Download Cardiovascular Case Study

Taryn Berry
Case Study #5-Myocardial Infarction
I.
Understanding the Disease and Pathophysiology
1. 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 Therapy
4. 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.
III.
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.”
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 kg
ii. 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
Protein: 142.4 g x 4 kcal =
Carbohydrates: 349.3 g x 4 kcal =
Fat: 77 g x 9 kcal =
Total kcal
569.6 kcal
1397.2 kcal
693 kcal
% Total Cal
21.6%
53%
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 2-12/2
Troponin T
<0.03
2.1
2.7
Troponin I
<0.2
2.4
2.8
Lactate
208-378
325
685
dehydrogenase
AST
0-35
25
245
Cholesterol (mg/dL) 120-199
235
226
HDL-C (mg/dL)
>45M
30
32
LDL-C (mg/dL)
<130
160
150
Triglycerides
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.
Chemistry
Cholesterol
(mg/dL)
HDL-C (mg/dL)
LDL-C (mg/dL)
Triglycerides
Ref Range
120-199
Day 1- 12/1
235
Day 2- 12/2
226
Day 3- 12/3
214
>45M
<130
40-160M
30
160
150
32
150
140
33
141
130
*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
Lopressor 50 mg daily
Possible Food-Medication Interactions
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?
 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 Diagnosis
15. Select two of the identified nutrition problems and complete the PES statement for each.
P Excessive energy related to
E increase calories as evidence by
S 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 to
E limited physical activity as evidence by
S patient information of daily physical activity, high cholesterol, and a BMI of 26.6 kg/m^2.
IV.
Nutrition Intervention
16. 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 22002300 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 Evaluation
18. 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/page039
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-be4e8e84ffa2a6a7%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/ConsumerBuyingUsingMedicineSafely
EnsuringSafeUseofMedicine/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=f63fdc75-106a4658-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=f63fdc75-106a4658-a5fa-465106adbedc%40sessionmgr115&vid=4&hid=107
Nelms, Sucher, Lacey, Roth. “Nutrition Therapy & Pathophysiology.” 2nd ed. Wadsworth. 2012.