Download Case study 1: acute myocardial infarction - Meg Fuchs

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
• Works in maintenance – constant movement
• Lifts weights and swims regularly
• No ethnic or religious considerations
Patient Profile
Admission
• 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
Patient profile
Past 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
Patient Profile
Family History
Very strong history of heart failure
Patient profile
Health 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
Patient Profile
Health 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
Patient profile
health history
• No dental problems
• No chewing or swallowing problems
• Normal digestion
• Elimination – regular bowel movements
Disease Background
Acute 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
Disease Background
Pathophysiology/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
Disease Background
Symptoms
• 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
Medical Diagnosis
Treatment
• 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
Disease
Background
Nutritional
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
Disease Background
Evidenced 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
Disease Background
Prognosis
• 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
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
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 4550%, and trace mitral regurgitation
• Chest x-ray found the trachea, heart, and mediastinal
structures to be normal, along with clear lungs and
pleural spaces
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
Current
Admission
Treatment
•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
Current Admission
Medications
• Chewable Aspirin
• Nitroglycerin
• Colace
• Plavix
• Coreg
• Prinivil
• Heparin
• Tylenol
• Lipitor
• Xanax
• Maalox
• Zofran
• Morphine
Nutrition Care Process
Nutrition 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
Nutrition Care Process
Nutrition 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
Nutrition Care Process
Nutrition 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)
Nutrition Care Process
Nutrition Assessment
Anthropometrics
Biochemical Labs
• Height: 5’9”
Lab
Result
Lab
Result
• Weight: 267.7 lb (122 kg)
Na
139
Alb
3.6
K
4.3
Mg
1.7
Glucose
113
Chol
261
• %IBW: 167%
BUN
12
HDL
33
• ABW: 187 lb (85 kg)
Creat
0.90
HA1C
6.2
Osmo
274
Trigly
432
Ca
8.9
BNP
149
Phos
3.2
Troponin > 50,000
I
CK-MB
index
19
CPK
• IBW: 160 lb ± 10%
• Usual wt: 250 lb (114 kg)
• % weight change: +7%
• BMI: 39.45 kg/m2
2200
Nutrition
care process
nutrition
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)
Nutrition Care Process
Nutrition 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
Nutrition Care Process
Nutrition Intervention
• Plan
•
•
•
•
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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.
Nutrition Care Process
Monitoring 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
Summary
• 46 year old male living a
moderately active lifestyle
• Medications: carvedilol,
aspirin, plavix, statin
• PMH: hypertension and
splenectomy
• Cardiac diet per MD
• Current medical diagnosis:
acute inferior myocardial
infarction
• Stent placement, EF 45-50%
• 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
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 Clin Nutr 2010; 91:535-46.
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 Clin Nutr 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.