Myocardial Infarction

Ischemic necrosis of part of the heart muscle.

11/28/2012 Daniel Lewis, Ariel Lebert, Courtney Kousser, Sarah Fecco

 Symptoms: Sudden onset of severe precordial pain Medical Diagnosis: Myocardial Infarction Medical Treatment: Emergency Angioplasty

Mr. Klosterman

Age 61 BP: 118/78 mmHg Temp: 98.4 F RR: 20 bpm SAO2: 80% HR: 92 bpm Pain: severe chest pain for past 1.5 hours Last ate: 1030 Last drank: 1100

Physical Findings @ 1354 3/25

Smokes (1 pack/day) for 40 years Patient Hx:

Emphysema/lung problems Angina/chest pain No HTN, Hypercholesterolemia, or diabetes

Family Hx:
CAD (Father) MI age 59 Cancer (maternal grandmother)

PMH: Surgery; cholecystectomy 10 years ago, appendectomy 30 years ago

Allergies/reaction: Sulfa/hives

Client History (CH)

Height: 70 Weight: 185 lbs BMI: 26.5 kg/m2 Weight history is not specifically stated. Assumption that he has a longstanding history of being overweight since there has been some attempt to change diet

Anthropometric Data (AD)

Day One Total Cholesterol LDL-C 235 mg/dl H 160 mg/dl H

Day Two 226 mg/dl H 150 mg/dl H

Day Three 214 mg/dl H 141 mg/dl H

Optimal Values <200 mg/dl <100 mg/dl

HDL-C
LDL-C/HDL-C ratio

30 mg/dl L
5.3 H

32 mg/dl L
4.7 H

33 mg/dl L
4.3 H

>/= 60 mg/dl
< 3.55

CPK
ALT

0 u/l
30 u/l

75 u/l H
215 u/l H

55 u/l H
185 u/l H

0 u/l
4-36 u/l

AST
LDH Troponin I Troponin T

25 u/l
325 u/l 2.4 ng/ml H 2.1 ng/ml H

245 u/l H
685 u/l H 2.8 ng/ml H 2.7 ng/ml H

175 u/l H
365 u/l ---

0-35 u/l
208-375 u/l < 0.2 ng/ml < 0.03 ng/ml

Biochemical Data

Risk Factors for CAD and IHD Elevated LDL-C levels and LDL-C/HDL-C ratio Low HDL-C levels Hypercholesterolemia MI-related values (Day 2**) Elevated LDH, ALT & AST: intracellular enzymes that are indicative of tissue damage when present in plasma Elevated CPK: Particularly notable is the CK3 isoform as it is most abundant in heart muscle Elevated Troponin I & Troponin T: Heart contractile proteins

Biochemical Data Interpretation

Lisinopril 10mg/day
Used to treat heart failure and HTN Used to improve survival after MI Angiotensin-converting enzyme (ACE) inhibitors Decreases tension on vessels, decreases blood volume

Lipitor 10mg/day
Reduce the risk of heart attack and stroke; decrease chance heart surgery will be necessary Decrease cholesterol by slowing production HMG-CoA reductase inhibitors (statins)

Medications

Lopressor 50mg/day Used to treat HTN, also to prevent angina, improve survival after MI Beta blocker Relaxes blood vessels, slows HR to improve blood flow and decrease BP Nitro-Bid 9mg twice daily Nitroglycerin ointment Used to prevent angina associated with CAD Vasodilator Relaxes blood vessels NTG 0.4mg sublingually prn chest pain

Medications cont

ASA (acetylsalicylic acidaspirin) 81 mg/day Used to prevent MI and stroke Antithrombotic Inhibition of thromboxane A2 synthesis inhibition of platelet aggregation Inhibits cyclooxygenase activity that produces prostaglandins pain relief
No vitamin/mineral supplements in use

Medications cont

Medication Lopressor 50 mg daily

Possible Food-Nutrient Interactions Avoid natural licorice. Take 2 hours before or 6 hours after calcium supplements and/or fortified orange juice. Calcium salts may decrease absorption. Avoid salt substitutes. Caution with K and Mg supplements. Decreased Na and Ca may be recommended. Avoid alcohol. May result in dangerously low blood pressure.

Lisinopril 10 mg daily

Nitro-Bid 9.0 mg twice daily

NTG 0.4 mg sl prn chest pain

ASA 81 mg daily (acetylsalicylic acidaspirin) Lipitor 10 mg daily

Avoid alcohol.
Taking with food can decrease absorption and diminish drug effects. Avoid grapefruit juice- increase risk of toxicity. Fibers such as oat bran and pectin may diminish drug effect.

Medications & Dietary Supplements

24 hour recall
Breakfast: None Midmorning Snack: 1 lg cinnamon raisin bagel w/ 1 tbsp fat-free cream-cheese, 8 oz orange juice, coffee Lunch: 1c canned veg beef soup; sandwich w/ 4 oz roast beef, lettuce, tomato, dill pickles, 2 tsp mayonnaise; 1 sm apple; 8 oz 2% milk Dinner: 2 lean 3oz pork chops, 1 lg baked potato, 2 tsp margarine, c green beans, c coleslaw (cabbage w/ 1 tbsp of salad dressing), 1 slice apple pie Snack: 8 oz 2% milk, 1 oz pretzels

Drinks alcohol (1 drink/day) Last drink: 3/24

Food/Nutrition Hx (FH)

24 hour recall
Breakfast: None Midmorning Snack: 1 lg cinnamon raisin bagel w/ 1 tbsp fat-free cream-cheese, 8 oz orange juice, coffee Lunch: 1c canned veg beef soup; sandwich w/ 4 oz roast beef, lettuce, tomato, dill pickles, 2 tsp mayonnaise; 1 sm apple; 8 oz 2% milk Dinner: 2 lean 3oz pork chops, 1 lg baked potato, 2 tsp margarine, c green beans, c coleslaw (cabbage w/ 1 tbsp of salad dressing), 1 slice apple pie Snack: 8 oz 2% milk, 1 oz pretzels

Drinks alcohol (1 drink/day) Last drink: 3/24

Food/Nutrition Hx (FH)

24 hour recall
Breakfast: None Midmorning Snack: 1 lg cinnamon raisin bagel w/ 1 tbsp fat-free cream-cheese, 8 oz orange juice, coffee Lunch: 1c canned veg beef soup; sandwich w/ 4 oz roast beef, lettuce, tomato, dill pickles, 2 tsp mayonnaise; 1 sm apple; 8 oz 2% milk Dinner: 2 lean 3oz pork chops, 1 lg baked potato, 2 tsp margarine, c green beans, c coleslaw (cabbage w/ 1 tbsp of salad dressing), 1 slice apple pie Snack: 8 oz 2% milk, 1 oz pretzels

Drinks alcohol (1 drink/day) Last drink: 3/24

Food/Nutrition Hx (FH)

Total kcal = 2879.32 kcal CHO: 354g (~49.5% of total kcal)

Fiber: 29g Sugars: 136g

Protein: 152g (~21.3% of total kcal) Fat: 95g (~30% of total kcal)
Sat. Fat: 37g Trans Fat: 2g

Cholesterol: 371mg Sodium: 5072mg Iron: 262% DV

Intake Analysis (NutriCalc)

Recommended Intakes TEE = 1086 - (10.1 x age in yrs [61]) + PA [1.12] x (13.7 x wt. in kg. [84.1]) + (416 x ht. in m. [1.78]) = ~2500 kcal Daily protein = 0.8 g x 84.1 kg = 67.28g
Recommended Weight IBW (based on Hamwi): 106 + 6*10 = 166lbs %IBW: 185/166 = 111% BMI : 26.5 kg/m2

Comparative Standards

 Excessive energy intake -- 112% of DRI

Fat Intake -- 119% of DRI Saturated Fat: -- 142% of DRI Trans Fat Protein Intake -- 226% of DRI

Excessive Sodium Intake 390% of DRI Inadequate fluid intake (Water)

Intake Problems

Clinical Domain Altered nutrition-related lab values Food-medication interactions Overweight Behavioral-Environmental Domain Self-monitoring deficit Willing to change Adherence to nutrition-related recommendations Physical Activity Physical Inactivity

Other Possible Problems

 Altered nutrition-related lab values (NC-2.2) related to excessive macronutrient intake as evidenced by total cholesterol of 235, LDL-C of 160 and HDL-C of 30. Physical inactivity (NB-2.1) related to sedentary lifestyle as evidenced by physical activity limited to walking the dog for 15 minutes a day.

Diagnoses

 Reduction in total cholesterol (<200) and LDLcholesterol (<100); Increase in HDL-cholesterol (>60).
Increase amount of physical activity to 30 minutes/day minimum.

Prescriptions

 Comprehensive nutrition education to include: recommended modifications regarding his daily intake (E-2.2) skill development for the purposes of food selection and meal preparation (E-2.5). recommended modifications regarding physical activity (E-2.2).

Nutrition Counseling including: motivational interviewing (C-2.1); goal setting regarding weight loss, physical activity level and proper nutrient consumption (C-2.2) self-monitoring regarding daily intake, weight and a daily/weekly physical activity log (C-2.3)

Interventions

Following MI:
NPO until after angioplasty Limit oral intake to clear liquids w/o caffeine to decrease risk of arrhythmia; decrease risk of vomiting and aspiration Follow-up with progression to the Therapeutic Lifestyle Changes (TLC) diet

Nutritional Therapy

Nutrient
Saturated Fat Polyunsaturated fat Monounsaturated fat Total Fat Cholesterol Fiber

Recommended Intake
Less than 7% of total kcal Up to 10% of total kcal Up to 20% of total kcal 25-35% of total kcal <200mg/day 20-30g/day

Protein
Sodium Stanol esters

Approx. 15% of total kcal

<2400 mg/day 3-4 g/day

TLC: Nutrient Composition

Breads & Cereals

At least 6 servings per day

Vegetables**
3-5 servings per day without added fat, sauce, salt

Fruit
2-4 servings per day

Dairy Products**
2-3 servings per day; low-fat or fat-free

Eggs
2 or fewer egg yolks per week

Meat, Poultry, Fish***

5 oz or fewer per day; lean cuts

Fats and Oils

Unsaturated oils, soft margarines, seeds and nuts

TLC: Foods to Eat More

Breads and Cereals***

Baked and processed goods, grain-based snacks

Vegetables
Fried or prepared with butter, cheese or cream sauce

Dairy
Full-fat products, ice cream, cream and cheese

Eggs
Whole eggs, egg yolks

Meat, Poultry, Fish**

Higher-fat cuts; fried meats

Fats and Oils***

Butter, shortening, stick margarine Trans Fats

TLC: Foods to Choose Less

Self-Monitor Record weight, BMI & waist circumference

Gradual weight loss Goal: lose 10% of body weight in 6 months Lose to 1 lb per week
Increase Physical Activity Make PA part of daily routines and recreational activities

TLC: Weight Reduction

Recommended by the American Heart Association and the American College of Cardiology to improve: Risk of heart disease Prevention of future hospital stays Health and well-being
Through: Exercise training Nutrition education and counseling Lifestyle coaching Smoking cessation Stress reducing techniques

Cardiac Rehabilitation

3-4 week check up Review TLC records Assess changes in PA and nutrient intake Review blood panel for changes in lipid levels Smoking Cessation?

Monitoring & Evaluation

Domain 1
Medication: Lopressor 50 mg daily, Lisinopril 10 mg daily Nitro-Bid 9.0 mg twice daily NTG 0.4 mg sl prn chest pain, ASA 81 mg daily (acetylsalicylic acid-aspirin), Lipitor 10 mg daily Physical Activity: 15min/day walking the dog Food preparation: Wife shops and prepares meals Intake: Breakfast: None Midmorning Snack: 1 lg cinnamon raisin bagel w/ 1 tbsp fat-free creamcheese, 8 oz orange juice, coffee Lunch: 1c canned veg. beef soup; sandwich w/ 4 oz roast beef, lettuce, tomato, dill pickles, 2 tsp mayonnaise; 1 sm apple; 8 oz 2% milk Dinner: 2 lean 3oz pork chops, 1 lg baked potato, 2 tsp margarine, c green beans, c coleslaw (cabbage w/ 1 tbsp of salad dressing), 1 slice apple pie Snack: 8 oz 2% milk, 1 oz pretzels

ADIME

Domain 2 Height: 70 Weight: 185 lbs BMI: 26.5 kg/m2 Weight history is not specifically stated. Assumption that he has a longstanding history of being overweight since there has been some attempt to change diet

Domain 3 (Day 2) Cholesterol: 226 mg/dl H LDL: 150 mg/dl H HDL: 32 mg/dl L LDL/HDL: 4.7 H Troponin I: 2.8 ng/ml H Troponin T: 2.7 ng/ml H ALT: 215 u/l H AST: 245 u/l H LDH: 685 u/l H CPK: 75 u/l H

ADIME

Domain 4 Age 61 BP: 118/78 mmHg Temp: 98.4 F RR: 20 bpm SAO2: 80% HR: 92 bpm Pain: severe chest pain for past 1.5 hours Last ate: 1030 Last drank: 1100

Domain 5 Smokes (1 pack/day) for 40 years Patient Hx: Emphysema/lung problems Angina/chest pain Family Hx: CAD (Father) MI age 59 Cancer (maternal grandmother) PMH: Surgery; cholecystectomy 10 years ago, appendectomy 30 years ago Allergies/reaction: Sulfa/hives

ADIME

Altered nutrition-related lab values (NC-2.2) related to excessive macronutrient intake as evidenced by total cholesterol of 235, LDL-C of 160 and HDL-C of 30. Physical inactivity (NB-2.1) related to sedentary lifestyle as evidenced by physical activity limited to walking the dog for 15 minutes a day.

ADIME

 Comprehensive nutrition education to include: recommended modifications regarding his daily intake (E2.2) skill development for the purposes of food selection and meal preparation (E-2.5). recommended modifications regarding physical activity (E2.2). Nutrition Counseling including: motivational interviewing (C-2.1); goal setting regarding weight loss, physical activity level and proper nutrient consumption (C-2.2) self-monitoring regarding daily intake, weight and a daily/weekly physical activity log (C-2.3)

ADIME

3-4 week check up Review TLC records Assess changes in PA and intake Review blood panel for changes in lipid levels Smoking Cessation?

ADIME

 Nelms, Marcia. Nutrition Therapy & Pathophysiology. Belmont, Ca. Cengage Learning: 2011. Harvey, Richard. Biochemistry. Lippincott: 2011 http://www.nhlbi.nih.gov/ www.heart.org/ www.acc.org/

References

Questions?