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Case study 1: acute myocardial infarction

Case study 1: acute myocardial infarction. Megan Fuchs Good Sam Dietetic Intern January 5, 2012. Patient Profile Personal Information. 46 year old white male Lives in Cincinnati, OH with wife, daughter, and grandson Leads a physically active lifestyle

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Case study 1: acute myocardial infarction

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  1. Case study 1: acute myocardial infarction Megan Fuchs Good Sam Dietetic Intern January 5, 2012

  2. Patient ProfilePersonal Information • 46 year old white male • Lives in Cincinnati, OH with wife, daughter, and grandson • Leads a physically active lifestyle • Works in maintenance – constant movement • Lifts weights and swims regularly • No ethnic or religious considerations

  3. Patient ProfileAdmission • JD presented to the Western Ridge ER with complaints of chest pain, N/V, and diaphoresis • Found to be having an acute inferior myocardial infarction (MI) • Immediately transferred to GSH ER • At GSH, doctors confirmed the diagnosis of an acute inferior MI based on • EKG results consistent with MI • Noted sinus arrhythmia • Rate of 89 • Marked segment elevation in inferior leads

  4. Patient profilePast medical History • Splenectomy(as a child, unknown reason for removal) • Surgical removal of the spleen due to rupture, enlargement, certain blood disorders, cancer, infections, or non-cancerous tumors • Spleen is an important part of fighting infection – filters damaged red blood cells • Complications may include hemorrhage, blood clots, infection, or injury to other organs • Hypertension(HTN) • High blood pressure • Diagnosed when ones blood pressure is 140/80 mmHg • Factors affecting BP include amount of water and salt in the body; function of the kidneys, nervous system, and blood vessels • Increased risk of developing HTN if one is obese, stressed/anxious, high salt diet, family history, diabetes, smoker, or African American

  5. Patient ProfileFamily History Very strong history of heart failure

  6. Patient profileHealth History • Generally sleeps well, 6-8 hours a night • Physically Active Lifestyle • Maintenance worker – uses stairs, walks to and from buildings • Lifts weights and swims 3-4 times/week • Non-smoker • Occasionally drinks alcohol • No substance abuse

  7. Patient ProfileHealth History • Height: 5’9” • Weight: 267.7 lb • Weight history: 5 lb weight gain/loss throughout the year • No large amount of weight loss or gain • Appetite • Prior to admission – very good appetite, enjoys all foods but eats very little vegetables • JD and his wife enjoy shopping and cooking together • During hospital stay – appetite improved but was initially very poor

  8. Patient profilehealth history • No dental problems • No chewing or swallowing problems • Normal digestion • Elimination – regular bowel movements

  9. Disease BackgroundAcute Inferior Myocardial infarction • Myocardial Infarction or Heart Attack • Occurs when blood flow to part of the heart is blocked resulting in damage or death to the muscle • Usually caused by a blood clot or plaque formation blocking the coronary artery, which supplies the heart with oxygen and blood

  10. Disease BackgroundPathophysiology/etiology • Most common etiologic factor: presence of atherosclerotic plaque blocking the coronary arteries • Plaque leads to the disruption of blood flow through the coronary arteries to the heart • Size of the thrombus determines the percent of blockage, ultimately determining the extent of damage • Decreased blood flow for an amount of time can trigger a process known as ischemic cascade • Causing the heart muscle to die and potentially resulting in cardiac arrhythmia

  11. Disease BackgroundSymptoms • Most often characterized by • Chest pain • Tightness in chest • Feeling of heaviness in the chest area • Nausea • Vomiting • SOB • Sweating • Often mistaken for heart burn or indigestion during initial onset • Usually chest pain or tightness will last longer than 20 minutes and increase in intensity

  12. Medical DiagnosisTreatment • Initial Treatment • Nitroglycerin or morphine to numb chest pain • Angioplasty for stent placement to unclog artery – most common emergency treatment • Drug therapy to break apart clots – thrombolytic therapy • Open heart surgery – most severe cases • After initial treatment • Medication to help protect the heart from future cardiovascular events – blood thinner, beta-blocker, or ACE inhibitor • Lifestyle changes • Slowly incorporating exercise • Changing dietary habits • Maintaining control of BP, blood sugar, and cholesterol levels

  13. Disease BackgroundNutritional Intervention Low sodium, low fat, low cholesterol ≤ 30% total kcal from fat – less than 1/3 of those kcal should be saturated 200 mg/day cholesterol Sodium Weigh loss if overweight should be stressed

  14. Disease BackgroundEvidenced Based Research • The New England Journal of Medicine • Goal: to determine if salt reduction in diet would decrease cardiovascular disease • The effects of salt reduction in association with CVD was compared • Decrease in cost of HTN medication was determined • Results • Reducing dietary salt to 3gm a day would reduce new cases of • CHD by 60,000-120,000 • MI by 54,000-99,000 • Stroke by 32,000-66,000 • Medical costs related to CVD would decrease by 10 billion to 24 billion dollars annually

  15. Disease BackgroundPrognosis • Usually, patients without complications can return to normal activity – slowly! • The prognosis is dependent on how much of the heart muscle was damaged • Amount of damage will determine how fast one returns to normal activities • Level of damage may cause arrhythmia, valve problems, or heart rupture • If the heart is no longer able to pump blood as well as it used to, heart failure may be a concern

  16. Application to patient • Initial Diagnosis: Acute Inferior Myocardial Infarction • November 20, 2011 • Symptoms: Chest pain (7 out of 10), nausea, vomiting, and diaphoresis • Sinus arrhythmia, marked segment elevation of inferior leads • Symptoms lasting 2 hr total • JD had a very good understanding of his diagnosis • Although discouraged because he lead an active lifestyle • Unaware of unhealthy eating habits in relation to diagnosis • Connection to strong family history of heart disease

  17. Current Admission • Diagnosis • Acute Inferior Myocardial Infarction • Diagnostic procedures • Metabolic panel, chest panel, and complete blood count • Echocardiogram showed mild decrease in the left atrium, left ventricular function decreased, ejection factor of 45-50%, and trace mitral regurgitation • Chest x-ray found the trachea, heart, and mediastinal structures to be normal, along with clear lungs and pleural spaces

  18. Current admission • Diagnostic procedures cont. • Coronary angiography summary noted • dominant right system single vessel disease • left ventriculography demonstrated severe inferior hypokinesis • The right coronary artery was proximally occluded and enlarged with no collateralization • Initially JD’s cardiac enzymes were • CK: 252 • MB: 4.4 • Troponin: 0.01

  19. Current AdmissionTreatment Stent placement to the right coronary artery occlusion JD was started on the beta-blocker Carvedilol to control his hypertension and treat his valve dysfunction in combination with a statin JD was also prescribed plavix and advised to take an aspirin to help avoid future cardiovascular events

  20. Current AdmissionMedications • Chewable Aspirin • Colace • Coreg • Heparin • Lipitor • Maalox • Morphine • Nitroglycerin • Plavix • Prinivil • Tylenol • Xanax • Zofran

  21. Nutrition Care ProcessNutrition Assessment • Current Diet Order • Cardiac: low fat/cholesterol, 3 gram Na, 0 caffeine • Diet History • Prior to admission JD did not follow any specific diet restrictions; 3 meals a day with an evening snack • Fast food (White Castle, Skyline), Sit down restaurants (Applebee’s 1-2 times/week), and home cooked meals (~4 times/week) • Ate very little vegetables; liked apples, oranges, and grapes; drank 2% milk • Both JD and his wife cook and grocery shop together • JD expressed interest in learning new recipes and substituting items to make each meal more heart healthy

  22. Nutrition Care ProcessNutrition Assessment • 24 hour recall • 25% po intake at breakfast – couple bites of low sodium scrambled eggs and whole wheat english muffin with a small amount of jelly, few sips of orange juice • 100% po intake at lunch – meatloaf, red skin mashed potatoes, vegetable medley (corn, red peppers, green beans), dinner roll, and 4 oz apple juice • 100% po intake at dinner – oven baked chicken, sliced potatoes, vegetables (yellow squash, carrots, and peppers), and 8 oz skim milk • JD avoided his deserts because he is not big on sweets

  23. Nutrition Care ProcessNutrition Assessment • JD had no prior MNT • Prior to admission JD clearly stated he ate few, if any vegetables and likes some fruits. Also, most of his meals during the week consist of fast food. JD’s diet is mainly high fat, high sodium foods • While in the hospital, JD received well balanced meals, and surprisingly he ate the vegetables! • Level of nutritional risk: moderate risk due to high-risk diagnosis and obesity (167% IBW)

  24. Nutrition Care ProcessNutritionAssessment Anthropometrics Biochemical Labs • Height: 5’9” • Weight: 267.7 lb (122 kg) • IBW: 160 lb ± 10% • %IBW: 167% • ABW: 187 lb (85 kg) • Usual wt: 250 lb (114 kg) • % weight change: +7% • BMI: 39.45 kg/m2

  25. Nutrition care processnutrition assessment Macronutrient Needs Calories: 2125 kcal (25 kcal/kg ABW) Protein: 68-85 gm (0.8-1.0 gm/kg ABW) Carbohydrates: 292 gm/day (55% total kcal) Fat: 71 gm/day (30% total kcal) *16.5 gm saturated fat/day (7% total fat)

  26. Nutrition Care ProcessNutrition Diagnosis • Nutrition Diagnosis • NC-3.3 Overweight/obesity • PES Statement • Overweight/obesity related to excessive kcal intake as evidenced by 167% IBW and a BMI of 39.45 kg/m2 • Goals included appropriate weight loss, appropriate oral intake, and appropriate kcal intake • Recommendation • A critical aspect of JD’s recovery is a decrease in weight and a more restrictive diet than he was used to – diet education is key in preventing future cardiac events

  27. Nutrition Care ProcessNutrition Intervention • Plan • Limit foods high in fat, cholesterol, and sodium • Cholesterol intake should be < 200 mg/day • Total percent of fat from kcal should be ≤ 30% • Increase MUFA and decrease saturated fats (7% of kcal/day) • Decreasing total kcal intake to obtain appropriate weight loss • Implement • Provided JD with a list of heart healthy foods • Explained what foods were high in fat, cholesterol, and sodium • Reviewed sources of saturated fat and MUFA • Explained how to read a nutrition fact label • Provided tips eating out • Diet education – low sodium, low fat, low cholesterol – and weight loss are the most important nutrition interventions for JD.

  28. Nutrition Care ProcessMonitoring and Evaluation • While in the hospital JD was receiving a cardiac diet per MD order • Extensive diet education was provided • JD expressed great intentions to follow a low fat, low cholesterol, low sodium diet at home • Monitoring JD’s progress • Keeping track of his daily sodium, cholesterol, and fat intake – comparing day to day • Writing down times a week he eats out and what he ate

  29. Summary • 46 year old male living a moderately active lifestyle • PMH: hypertension and splenectomy • Current medical diagnosis: acute inferior myocardial infarction • Stent placement, EF 45-50% • Medications: carvedilol, aspirin, plavix, statin • Cardiac diet per MD • Educated on importance of low sodium, low fat, low cholesterol diet, along with weight loss • Encouraged to keep records of fat, cholesterol, and sodium for self monitoring

  30. References • Mayo Foundation for Medical Education and Research. Splenectomy. Available at http://www.mayoclinic.com/health/splenectomy/MY01271. Accessed 11/30/2011. • Dugdale, DC. PubMed Health. Hypertension. Available at http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001502/. Accessed 11/30/2011. • Chen, MA. PubMed Health. Heart Attack. Available at http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001246/. Accessed 11/30/2011. • Khera, AV. Cuchel, M. de la Llera-Moya, M. Rodrigues, A. Burke, MF. Jafri, K. French, BC. Phillips, JA. Muchsavage, ML. Wilensky, RL. Mohler, ER. Rothblat, GH. Rader, DJ. Cholesterol Efflux Capacity, High-Density Lipoprotein Function, and Atherosclerosis. N Engl J Med 2011; 364:127-35. • Siri-Tarino, PW. Sun, Q. Hu, FB. Krauss, RM. Meta-analysis of prospective cohort studies evaluating the association of saturated fat with cardiovascular disease. Am J ClinNutr 2010; 91:535-46.

  31. References • Bibbins-Domingo, K. Chertow, GM. Coxson, PG. Moran, A. Lightwood, JM. Pletcher, MJ. Goldman, L. Projected Effect of Dietary Salt Reductions on Future Cardiovascular Disease. N Engl J Med 2010; 362:590-9. • TriHealth, Inc. Eating with your Hearts Consent. The Heart and Vascular Center. • Lee, CD. Jacobs, DR. Schreiner, PJ. Iribarren, C. Hankinson, A. Abdominal Obesity and Coronary Artery Calcification in Young Adults: the Coronary Artery Risk Development in Young Adults (CARDIA) Study. Am J ClinNutr 2007; 86:48-54. • Martin, T. The Normal Range for Creatine Kinase Blood Test. Available at http://www.brighthub.com/science/medical/articles/75706.aspx. Accessed 11/30/2011. • The American Association for Clinical Chemistry. CK-MD, The Test. Available at http://labtestsonline.org/understanding/analytes/ckmb/tab/test. Accessed 11/30/2011. • Pronsky, ZM. Crowe, SR JP. Food Medication Interactions, 16th edition. 2010; p. 3-339. • Khan, S. Myocardial Infarction Pathophysiology. Available at http://www.buzzle.com/articles/myocardial-infarction-pathophysiology.html. Accessed 12/30/11.

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