myocardial infarction

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Myocardial InfarctionMolly Chaffin

Denielle SaittaClaire HolladayLauren MitchellKarly Childress

+What is a myocardial infarction?

A heart attack occurs when blood flow to the heart muscle is decreased or blocked completely, keeping the heart from getting enough oxygen, which can damage or destroy part of the heart muscle.

Heart attacks are most often caused by the buildup of plaque in the arteries that lead to the heart.

Plaque is the accumulation of calcium and fatty acids such as cholesterol and triglyceride.

+What are the symptoms?

Most common warning symptoms of a heart attack: Chest pain or discomfort Upper body discomfort Shortness of breath

Other possible symptoms of a heart attack include: Breaking out in a cold sweat Feeling unusually tired for no reason, sometimes for days

(especially if you are a woman) Nausea and vomiting Light-headedness or sudden dizziness

+What is angioplasty?

Angioplasty is a nonsurgical procedure to open narrowed or blocked coronary arteries that supply blood to the heart.

A coronary artery stent is a small, metal mesh tube with a balloon that expands inside a coronary artery which is placed during or after an angioplasty. The stent helps prevent blockages in the artery in the future.

+Meet James Klosterman

+Client History (CH)

Personal History 61 y.o. male Occupation: Lutheran Minister Marital Status: Married, with grown children Tobacco use: 1 ppd for 40 years Alcohol use: 1 glass of wine per day

Patient Medical History Brought to emergency room by his wife after having

severe chest pain returning home from work. He described having pressure-like pain radiating to his jaw and left arm and had an episode of emesis and nausea


Medical History con’t Surgical History:

Appendectomy Cholecystectomy (10 years prior)

Allergies: none

Family History Father: Coronary Artery Disease;

MI age 59


Treatments/ Therapy Alternative Medicine Surgical treatment

Diagnosed as myocardial infarction Angioplasty of distal right coronary artery Stent placement to stabilize patient

+Anthropometric Measurements (AD)

Height: 5 feet 10 inches

Weight: 185 pounds

BMI: 26.6 kg/m2

Unplanned Weight Loss: N/A

+Nutrition-Focused Physical Findings (PD)

Overall Appearance Slightly overweight, pale, distressed

Nerves and Cognition Alert and focused

Vital Signs Temp: 98.4 BP: 118/78 Pulse: 92 bpm Respiratory rate: 20 bpm

+Biochemical Data, Medical Tests and Procedures (BD)

Chemistry Day 1 Day 2 Day 3 Ref. Range

Carbon Dioxide (CO2, mEq/L)

20 L 24 26 23-30

Glucose (mg/dL)

136 H 106 104 70-110

ALT (U/L) 30 215 H 185 H 4-36

AST (U/L) 25 245 H 175 H 0-35

CPK (U/L) 75 500 H 335 H 55-170 (M)

CPK-MB (U/L) 0 75 H 55 H 0

Lactate Dehydrogenase (U/L)

325 685 H 365 208-378

+Biochemical Data, Medical Tests and Procedures (BD)

Chemistry Day 1 Day 2 Day 3 Ref. Range

Troponin I (ng/dL)

2.4 H 2.8 H <0.2

Troponin T (ng/dL

2.1 H 2.7 H <0.03

Cholesterol (mg/dL)

235 H 226 H 214 H 120-199

HDL-C (mg/dL)

30 L 32 L 33 L > 45 (M)

LDL-C (mg/dL)

160 H 150 H 141 H <130

LDL/HDL ratio

5.3 H 4.7 H 4.3 H <3.55 (M)

Apo A (mg/dL)

72 L 80 L 98 94-178 (M)

Apo B (mg/dL)

115 110 105 63-133 (M)

PT (sec) 12.6 12.6 12.4 12.4-14.4

+Food and Nutrition-Related History (FH): Food and Nutrient Intake Drug-Nutrient Interactions

Lopressor Lisinopril Nitro-Bid NTG Aspirin

Purpose Blood Pressure

Blood Pressure

Chest Pain Chest Pain Blood thinner

Mechanism

Beta blocker

ACE inhibitor

Vasodilator Vasodilator COX inhibitor

Nutritional Interaction

Calcium interferes with absorption, avoid licorice

Avoid high potassium

Avoid alcohol

Avoid alcohol

Vitamin K affects thickness of blood, Calcium decreases absorption

Unclear as to why Mr. Klosterman was not prescribed a statin drug

+Food and Nutrition-Related History (FH): Food and Nutrient Intake

Previous nutrition therapy: Year prior with community dietitian

Hospital medical treatment: Nitroglycerin and morphine until pain recession IV Heparin: 5000 bolus units; 1,000 unit/hr continuous infusion Chewable aspirin: 160 mg continued daily Lopressor: 50mg twice daily Lidocaine: as needed

Current dietary prescription: Pre-surgery: NPO Post-surgery:

High protein (1g/kg body weight) Low saturated fat (5-6%) Moderate cholesterol

New guidelines supported by AHA suggest no specific limit for dietary cholesterol

+Food and Nutrition-Related History (FH): Food and Nutrient Intake24 hour recall: Breakfast None

Morning snack 1 large cinnamon raisin bagel1 tbsp fat-free cream cheese8 oz orange juicecoffee

Lunch 1 cup canned vegetable beef soupSandwich (4oz roast beef, lettuce, tomato, dill pickles, 2 tsp mayonnaise)1 small apple8 oz 2% milk

Dinner 2 lean pork chops (3 oz each)1 large baked potato (2 tbsp margarine)½ cup green beans ½ cup coleslaw1 slice apple pie

Snack 1 oz pretzels8 oz 2% milk

+Mid-Morning Snack

Food List Carbohydrate (g)

Protein (g) Fat (g) Calories

Large Cinnamon Raisin Bagel (4 carb exchanges)

60g (0-12)g (0-4)g 320

1 tbsp fat free cream cheese(1 free exchange)

8 oz orange juice (2 fruit carb exchange)

30g 120

coffee

TOTAL 90g 0-12g 0-4g =440

+Lunch



1 c. canned vegetable beef (1 carb exchange)

15g (0-3)g (0-1)g 80

Sandwich bread (2 carb) 4oz roast beef lettuce, tomato, pickels 2 tsp mayo

30g30g

28-34g(0-6)g28g

10-15g(0-1)g(0-4)g

10g

434160184

90

1 small apple (1 fruit exchange)

15g 60

8 oz 2% milk 12g 8g 5g 120

TOTAL 72g 36-45g 15-21g =694

+Dinner



2 lean pork chops (6 meat exchanges)

42g (0-18)g 600

Large baked potato (4 starch exchange)

60g (0-12)g (0-4)g 320

½ cup green beans (2 low carb exchanges)

10g 4g 50

½ cup coleslaw (1 carb + 1.5 fat exchanges)

15g (0-3)g 7.5g 147.5

1 slice apple pie (3 carb + 1 fat exchange)

45g (0-9)g (5-6)g 285

TOTAL 130g 46-70g 12.5-35.5g =1,402.5

+Snacks



1oz pretzels (1.25 carb exchange)

18.75 g (0-3.75)g (0-1.25)g 100

8 oz 2% milk (1 milk exchange)

12g 8g 5g 120

TOTAL 30.75g 8-11.75g 5-6.25g =220


Current dietary intake (according to online nutrition database) Calories= 2,201 Carbs = 280 g (54% ) Protein = 106 g (19%) Fat = 89 g (36%)

Sat. Fat 12% = 30 g (rec. <5-6%)

Fiber 19 g (recommended 30g) Sodium 5,064 mg

(recommended < 1,500mg)

Dietary Intake (according to food exchange list)

Calories = 2,756.5 Carbs = 322.75 g Protein = 90-138.75 g Fat = 65-66.75 g


History: Appetite good Recent diet changes

Corn oil instead of butter Less fried foods

Food Allergies: none

Physical Activity 15 minute walk daily—walking dog, leisurely pace

+Comparative Standards (CS):

Resting Energy Requirements (using Mifflin St. Jeor) REE= (10 * 84kg) + (6.25 * 178cm) – (5 * 61yr) + 5 =

1,652 kcal

Total Energy Requirements Normal activity factor: 1.4 (low activity)

1,652 kcal/day x 1.4 = 2,313 kcal/day Hospitalized factor: 1.2 (surgery)

1,652 kcal/day x 1.2 = 1,982 kcal/day

+Comparative Standards (CS):

Macronutrient needs Normal protein needs (67-84 g/day)

84 kg x 0.8-1.0= 67.2-84 g protein/day Post-op protein needs (84-126 g/day)

84 kg x 1.0-1.5= 84-126 g protein/day

+Nutrition Diagnoses

PES #1: Altered nutrition-related laboratory values

related to high saturated fat diet as evidenced by total cholesterol >200mg/dL, HDL <45mg/dL, and LDL >130mg/dL

PES #2: Physical inactivity related to sedentary

lifestyle as evidenced by only walking 15 minutes each day

+Nutrition Intervention

PES #1: Altered nutrition-related laboratory values related to high saturated fat diet as evidenced by total cholesterol >200 mg/dL, HDL <45 mg/dL, and LDL >130 mg/dL

Nutrition Rx: Modify diet to consume less than 5-6% of daily calories from saturated fats; this translates to between 99.1-118.92 calories from saturated fat or 16 grams of saturated fat per day for Mr. Klosterman

Nutrition Intervention: This can be done by decreasing dietary consumption of saturated fats by choosing a lower fat milk option. Provide nutrition education to promote healthy cooking and appropriate portion sizes. Also, continue to replace butter with oil when cooking and reduce fried foods. Participate in the DASH diet to reduce sodium intake and have a better heart healthy diet and help reduce BMI.

+Nutrition Intervention

PES #2 Physical inactivity related to sedentary lifestyle as evidenced by only walking 15 minutes each day

Nutrition Rx: Increase physical activity to 150 minutes per week of moderate intensity physical activity.

Nutrition intervention: From Nutrition Care Manual, increase walking to 30 minute per day, five or more times per week. Discuss other options for physical activity to decrease sedentary time. Gradually increase daily activity time to walking the dog for 30 minutes twice daily two times per week. Also, meet with a personal trainer to set and achieve specific goals.

+Monitoring and Evaluation

Evaluate the effectiveness of the nutrition interventions in meeting the nutrition goals

Monitor the patient’s Cholesterol (>200mg/dL), HDL (<45 mg/dL) and LDL (>130 mg/dL) levels for changes through laboratory values

Monitor Anthropometrics by checking weight, BMI, and waist circumference

Have patient keep track of a food diary so dietary intake can be monitored

Monitor his daily physical activity to see an increase from only walking 15 minutes per day

Monitor the patient’s progress in his cardiac rehab program

Monitor the patient’s progress in cessation of smoking

ADIME Notes

Client History (CH): Age – 61 Gender – Male Race/Ethnicity – White Living/housing situation- living with wife Smokes 1 PPD Dx: Myocardial Infarction s/p angioplasty

ADIME Notes, cont. Food- and Nutrition- Related History (FH):

Meal type: clear liquids, no caffeine History: Appetite good. Has been trying to change diet. Wife indicates

that she has been using “corn oil” instead of butter and has tried not to fry foods as often.

24-hour recall: Breakfast- none Midmorning snack- 1 large cinnamom rasiin bagel with 1 tbsp. fat-

free cream cheese, 8 oz orange juice, coffee Lunch- 1 c canned vegetable beef soup, sandwich with 4 oz roast

beef, lettuce, tomato, dill pickles, 2 tsp mayonnaise, 1 small apple, 8 oz 2% milk

Dinner:- 2 lean pork chops (3 oz each), 1 large baked potato, 2 tsp margarine, ½ c green beans, ½ c coleslaw (cabbage with 1 tbsp. salad dressing), 1 slice apple pie

Snack- 8 oz 2% milk 1 oz pretzels Food allergies/intolerances/aversions: none Previous nutrition therapy? Yes, last year with community dietation Food purchase/ preparation: spouse Vitamin/mineral intake: none

ADIME Notes, cont. Anthropetric Data (AD):

Height and Weight: 5’10 and 185 pounds: BMI: 26.6 kg/m2

Biochemical Data (BD): Cholesterol214mg/dL HDL 30mg/dL LDL 141mg/dL VLDL 40mg/dL HDL/LDL ratio 4.8 ApoA 98mg/dL

Physical Findings (PD): Vital signs

Blood Pressure 118/78 mm Hg Temperature 98.4 F Pulse 92 bpm Respiratory rate 20 bpm

Comparative Standards (CS): Total Energy estimated needs: 2300 calories Total Protein estimated needs: 67.2 – 84 g protein/day Total Fat estimated needs: 25-35%

ADIME Notes, cont.

Diagnosis: PES #1: Altered nutrition-related laboratory

values related to high saturated fat diet as evidenced by total cholesterol >200mg/dL, HDL <45mg/dL, and LDL >130mg/dL

PES #2: Physical inactivity related to sedentary lifestyle as evidenced by only walking 15 minutes each day

ADIME Notes, cont Intervention

PES #1: Nutrition Rx: Modify diet to consume less than 5-6% of daily calories from

saturated fats; this translates to less than 162 calories or 18 grams of fat for Mr. Klosterman.

Nutrition intervention: This can be done by decreasing dietary consumption of saturated fats by choosing a lower fat milk option. Provide nutrition education to promote healthy cooking and appropriate portion sizes. Also, continue to replace butter with oil when cooking and reduce fried foods. Participate in the DASH diet to reduce sodium intake and have a better heart healthy diet and help reduce BMI.

PES #2: Nutrition Rx: Increase physical activity to 150 minutes per week of moderate

intensity physical activity (1). Nutrition intervention: Increase walking to 30 minute per day, five or more

times per week. Discuss other options for physical activity to decrease sedentary time. Gradually increase daily activity time to add up to 300 minutes per week until healthy weight is reached.

+References

Nahikian-Nelms, Marcia, and Sara Long. Roth. Medical Nutrition Therapy: A Case Study Approach. Belmont, CA: Wadsworth/Thomson Learning, 4th ed., copyright 2014. Print.

Internet Resources American Heart Association: http://www.heart.org/ Academy of Nutrition and Dietetics: http://www.eatright.org Nutrition Care Manual: http://www.nutritioncaremanual.org National Heart, Lung, and Blood Institute:

http://www.nhlbi.nih.gov/health/health-topics/topics/heartattack/

myocardial infarction

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