Download Acute Care Case Study Presentation

Coronary Artery Disease: A
Time for Dietary Intervention
HILARY SHONE
QUEEN OF THE VALLEY MEDICAL CENTER
MARCH 25, 2015
Outline
• Introduction/Patient Profile
• Medical/Surgical Data
• Summary/Overview of Disease State(s)
• Admission Nutrition Assessment
• Chronology of Medical and Nutrition Treatments
• Discharge Plan
• Summary
Introduction/Patient Profile
PG is a 59 year old Caucasian male, works in furniture restoration
He is married, lives with his wife and they have one son
Non-smoker, chronic alcoholic until December 26, 2014
Reason for admission: Chest pain (determined to be unstable angina)
Admitting diagnosis: Atrial fibrillation with rapid ventricular response
• Discovered first in ER
• Likely the result of preceding cardiac events
• Other forms of cardiovascular disease discovered soon after in
hospital course
Introduction/Patient Profile
Primary Medical Diagnosis: Coronary Artery Disease
Coronary Artery Disease (CAD):
• Narrowing or blockage of the arteries that deliver blood and oxygen to
the heart
• Caused by atherosclerosis
• Reduces blood and oxygen flow to myocardium = ischemia
• AKA Ischemic Heart Disease (IHD), Coronary Heart Disease (CHD),
Atherosclerotic Heart Disease (AHD)
• Ischemic Heart Disease more broad than Coronary Artery Disease
Medical & Surgical Data
Past Medical History
 History of hypertension
 Heavy alcohol consumption, recently discontinued
 Atrial fibrillation ‘apparently’ for 3 years; intermittent chest pain for years
Surgical History
 Varicose vein stripping
Family Medical History
 Father deceased at age 35 ‘secondary to angina’
 Brother has a history of atrial fibrillation
 Son experienced a CVA at age 12, unidentified etiology
 Hospitalization was pt’s first documented cardiovascular event
Admission Physical Data
 General: Pleasant, alert male, currently in no acute distress
 Vital signs: Blood pressure initially 192/148 w/heart rates ranging between
115 and 143, respirations 19, afebrile
 Cardiovascular: Tachycardic and irregular
 Abdomen: Positive bowel sounds. Soft, nontender
 Extremities: No clubbing, cyanosis or edema
 No outpatient medications
Normal Cardiovascular Function
 Forms a closed loop of blood
vessels
 Heart acts as two pumps
 Right atrium and ventricle pump
through pulmonary circulation for O2
 Left atrium and ventricle pump O2rich blood through systemic
circulation
 Cardiac muscle has unique
electrical properties
Normal Cardiovascular Function
Electrical Properties of the Heart:
 Myocardial cells generate spontaneous
electrical activity at SA node
 Atria contract
 Electric current spreads to AV node
 Current spreads to ventricles, causing
contraction
 Measured on electrocardiogram (ECG/EKG)
Pathophysiology of CAD
Atherosclerosis (AS):
 Root cause of CAD and stroke
 Development of atherosclerotic plaque in the vascular wall that will occlude the lumen of the vessel, creating ischemic
conditions
 Begins as fatty, fibrous growth and with time may calcify
 Atherosclerotic plaque can result in partial or complete stenosis of the blood vessel
 If severe, may cause an infarct
myocardial infarction
 Severe CAD can lead to Congestive Heart Failure
Non-Modifiable Risk Factors for AS:
Modifiable Risk Factors for AS:
 Family history
 Obesity
 Atherogenic diet
 Ethnicity
 Dyslipidemia
 Cigarette smoking
 Age
 Hypertension
 Impaired fasting glucose
 Sex
 Physical Inactivity
Pathophysiology of CAD
Stable vs unstable angina
 Angina is primary
symptom of CAD
Collateral artery
compensation
Dislodged clot-thrombus
Majority of MI result of
blood clots and
atherosclerotic debris
Acute Coronary Syndrome
Coronary Artery Disease
Definition:
 Narrowing or blockage of the arteries that deliver blood and oxygen to the heart (atherosclerosis)
 Creates ischemic conditions, can lead to myocardial infarction
Diagnosis:
 Personal/family medical history, risk factors and physical exam
 EKG
 Stress test
 Chest x ray
 Blood test
 Cardiac catheterization/coronary angiogram
Etiologies
Presence of 5 major risk factors:
 Smoked for 20 years, quit a few years ago
 Hypertension
 Low HDL cholesterol (< 40 mg/dL)
 Family history of premature CAD
 Age (men > 45 years)
Strong genetic predisposition
Diet history:
 Had poor diet in younger years, high fat and salt
 Alcoholic for most of life, quit day after Christmas
Physical inactivity
 Only recently began exercising regularly
Clinical Manifestations
Admit diagnosis: Atrial fibrillation w/rapid ventricular response
 Discovered on EKG, then uncovered presence of other cardiac events
Intermittent chest pain for years upon exertion
 Recent episode occurred while pt doing paperwork (at rest) with no trigger
 Severe intensity
EKG showed ST depression, indicating myocardial injury
 Troponin I level 0.82, normal level below 0.04 ng/mL (QVMC), 0.5 ng/dL (literature)
 Diagnostic of myocardial infarction, ruled in while in ER
Exact chronology unclear
 Unstable angina was very brief warning of MI
 Afib w/RVR may have immediately followed MI
 Cardiac muscle near area of infarct can become irritated, causing arrhythmias
Clinical Manifestations
Determined to have Acute Coronary Syndrome:
 Acute on chronic of Coronary Artery Disease
 Change in atherosclerotic plaque causing unstable angina
 Plaque expanded, eroded or ruptured
 Thrombus has moved or broken loose
 Coronary artery suddenly tightened in vasospasm
 Unstable angina can be brief or last to cause sufficient ischemia leading to MI
Based on findings, pt eligible for cardiac catheterization
 Found to have obstruction in left main (coronary artery) and circumflex
 Stenosis of left anterior descending (LAD)
 Surgical candidate for urgent revascularization
 Coronary Artery Bypass Graft (CABG)
Coronary Artery Bypass Graft (CABG)
Goal: Restore perfusion of oxygen and nutrient-rich blood to the cardiac muscle
Using grafted artery or vein to bypass blocked coronary artery(ies)
Indications:
 Classification by American College of Cardiology & American Heart Association
 Level of evidence rating usefulness and efficacy of procedure (Class I, II, IIa, IIb, III)
 Class I for:
 Left main stenosis
 Stenosis of proximal LAD and circumflex
 3 vessel disease
 NSTE-ACS and unstable hemodynamics
Studies have shown 33% reduction in risk of all cause mortality after 5 years of CABG placement
as compared to percutaneous coronary intervention (PCI)
CABG
PG had CABG x 2
Left radial artery grafted onto left marginal artery
Internal mammary artery grafted onto LAD distal to
obstruction
Customary Nutrition Interventions
Post MI period in CAD:
 No caffeine
 Low cholesterol, Therapeutic Lifestyle Changes guidelines (< 200 mg/day)
 Restrict sodium if HTN present
Therapeutic Lifestyle Changes (ATP III):
 < 7% of daily total energy from saturated and trans fat
 25-35% daily total energy from fat w/unsaturated, including omega-3 FA’s, in place of saturated fat
 50-60% daily total energy from carbohydrate, approx. 15% daily total energy from protein
Additionally include:
 25-35 g daily fiber intake, at least half from soluble fiber
 Plant stanols/sterols (2 g per day) as an option
 Adequate energy intake to maintain desirable body weight or prevent weight gain
 Moderate exercise to expend at least 200 kcal per day
If indicated, patients w/HTN may have sodium restriction of 1500-2300 mg/day
Admission Nutrition Assessment
Diet History
Usual dietary intake:
 Breakfast: Bowl of oatmeal (prepared w/water), blueberries, walnuts and maple syrup
 Lunch: 3 different pieces of fruits and/or vegetables, several pieces of cheese and salami or other
meat, yogurt and a handful of nuts
 Dinner: Chicken and mashed potatoes, vegetable sides, occasionally has red meat, shares steak w/wife
 Fluid choices: water and non-fat milk
States a recent cut back on salt and red meat, ‘started eating healthier a few years ago’
Wife does all of meal preparation and cooking
 States almost all cooking is done w/olive oil, butter is used ‘when the food calls for it but not often’
Admission Nutrition Assessment
Allergies: NKFA
No previous MNT, doctor ‘has been on me for years’ regarding weight and alcohol consumption
 Has not been to a doctor in over 5 years
 Wife has attempted intervention for EtOH, unsuccessful
 Hospitalization and need for surgery was ‘wake up call’
Diet Order: Cardiac AHA Heart Healthy
Anthropometrics:
 Height: 6’2” (188 cm)
BMI: 29.4
 Weight: 104 kg (240 lbs)
 Weight history: has been ‘about this weight for years’, small fluctuations
 UBW: ~220 lbs, ‘224 at Christmas, 210 when I’m hiking’
 ABW: 92 kg (202 lbs)
 IBW: 86.4 kg (190 lbs)
 %IBW: 121% IBW
Estimated Needs & Current Intake
Kcal: (MSJ x 1.1-1.3) = 2125-2511 kcal
Protein: 125-146 grams (1.2-1.4 g/kg body weight)
Fluids: 2125-2511 mL (1 mL/kcal)
Evaluation of intake at QVMC: Adequate, pt consuming 100% of all meals
Adequacy of diet order: Approx. 115% average intake of diet needed to meet estimated needs,
elevated energy requirements d/t elevated body weight; diet order adequate to meet needs.
Evaluation of intake prior to admission*
2237 kcals consumed on average day – 97% of EER
Breakfast: 480 kcals
Lunch: 1200 kcals
Dinner: 557 kcals
109 grams protein consumed on average day – 81% of estimated needs
Approx. 30 fl oz (900 mLs) – 39% of estimated fluid requirements
*using USDA Super Tracker
Admission Nutrition Assessment
2/11/15
Day prior to CABG placement
Medical treatments:
Stabilized in ER w/meds
Referred to cardiology and cardiothoracic surgeon
Recommended cardiac catheterization/coronary angiogram
Determined a candidate for CABG
Treatment goals:
Revascularize the heart
Restore cardiac blood perfusion
Diagnostic tests:
EKG (MI)
Cardiac catheterization/coronary angiogram (CAD, need for CABG)
Blood Pressure
240
High: 214/81
4 hours after surgery
220
Low: 92/69
Blood Pressure (mmHg)
200
180
Average: 146/66
160
Most monitored on 2/12
140
120
100
80
60
40
2/9/15
Time
2/16/15
Lab Results
2/9/15
2/9/15
2/10/15
2/11/15
0.61
0.97
0.65
50
Troponin I 0.82
2 hours after surgery
45
*Released after death of cardiomyocytes
40
35
gm/dL %
30
25
Hemoglobin
Lipid Panel
20
Hematocrit
Triglycerides
151
15
Cholesterol
137
10
LDL Cholesterol
79
5
HDL Cholesterol
28
0
2/9/15
Time
 Includes POC Hgb (12.5-16.3) & Hct (36.7-47.1)
 Checked q 2 hours after surgery
 Checked 1x/day after
2/15/15
Albumin (2/10/15): 5.2
Nutrition-related Medications
Pt was on variety of medications w/varying degrees of nutrition implications
Majority were a one time frequency on operative days, insufficient time for effect of potential
nutrition implications
Two medications prescribed several times for several days:
Medication
Uses
Potential Nutrition
Implications
When prescribed
Metoprolol
tartrate
(Lopressor)
Antihypertensive,
antiangina, CHF
treatment, MI
treatment
Recommended decrease
dietary Na & kcal, decrease in
BP w/possible hypotension,
avoid natural licorice
(↑[cortisol], ↑Na
reabsorption, water retention,
K excretion and BP)
On admission, for 2 days
btwn angiogram and
CABG*, day after CABG
until discharge*
Avoid salt subs, caution w/ K
supplement, ↑ serum K
HCTZ: ↓ serum Na, Cl, K, ↑
glc (urinary excretion)
For 2 days btwn
angiogram and CABG, day
after CABG until discharge
Cardioselective BetaBlocker
Lisinopril
(Zestril)
ACE inhibitor,
antihypertensive,
acute MI adjunct
*highest doses
Initial Diagnosis and Interventions
Nutrition Diagnosis:
 Overweight R/T excessive energy intake prior to admission AEB BMI 29.5
Nutrition Interventions
Diet Order: Cardiac AHA Heart Healthy Diet
Counseling & Education:
Educated patient on the Therapeutic Lifestyle Changes diet
Discussed lifestyle habits that in combination w/genetics may have led to CAD
Advised that surgery is first part of solution, lifestyle changes are necessary second
Will need to monitor more closely which foods are consumed and portion size
Will need to start incorporating regular physical activity, 30 minutes, 5x/week once medically cleared (pt/wife
admitted low)
Initial Goals and Monitoring
Primary goals and objectives for MNT:
Gain an understanding of TLC diet and its importance to medical condition
Recognize dietary and lifestyle factors that likely contributed to development of CAD
Openness to change/modification
Nutrition Monitoring and Evaluation:
Continue to provide cardiac diet-related nutrition education
Monitor PO intake and weight trends
Assess patient knowledge of information presented at next visit
Next education planned POD #1
Follow-Up Nutrition Education
2/13/15
POD #1 s/p CABG placement
*In ICU, pt’s wife and son present
Medical treatments:
CABG placed on 2/12 in AM
Intubated for 6 hours on ICU on 2/12
Treatment goals:
Restore cardiac blood perfusion
Achieve hemodynamic stability
Stable recovery
Follow-Up Nutrition Education
Diet Order: Cardiac AHA Heart Healthy
Intake: 100% average meal intake
Nutrition Interventions:
Provided and went over CABG nutrition therapy (TLC diet) guidelines handout w/wife
 Types and sources of lipids
 Limiting cholesterol in diet (egg example)
 Choosing leaner proteins
 Tending toward a more plant-based diet
 Including fiber, especially soluble, in diet
Asked/confirmed typical preparation methods at home
Frequency of eating out/choices when eating out
Wife asked questions about specific foods (salami, olive oil, proteins)
Follow Up Nutrition Education
Nutrition Monitoring and Evaluation:
Important to have pt’s wife understand nutrition education
 Meal preparation, dietary and lifestyle change support, emotional support
Pt hearing information again, will provide continuing education on POD #4, continue to assess
knowledge and change readiness
Continue to monitor nutrition parameters
 Laboratory values
 Weight trends (awareness of fluid gains)
 Adequacy of intake
 Changes in medical conditions and/or medical treatments
Nutrition Assessment #2
2/16/15
POD #4, day of discharge
No new medical treatments
Treatment goal: discharge patient
Nutrition Diagnosis:
Food and nutrition-related knowledge deficit R/T new diagnosis of acute MI, atrial fib, coronary artery
disease AEB need for CABG placement and lack of prior cardiac diet education
Nutrition Interventions
Diet Order: Cardiac AHA Heart Healthy Diet
Nutrition Assessment #2
Date
2/9
Blood Glucose Levels
Weight (kg)  Likely fluid gain, not
true weight gain
102
150
140
103
2/11
104.2
2/12
104.9
2/14
109.9
2/15
109.1
90
2/16
109
80
Reference
Ranges
 Received many IV
medications and fluids
Blood Glucose (mg/dL)
2/10
130
120
110
100
Time
2/9/15
2/12 2/12
2/12
2/12
2/13
2/14
2/15
Na (POC)
136-145
140
140
140
135
133
131
134
K (POC)
3.5-5.1
4.5
4.6
4.4
4.1
4.2
4.2
4.0
4.64-5.28
4.7
4.4 (L)
X
X
Ionized Ca2+
4.4 (L) 4.2 (L) 4.3 (L)
2/16/15
 Monitoring Na for blood pressure,
hypertension
 Monitoring K for hyperkalemia, cardiac
arrest potential
 Ionized calcium: major surgery, low
levels of free Ca2+ can cause tachy- or
bradycardia, muscle spasms, even coma
 Key player in cardiac contractility
Nutrition-related medications at discharge
Lopressor and Lisinopril also prescribed at discharge
Medication
Uses
Potential nutrition implications
When prescribed
Docusate sodium
(Colace)
Stool softener,
laxative
High fiber w/1500-2000 mL fluid to
prevent constipation, altered int abs
of water & electrolytes
After CABG through discharge, at
discharge as outpt
Aspirin
To prevent CVA or MI,
platelet aggregation
inhibitor
N/V, dyspepsia, black tarry stools,
limit caffeine, limit foods that affect
coagulation, anorexia
After CABG through discharge, at
discharge as outpt
Acetominophen
Analgesic, antipyretic
Avoid alcohol (hepatotoxicity), ↑liver
function enzymes
At discharge as outpt
Atorvastatin calcium
(Lipitor)
Antihyperlipidemic,
Caution w/grapefruit/related citrus,
↓risk of cardio events ↓serum chol, TG, LDL, VLDL, ↑ HDL
and ↓prog. of athero.
At discharge as outpt
Amiodarone HCl
(Pacerone)
Antiarrhythmic
Avoid grapefruit/related citrus,
anorexia, N/V, constipation
At discharge as outpt
Pantoprazole sodium
(Protonix)
Anti-GERD
May ↓abs of Fe, B12, ↓gastric acid
secretion, ↑gastric pH, diarrhea
After CABG through discharge, at
discharge as outpt
Nutrition Assessment #2
Counseling & Education:
Reinforced 4 key components of TLC diet:
Most applicable to patient
 Limiting saturated fat intake
 Increasing unsaturated fatty acids
 Increasing intake of dietary fiber, especially soluble
 Limiting sodium
Explained rationale of each component in relation to cardiac condition
Provided handout on sources of soluble dietary fiber
Offered to go over a general meal plan, pt responded “I think I get the food changes in the new lifestyle”
Discussed potential obstacles to implementing changes/equipped for success at home
“I don’t know, I just know I don’t ever want go through this again”
Nutrition Assessment #2
Memorable quotes from final education:
o “I know how important the salt reduction is”
o “I didn’t put brown sugar in my oatmeal this morning because I knew I didn’t need it”
o “I got to live 59 years with an extravagant lifestyle (food/alcohol), now I don’t get to do that”
o “I realize that just because a food is good quality doesn’t mean it’s appropriate for me”
o “Thank you for your help”
o “I think I can do this”
Discharge Plan
Hospital protocol for MD to refer a post-CABG pt to a Cardiac Rehabilitation Program:
Several months in length
Monitored moderate physical activity
Monitored respiratory and cardiac function while exercising
Nutrition counseling (TLC diet, weight management as needed)
Discharge report:
Adhere to a sodium restricted, low cholesterol, low fat diet
No fluid restriction
Check weight daily (especially rapid/significant gains)
Adhere to all prescribed medications
Gradually begin physical activity, no fatigue
Watch for certain signs and symptoms indicating cardiac dysfunction
Follow up as outpt w/cardiologist in 1-2 weeks, w/surgeon in 4 weeks
Gave point of contact to wife for any questions
Summary
Suspected major contributors to CAD:
Genetics
HTN
Dietary choices and lack of physical activity
Medical and dietary intervention to remedy an acute on chronic cardiac event
Coronary angiogram
CABG placement
Pt given extensive education on dietary management of CAD and post-CABG
Equipped w/tools for success
Hope lesson was learned and pt has good prognosis
Effectiveness of MNT reflected in quotes, pt and wife’s attitude toward nutrition counseling
Increasingly tailored to pt’s education readiness, needs and learning lifestyle
• Approx. 1 in 18 Americans 18
y/o and older has CAD (CDC
2013)
• Chronic development,
strongest risk factor is age
• Annually, 935,000 Americans
have a heart attack (2/3 are
first time)
• Heart disease is leading cause
of death (1 in every 4)
• 30% reduction in mortality
since 1950’s, due to medical
intervention such as CABG
• Early intervention is key
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