Mr. Klosterman

Myocardial Infarction Ischemic necrosis of part of the heart muscle.

11/28/2012 Daniel Lewis, Ariel Lebert, Courtney Kousser, Sarah Fecco

• Symptoms: Sudden onset of severe precordial pain • Medical Diagnosis: Myocardial Infarction • Medical Treatment: Emergency Angioplasty

Mr. Klosterman

• • • • • • • • •

Age 61 BP: 118/78 mmHg Temp: 98.4° F RR: 20 bpm SAO2: 80% HR: 92 bpm Pain: severe chest pain for past 1.5 hours Last ate: 1030 Last drank: 1100

Physical Findings @ 1354 3/25

Smokes (1 pack/day) for 40 years Patient Hx: • Emphysema/lung problems • Angina/chest pain • No HTN, Hypercholesterolemia, or diabetes

Family Hx: • CAD (Father) – MI age 59 • Cancer (maternal grandmother)

PMH: Surgery; cholecystectomy 10 years ago, appendectomy 30 years ago

Allergies/reaction: Sulfa/hives

Client History (CH)

• • • •

Height: 70” Weight: 185 lbs BMI: 26.5 kg/m2 Weight history is not specifically stated. • Assumption that he has a longstanding history of being overweight since there has been some attempt to change diet

Anthropometric Data (AD)

Day One

Day Two

Day Three

Optimal Values

Total Cholesterol

235 mg/dl H

226 mg/dl H

214 mg/dl H

<200 mg/dl

LDL-C

160 mg/dl H

150 mg/dl H

141 mg/dl H

<100 mg/dl

HDL-C

30 mg/dl L

32 mg/dl L

33 mg/dl L

>/= 60 mg/dl

LDL-C/HDL-C ratio

5.3 H

4.7 H

4.3 H

< 3.55

CPK

0 u/l

75 u/l H

55 u/l H

0 u/l

ALT

30 u/l

215 u/l H

185 u/l H

4-36 u/l

AST

25 u/l

245 u/l H

175 u/l H

0-35 u/l

LDH

325 u/l

685 u/l H

365 u/l

208-375 u/l

Troponin I

2.4 ng/ml H

2.8 ng/ml H

--

< 0.2 ng/ml

Troponin T

2.1 ng/ml H

2.7 ng/ml H

--

< 0.03 ng/ml

Biochemical Data

Risk Factors for CAD and IHD • Elevated LDL-C levels and LDL-C/HDL-C ratio • Low HDL-C levels • Hypercholesterolemia MI-related values (Day 2**) • Elevated LDH, ALT & AST: intracellular enzymes that are indicative of tissue damage when present in plasma • Elevated CPK: Particularly notable is the CK3 isoform as it is most abundant in heart muscle • Elevated Troponin I & Troponin T: Heart contractile proteins

Biochemical Data Interpretation

Lisinopril 10mg/day • • • •

Used to treat heart failure and HTN Used to improve survival after MI Angiotensin-converting enzyme (ACE) inhibitors Decreases tension on vessels, decreases blood volume

Lipitor 10mg/day • Reduce the risk of heart attack and stroke; decrease chance heart surgery will be necessary • Decrease cholesterol by slowing production • HMG-CoA reductase inhibitors (statins)

Medications

Lopressor 50mg/day • Used to treat HTN, also to prevent angina, improve survival after MI • Beta blocker • Relaxes blood vessels, slows HR to improve blood flow and decrease BP Nitro-Bid 9mg twice daily • Nitroglycerin ointment • Used to prevent angina associated with CAD • Vasodilator • Relaxes blood vessels NTG 0.4mg sublingually prn chest pain

Medications cont…

ASA (acetylsalicylic acid—aspirin) 81 mg/day • Used to prevent MI and stroke • Antithrombotic • Inhibition of thromboxane A2 synthesis  inhibition of platelet aggregation • Inhibits cyclooxygenase activity that produces prostaglandins  pain relief No vitamin/mineral supplements in use

Medications cont…

Medication

Possible Food-Nutrient Interactions

Lopressor 50 mg daily

Avoid natural licorice. Take 2 hours before or 6 hours after calcium supplements and/or fortified orange juice. Calcium salts may decrease absorption.

Lisinopril 10 mg daily

Avoid salt substitutes. Caution with K and Mg supplements. Decreased Na and Ca may be recommended.

Nitro-Bid 9.0 mg twice daily

Avoid alcohol. May result in dangerously low blood pressure.

NTG 0.4 mg sl prn chest pain

Avoid alcohol.

ASA 81 mg daily (acetylsalicylic acidaspirin)

Taking with food can decrease absorption and diminish drug effects.

Lipitor 10 mg daily

Avoid grapefruit juice- increase risk of toxicity. Fibers such as oat bran and pectin may diminish drug effect.

Medications & Dietary Supplements

24 hour recall • Breakfast: None • Midmorning Snack: 1 lg cinnamon raisin bagel w/ 1 tbsp fat-free cream-cheese, 8 oz orange juice, coffee • Lunch: 1c canned veg beef soup; sandwich w/ 4 oz roast beef, lettuce, tomato, dill pickles, 2 tsp mayonnaise; 1 sm apple; 8 oz 2% milk • Dinner: 2 lean 3oz pork chops, 1 lg baked potato, 2 tsp margarine, ½ c green beans, ½ c coleslaw (cabbage w/ 1 tbsp of salad dressing), 1 slice apple pie • Snack: 8 oz 2% milk, 1 oz pretzels

Drinks alcohol (1 drink/day) • Last drink: 3/24

Food/Nutrition Hx (FH)

24 hour recall • Breakfast: None • Midmorning Snack: 1 lg cinnamon raisin bagel w/ 1 tbsp fat-free cream-cheese, 8 oz orange juice, coffee • Lunch: 1c canned veg beef soup; sandwich w/ 4 oz roast beef, lettuce, tomato, dill pickles, 2 tsp mayonnaise; 1 sm apple; 8 oz 2% milk • Dinner: 2 lean 3oz pork chops, 1 lg baked potato, 2 tsp margarine, ½ c green beans, ½ c coleslaw (cabbage w/ 1 tbsp of salad dressing), 1 slice apple pie • Snack: 8 oz 2% milk, 1 oz pretzels

Drinks alcohol (1 drink/day) • Last drink: 3/24

Food/Nutrition Hx (FH)

24 hour recall • Breakfast: None • Midmorning Snack: 1 lg cinnamon raisin bagel w/ 1 tbsp fat-free cream-cheese, 8 oz orange juice, coffee • Lunch: 1c canned veg beef soup; sandwich w/ 4 oz roast beef, lettuce, tomato, dill pickles, 2 tsp mayonnaise; 1 sm apple; 8 oz 2% milk • Dinner: 2 lean 3oz pork chops, 1 lg baked potato, 2 tsp margarine, ½ c green beans, ½ c coleslaw (cabbage w/ 1 tbsp of salad dressing), 1 slice apple pie • Snack: 8 oz 2% milk, 1 oz pretzels

Drinks alcohol (1 drink/day) • Last drink: 3/24

Food/Nutrition Hx (FH)

Total kcal = 2879.32 kcal • CHO: 354g (~49.5% of total kcal) • Fiber: 29g • Sugars: 136g

• Protein: 152g (~21.3% of total kcal) • Fat: 95g (~30% of total kcal) • Sat. Fat: 37g • Trans Fat: 2g

Cholesterol: 371mg Sodium: 5072mg Iron: 262% DV

Intake Analysis (NutriCalc)

Recommended Intakes • TEE = 1086 - (10.1 x age in yrs [61]) + PA [1.12] x (13.7 x wt. in kg. [84.1]) + (416 x ht. in m. [1.78]) = ~2500 kcal • Daily protein = 0.8 g x 84.1 kg = 67.28g Recommended Weight • IBW (based on Hamwi): 106 + 6*10 = 166lbs • %IBW: 185/166 = 111% • BMI : 26.5 kg/m2

Comparative Standards

• Excessive energy intake -- 112% of DRI • Fat Intake -- 119% of DRI • Saturated Fat: -- 142% of DRI • Trans Fat • Protein Intake -- 226% of DRI

• Excessive Sodium Intake – 390% of DRI • Inadequate fluid intake (Water)

Intake Problems

Clinical Domain • Altered nutrition-related lab values • Food-medication interactions • Overweight Behavioral-Environmental Domain • Self-monitoring deficit • Willing to change • Adherence to nutrition-related recommendations Physical Activity • Physical Inactivity

Other Possible Problems

• Altered nutrition-related lab values (NC-2.2) related to excessive macronutrient intake as evidenced by total cholesterol of 235, LDL-C of 160 and HDL-C of 30. • Physical inactivity (NB-2.1) related to sedentary lifestyle as evidenced by physical activity limited to walking the dog for 15 minutes a day.

Diagnoses

• Reduction in total cholesterol (<200) and LDLcholesterol (<100); Increase in HDL-cholesterol (>60). • Increase amount of physical activity to 30 minutes/day minimum.

Prescriptions

• Comprehensive nutrition education to include: • recommended modifications regarding his daily intake (E-2.2) • skill development for the purposes of food selection and meal preparation (E-2.5). • recommended modifications regarding physical activity (E-2.2).

• Nutrition Counseling including: • motivational interviewing (C-2.1); • goal setting regarding weight loss, physical activity level and proper nutrient consumption (C-2.2) • self-monitoring regarding daily intake, weight and a daily/weekly physical activity log (C-2.3)

Interventions

Following MI: • NPO until after angioplasty • Limit oral intake to clear liquids w/o caffeine to decrease risk of arrhythmia; decrease risk of vomiting and aspiration • Follow-up with progression to the Therapeutic Lifestyle Changes (TLC) diet

Nutritional Therapy

Nutrient

Recommended Intake

Saturated Fat

Less than 7% of total kcal

Polyunsaturated fat

Up to 10% of total kcal

Monounsaturated fat

Up to 20% of total kcal

Total Fat

25-35% of total kcal

Cholesterol

<200mg/day

Fiber

20-30g/day

Protein

Approx. 15% of total kcal

Sodium

<2400 mg/day

Stanol esters

3-4 g/day

TLC: Nutrient Composition

Breads & Cereals • At least 6 servings per day

Vegetables** • 3-5 servings per day without added fat, sauce, salt

Fruit • 2-4 servings per day

Dairy Products** • 2-3 servings per day; low-fat or fat-free

Eggs • 2 or fewer egg yolks per week

Meat, Poultry, Fish*** • 5 oz or fewer per day; lean cuts

Fats and Oils • Unsaturated oils, soft margarines, seeds and nuts

TLC: Foods to Eat More

Breads and Cereals*** • Baked and processed goods, grain-based snacks

Vegetables • Fried or prepared with butter, cheese or cream sauce

Dairy • Full-fat products, ice cream, cream and cheese

Eggs • Whole eggs, egg yolks

Meat, Poultry, Fish** • Higher-fat cuts; fried meats

Fats and Oils*** • Butter, shortening, stick margarine • Trans Fats

TLC: Foods to Choose Less

Self-Monitor • Record weight, BMI & waist circumference

Gradual weight loss • Goal: lose 10% of body weight in 6 months • Lose ½ to 1 lb per week Increase Physical Activity • Make PA part of daily routines and recreational activities

TLC: Weight Reduction

Recommended by the American Heart Association and the American College of Cardiology to improve: • Risk of heart disease • Prevention of future hospital stays • Health and well-being Through: • Exercise training • Nutrition education and counseling • Lifestyle coaching • Smoking cessation • Stress reducing techniques

Cardiac Rehabilitation

3-4 week check up • Review TLC records • Assess changes in PA and nutrient intake • Review blood panel for changes in lipid levels • Smoking Cessation?

Monitoring & Evaluation

Domain 1 Medication: Lopressor 50 mg daily, Lisinopril 10 mg daily Nitro-Bid 9.0 mg twice daily NTG 0.4 mg sl prn chest pain, ASA 81 mg daily (acetylsalicylic acid-aspirin), Lipitor 10 mg daily Physical Activity: 15min/day walking the dog Food preparation: Wife shops and prepares meals Intake: • Breakfast: None • Midmorning Snack: 1 lg cinnamon raisin bagel w/ 1 tbsp fat-free creamcheese, 8 oz orange juice, coffee • Lunch: 1c canned veg. beef soup; sandwich w/ 4 oz roast beef, lettuce, tomato, dill pickles, 2 tsp mayonnaise; 1 sm apple; 8 oz 2% milk • Dinner: 2 lean 3oz pork chops, 1 lg baked potato, 2 tsp margarine, ½ c green beans, ½ c coleslaw (cabbage w/ 1 tbsp of salad dressing), 1 slice apple pie • Snack: 8 oz 2% milk, 1 oz pretzels

ADIME

Domain 2 • Height: 70” • Weight: 185 lbs • BMI: 26.5 kg/m2 • Weight history is not specifically stated. • Assumption that he has a longstanding history of being overweight since there has been some attempt to change diet

ADIME

Domain 3 (Day 2) Cholesterol: 226 mg/dl H LDL: 150 mg/dl H HDL: 32 mg/dl L LDL/HDL: 4.7 H Troponin I: 2.8 ng/ml H Troponin T: 2.7 ng/ml H ALT: 215 u/l H AST: 245 u/l H LDH: 685 u/l H CPK: 75 u/l H

Domain 4 • Age 61 • BP: 118/78 mmHg • Temp: 98.4° F • RR: 20 bpm • SAO2: 80% • HR: 92 bpm • Pain: severe chest pain for past 1.5 hours • Last ate: 1030 • Last drank: 1100

ADIME

Domain 5 Smokes (1 pack/day) for 40 years Patient Hx: Emphysema/lung problems Angina/chest pain Family Hx: CAD (Father) – MI age 59 Cancer (maternal grandmother) PMH: Surgery; cholecystectomy 10 years ago, appendectomy 30 years ago Allergies/reaction: Sulfa/hives

Altered nutrition-related lab values (NC-2.2) related to excessive macronutrient intake as evidenced by total cholesterol of 235, LDL-C of 160 and HDL-C of 30. Physical inactivity (NB-2.1) related to sedentary lifestyle as evidenced by physical activity limited to walking the dog for 15 minutes a day.

ADIME

• Comprehensive nutrition education to include: • recommended modifications regarding his daily intake (E2.2) • skill development for the purposes of food selection and meal preparation (E-2.5). • recommended modifications regarding physical activity (E2.2). • Nutrition Counseling including: • motivational interviewing (C-2.1); • goal setting regarding weight loss, physical activity level and proper nutrient consumption (C-2.2) • self-monitoring regarding daily intake, weight and a daily/weekly physical activity log (C-2.3)

ADIME

3-4 week check up • Review TLC records • Assess changes in PA and intake • Review blood panel for changes in lipid levels • Smoking Cessation?

ADIME

• Nelms, Marcia. Nutrition Therapy & Pathophysiology. Belmont, Ca. Cengage Learning: 2011. • Harvey, Richard. Biochemistry. Lippincott: 2011 • http://www.nhlbi.nih.gov/ • www.heart.org/ • www.acc.org/

References

Questions?