Taryn BerryCase Study #5-Myocardial Infarction

I. Understanding the Disease and Pathophysiology1. Mr. Klosterman had a myocardial infarction. Explain what happened to his heart.

The muscles of the heart have three levels. From superficial to deep, the muscles are epicardium, myocardium, and endocardium. The myocardium, the middle layer of the cardiac wall, is in charge of contracting to eject blood through the different atria, ventricles, out to the lungs to be oxygenated, and through the aorta to be pumped throughout the body. One of the key points of this process is the oxygenation of the blood. Without the work of the myocardium to contact, the blood would not be able to travel, thus not getting the blood oxygenated. A myocardial infarction, or heart attack, takes place when myocardial cells die because they have been deprived of oxygen for too long. This can happen a few different ways, a blood clot forming in a coronary artery (thrombosis), which is usually caused by plaque within the arteries lining (atheroma). This plaque gets built up to the point that a coronary artery or a smaller branched section is blocked. This does not allow for the proceeding part of the myocardium to be supplied with oxygenated blood, making it at risk for cell death. It is said that the muscle is then “infarcted” and oxygen is only restored through removing the blockage or the cells will die. If the blockage is not removed, a collagen scar forms in the place of the infarcted area. Collagen is not elastic, thus cannot achieve the expanding and contracting motions of the myocardium. Also, the electrical signals that indicate when the heart should and should not contract in the rhythmic pattern are not apparent in the new formed collagen scar. Mr. Klosterman had “pressure-like pain radiating to the jaw and left arm. The patient has noted an episode of emesis and nausea.” (Case Study #5), which are all an indication of a myocardial infarction. The above description of a myocardial infarction is what likely happen to Mr. Klosterman’s, the infarcted area being the distal right coronary artery.

From Pathophysiology series 2: acute myocardial infarction.

2. Mr. Klosterman’s chest pain resolved after two sublingual NTG at 3 – minute intervals and 2mgm of IV morphine. In the cath lab he was found to have a totally occluded distal right coronary artery and 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 postero-basilar scar was present with hypokinesis. Explain angioplasty and stent placement. What is the purpose of this medical procedure?

Angioplasty is a procedure done in order to open a blocked or narrowed blood vessel so that it can be opened and blood flow can increase. Either a tube or balloon is placed in the blood vessel then inflated to open the blocked or narrowed area. The inflation compresses the fatty blockage, thus increasing

blood flow through the blood vessel. In this case, Mr. Klosterman’s underwent an angioplasty of the distal right coronary artery, which was completely blocked as indicated above. This procedure opened the distal right coronary artery to accomplish near-normal blood flow. A stent is wire mesh that is put in a blood vessel to prop it open. Most of the time it is inserted in an angioplasty in order to keep the blood vessel open from the work of the balloon or tube. The stent opens with the balloon or tube, then the balloon or tube is deflated but the stent stays in order to keep the blood vessel propped open. In Mr. Klosterman’s case, a stent was put in the distal right coronary artery to keep the artery open after the tube or balloon was removed. This helped with the blood flow as indicated by the normal left ventricular ejection fraction of 42%. Left ventricular ejection fraction is the fraction of end diastolic volume (EDV) that is ejected from the left ventricle of the heart through contraction. After the blood leaves the left ventricle it leaves the heart through the aorta to be circulated throughout the body. It is very important have a functioning left ventricle so that oxygenated blood can circulate the body optimally (284-287).

From “Nutrition Therapy & Pathophysiology”

3. 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 the physical, mental, and social conditions that ensure that the necessary activities can be accomplished for returning to good health. This assures that the patient is educated on changes or adjustment that need to be made to return to good health. In order to ensure that another heart attack does not happen in the future, the main areas of focuses for cardiac rehabilitation are the following, education, behavior modification, and patient and family support. Specific topics that should be discussed are extensive nutrition education, physical therapy, psychiatry, occupational therapy, easing back into daily tasks, exercise science, and passing certain tests before they are released. If these are all taken into account and followed, Mr. Klosterman’s heart should be able to return to a healthy state.

From Cardiac rehabilitation.

II. Understanding the Nutrition Therapy4. What risk factors indicated in his medical record can be addressed through nutrition

therapy? Mr. Klosterman’s total cholesterol as well as his LDL as well as his HDL can be

addressed and improved by nutrition therapy by changing the diet. Another risk factor is that Mr. Klosterman is overweight with a 26.6 BMI. As evidence from the 24-hour recall, food such as canned goods, pretzels, roast beef, and 2% milk, contribute to the high sodium and fat content of his diet.

5. What are the current recommendations for nutritional intake during hospitalization following a myocardial infarction?

While in the hospital, sodium needs to be adjusted from the standard recommendation of 2000 mg per day to 1000 mg or 500 mg per day depending on the patient. This includes fluid and volume states, not just oral intake. Fluids also need to be restricted. Limitation to 1500 mL/day, as compared to the normal recommendation of 2000 mL/day, will help to prevent volume overload. Making sure the patient is aware of all different kinds of liquids is important. Some micronutrients need to be monitored, such as potassium, magnesium, thiamin, riboflavin, and pyridoxine. Diuretics can remove these water-soluble vitamins from the body. A multivitamin is suggested and a thiamin supplementation at 200 mg/day for six weeks or a parenteral dose followed by a multivitamin (326-327).

“Nutrition Therapy & Pathophysiology.”III. Nutrition Assessment

6. What is the healthy weight range for an individual of Mr. Klosterman’s height? BMI : 77.6 kg/1.78 m^2 = 26.6 Overweight

i. 170.8 lbs x (1kg/2.2 lbs) = 77.6 kgii. 70 in x (1 cm/0.3937 in) = 177.8 cm

iii. 177.8/100 = 1.78 m^2 Ideal : Using the Hamwi Method for a 5’10” adult male, 106 + 6(10) = 166 pounds Adjusted : (185-166) x .25 = 4.75 166 + 4.75 = 170.8 pounds

7. The patient is a Lutheran minister. He does get some exercise daily. He walks his dog outside for about 15 minutes at a leisurely pace. Calculate his energy and protein requirements.

Seated work PAL: 1.4-1.5 170.8 lbs x (1kg/2.2 lbs) = 77.6 kg 70 in x (1 cm/0.3937 in) = 177.8 cm Mifflin-St. Jeor : (10 x 77.6 kg) + (6.25 x 177.8 cm) – (5 x 61 yrs) + 5 = 1587.25 kcal

x 1.4 = 2200-2300 kcal 1.4 was chosen because he is not in bed all day but does not do enough physical

activity to be in the next category. Post-angioplasty : Protein needs increase after surgery in order for tissue to heal

properly and timely. 2200 x 1.1 = 2420 2300 x 1.1 = 2530 2420-2530 kcal

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.

Total calories: 2636 kcal Macronutrient Total kcal % Total Cal Protein: 142.4 g x 4 kcal = 569.6 kcal 21.6% Carbohydrates: 349.3 g x 4 kcal = 1397.2 kcal 53% Fat: 77 g x 9 kcal = 693 kcal 26.3%

9. Examine the chemistry results for Mr. Klosterman. Which labs are consistent with the MI diagnosis? Explain. Why were the levels higher on day 2?

Chemistry Ref Range Day 1- 12/1 Day 2-12/2Troponin T <0.03 2.1 2.7Troponin I <0.2 2.4 2.8Lactate dehydrogenase

208-378 325 685

AST 0-35 25 245Cholesterol (mg/dL) 120-199 235 226HDL-C (mg/dL) >45M 30 32LDL-C (mg/dL) <130 160 150Triglycerides 40-160M 150 140

The heightened total cholesterol, triglycerides, and LDL and the low HDL is attributed to plaque build up in the arteries. Troponin I and T are released after cardiac injury by myocardial cells, which is why these values increased the second day. Cardiac enzymes such as lactate dehydrogenase, and aspartate aminotransferase are cardiac enzymes and isoenzymes that release as a result of cell oxygen deprivation, which can be in relation to cardiac tissue. This may be why the AST and lactate dehydrogenase values increased on the second day (320).

From “Nutrition Therapy & Pathophysiology”

10. What is abnormal about his lipid profile? Indicate the abnormal values.

*All values in red are

abnormal.

11. Mr. Klosterman was prescribed the following medications on discharge. What are the food-medication interactions for this list of medications?

Medication Possible Food-Medication InteractionsLopressor 50 mg daily Avoid alcohol, increases blood glucose, food helps with

absorption so take right after meal, and avoid taking with multivitamins because some vitamins affect absorption.

Lisinopril 10 mg daily Reduce BP. Avoid moderately high to high potassium intake.

Nitro- Bid 9.0 mg twice daily Avoid alcohol. Can take on a full or empty stomach.NTG 0.4 mg sl prn chest pain Avoid alcohol.ASA 81 mg daily Blood thinner. Avoid alcohol and caffeine. Can cause

nausea or vomiting. From the Food and Drug Administration: Avoiding Food-Drug Interactions.

12. 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?

Who usually buys the groceries? How often? Do you read nutrition labels? Do you know which foods are high in fat/cholesterol? What are the staples that you usually have in your pantry? What are your favorite meals? Do you add salt during preparation or at the table? What are your favorite vegetables and how do you prepare these? Do you eat together? How often do you eat out? What restaurants? How often do you exercise?

Chemistry Ref Range Day 1- 12/1 Day 2- 12/2 Day 3- 12/3Cholesterol (mg/dL)

120-199 235 226 214

HDL-C (mg/dL) >45M 30 32 33LDL-C (mg/dL) <130 160 150 141Triglycerides 40-160M 150 140 130

Are you willing to change your eating and exercising patterns?13. What other issues might you consider to support successful lifestyle changes for Mr.

Klosterman? He is overweight, so his ability to be active and exercise. Does he have a safe

environment or access to an exercise facility? His willingness to stop smoking in order to better his health and decreases his

chances of a future MI. Does he have enough money and resources to change his diet?

14. From the information gathered within the assessment, list possible nutrition problems using the correct diagnostic terms.

NI-1.3 : Excessive Energy Intake NI-2.2 : Excessive Oral Intake NI-5.6.2 : Excessive Fat Intake NC-3.3 : Overweight NB-1.1 : Food- and Nutrition-related knowledge deficit NB-2.1 : Physical Inactivity From Nutrition Terminology Reference Manuel

Nutrition Diagnosis15. Select two of the identified nutrition problems and complete the PES statement for

each. P Excessive energy related toE increase calories as evidence byS high caloric foods that were recorded in the 24 recall, such as roast beef, canned soup, 2% milk, and apple pie.

P Excessive weight related toE limited physical activity as evidence byS patient information of daily physical activity, high cholesterol, and a BMI of 26.6 kg/m^2.

IV. Nutrition Intervention16. 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). Goal: Decrease 250 kcal a day for the first two weeks then decreasing 500 kcal

the next weeks until 15 pounds are lost or a normal BMI is reached. Sodium intake must be lowered to 2000 mg/day. Intervention: Instruct client on a 2200-2300 calorie diet in order to lower BMI. Educating on low calorie foods that are nutrient dense and low in sodium. Sodium intake can be lowered by adding other herbs and spices.

Goal : Increase physical activity in order to lose weight and decrease BMI. Also lower cholesterol to 200 mg/dL, LDL to 130 mg/dL, and HDL to 45 mg/dL. Intervention: Instruct client on a plausible physical activity regimen of walking the dog for 15 minutes two times a day in the first week then increase time by 5

minutes every week after (if able, take it easy the first week or so). Also parking farther away at church to increase walking. Lastly, help out in the community at a local school or after school care to limit sedentary time.

17. Mr. Klosterman 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?

Several large clinical trials have presented information on fish oil and flaxseed oil in relation to its ability to help the body convert alpha-linolenic acid (ALA) to eicosapentaenoic acid (EPA) and docosahexenoic acid (DHA). Increasing ALA has been seen to reduce mortality rate but some results are still mixed. EPA is important for many different processes, such as vasoconstriction, vasodilation, platelet function, immune system response, and inflammatory response. Thus, the American Heart Association suggests that CHD patients consume 1g of EPA and DHA daily (312-313). Based on this information, it is very easy to get this one-gram from a food source rather then supplementing. Food sources of EPA and DHA are walnuts, flax seed, and salmon.

From “Nutrition Therapy & Pathophysiology”

V. Nutrition Monitory and Evaluation18. What would you want to assess in three to four weeks when he and his wife return for

additional counseling? Monitor: I will want to monitor the patient compliance by taking a look at Mr.

Klosterman’s food journal, including assessment of calories, fat, sodium, fluid intake, and saturated fat. I also want to check BMI, cholesterol, LDL, HDL, and LDL/HDL ratio. Next I will want to hear about how he has felt everyday in regards to daily tasks and physical abilities. I will check his physical activity journal as well to see if he has been able to accomplish more exercising daily. Lastly, talk to Mrs. Klosterman to make sure she does not have any questions on the diet or exercise (since she seemed very influential). Evaluate: I will evaluate by comparing these lab results to his past numbers.

Resources

Academy of Nutrition and Dietetics. Nutrition Terminology Reference Manuel: Dietetics Language for Nutrition Care. 2014. Retrieved from website: http://ncpt.webauthor.com/pubs/idnt-en/page-039

British Journal of Healthcare Assistants. Vo. 8 No. 5. 1 May 2014. Pathophysiology series 2: acute myocardial infarction. Miami University Library Database. Retrieved from website: http://eds.a.ebscohost.com/eds/pdfviewer/pdfviewer?sid=49b4bbce-3fb6-463a-be4e-8e84ffa2a6a7%40sessionmgr4004&vid=1&hid=4202

Food and Drug Administration, (n.d.). Avoid food-drug interactions. Retrieved from website:http://www.fda.gov/downloads/Drugs/ResourcesForYou/ConsumerBuyingUsingMedicineSafelyEnsuringSafeUseofMedicine/GeneralUseofMedicine/UCM229033.pdf

Magill’s Medical Guide. Online Edition. October 2013. Angioplasty. Miami University Library Database. Retrieved from website: http://eds.b.ebscohost.com/eds/detail/detail?sid=f63fdc75-106a-4658-a5fa 465106adbedc%40sessionmgr115&vid=2&hid=107&bdata=JnNpdGU9Z WRzLWxpdmU%3d#db=ers&AN=87690435

Magill’s Medical Guide. Online Edition. October 2013. Cardiac rehabilitation. Miami University Library Database. Retrieved from website: http://eds.b.ebscohost.com/eds/detail/detail?sid= cb6e2167-09bd-47c5-952f-de2958575d60%40sessionmgr115&vid=1&hid=107&bdata=JnNpd GU9ZWRzLWxpdmU%3d#db=ers&AN=87690466

Magill’s Medical Guide. Online Edition. October 2013. Stents. Miami University Library Database. Retrieved from website: http://eds.b.ebscohost.com/eds/command/detail?sid=f63fdc75-106a-4658-a5fa-465106adbedc%40sessionmgr115&vid=4&hid=107

Nelms, Sucher, Lacey, Roth. “Nutrition Therapy & Pathophysiology.” 2nd ed. Wadsworth. 2012.