbi.nih.gov/health/health-topics/topics/angioplasty. Accessed January 10, 2016 5. Nutrition Care Manual. Academy of Nutrition and Dietetics website. https://www-nutritioncaremanual-org-proxy1-cl-msuedu.proxy2.cl.msu.edu/topic.cfm?ncm_category_ id=1&lv1=5543&lv2=145193&ncm_toc_id=145193&ncm_heading=Nutrition %20Care. Accessed January 10, 2016. 6. Sigwart U. Treatment of coronary artery disease from the inside: Light at

the end of the tunnel? Global Cardiology Science & Practice. 2015;2015(4):53.