Case Study M.

K Myocardial Infarction
Brittany Brockner
Marywood University
MNT- ND-420-01
Helen Battisti, PhD, RDN, CDN
11/18/16

MNT Case Study Myocardial Infarction

Patient Description
Demographics
According to the case study book, patient M.K is a 61 year old German American male who
speaks English. He is married to S.K, a 59 year old women. Him and his wife live in their home
together. He has children who are adults and do not live with him anymore. He has a bachelors
degree and works fulltime as a Lutheran minister, and expresses he does not have time to
exercise.
Anthropometrics
Patient M.K is 510 and weights 185 pounds. His BMI is 26.6, which is classified as
overweight. His IBW is 160lbs. His IBW% is 185/160= 115%.
Medicines and Usage
Does not take any medication at home. Is allergic to sulfa drugs, which are used as antibiotics.
Histories
The onset of his MI began with sudden onset unstable angina on the way home from work.
The pain was described as pressure pain radiating to the jaw and left arm, which is indicative of a
heart attack. Patient also noted emesis and nausea. However patient has not experienced prior
pain . Patient also denies prior diagnosis of hypertension, diabetes, or high cholesterol. Before
the MI, patient does not have significant medical history. Patients has undergone 2 surgeries.
Cholecystectomy 10 years ago and appendectomy 30 years ago. Patient is unclear on family
history but noted his father experience MI at age 59. Patient does smoke 1 pack of cigarettes a
day and has done so for the past 40 years. Patients also drinks 1 glass of wine per day. Risk

MNT Case Study Myocardial Infarction

factors of a myocardial infarction that this patient possesses are: Gender, age, dyslipidemia,
smoking, overweight, and family history.
Patient does not have any food allergies. His wife does the food purchasing and preparation. He
does not take any vitamin or mineral supplements. He typically does not eat breakfast. He has a
good appetite, and his wife has switched from butter to corn oil in effort to eat healthier. Hospital
diet order is currently clear liquids with no caffeine. The hospital has also ordered the following:
IV heparin- 500 unites followed by 1000 unit/hour continuous infusion with a PTT at 2x control.
Chewable aspirin 160mg PO continued everyday, Lopressor 50mg twice daily, Lidocaine prn,
and NPO until procedure is completed.
Disease Information
Disease/ Etiology
M.K sufferes from ischemic heart disease and experienced a myocardial infarction and was
treated at the hospital with an emergency coronary angioplasty with angioplasty of the infarctrelated artery. The onset of myocardial infarction for patient M.K was severe precordial pain on
his way home from work, this indicates heart problems, which is how he was sent to the hospital.
The condition occurs when the coronary artery has been narrowed, usually from atherosclerosis.
When a coronary artery is blocked, blood cannot get to the heart efficiently, and interferes with
the heart ability to pump blood. The area where there is a blockage in the coronary artery will
cause pain to the patient and is often experienced as severe precordial pain at rest (Lewine).
Through the interdisciplinary work among cardiologists, engineers, radiologists and pathologists,
the technique of surgical angioplasty is an improved vascular technique that can open
obstructions to the heart and improve circulation (Nabel).The angioplasty surgery surgically
unblocks the blood vessel, which is blocked from atherosclerotic plaque (Nelms,307). To prepare

MNT Case Study Myocardial Infarction

for the surgery, patient M.K was put on blood thinner.The specific order was as follows: IV
heparin- 5000 units bolus followed by 1000 units/hour continuous infusion with a PTT at 2X
control. In addition, he was also made NPO until the completion of the procedure surgery. After
completion of the surgery he was put on clear liquids with no caffeine.
Admitting Signs/ Symptoms
Patient M.K was admitted to the hospital with unstable angina and was found to have suffered
a myocardial infarction on his way home from work. This is a condition associated with sever
angina pain at rest is a sign of the onset of a myocardial infarction. Patients with unstable angina
often show biochemical evidence of obstructive coronary artery disease. Evidence includes:
myonecrosis and severe multivessel obstructive coronary artery disease (Nabel). Patient M.K
also experience nausea and vomiting. A study done by Eileen Fuller, Rahel Alemu, John Harper,
and Mark Feldman aimed to determine if nausea and vomiting in patients with myocardial
infarction has correlation to the infarct location. The study included 180 patients who experience
myocardial infarction with symptoms of chest pain nausea and vomiting. The location of infarcts
where as follows: 60% of patients had inferior infarcts and 40% had anterior infarcts. Both
nausea and vomiting were found to be associated more closely with inferior infarcts however the
results were not statistically significant. The result of the study showed that nausea, vomiting,
and chest pain are common symptoms in patients experiencing myocardial infarction and is not
closely related to the location of the infarct (Fuller). Patient M.K had experienced pressure like
pain radiating to his jaw and left arm. Upper body discomfort in the jaw and arms is a common
warning symptom of a myocardial infarction for both men and women (How is a Heart Attack
Diagnosed).

MNT Case Study Myocardial Infarction

Diagnostic Tests
Diagnostic tests for myocardial infarction include electrocardiogram(EKG), blood tests, and
coronary angiography. The EKG records the hearts electrical activity. The test measures the
strength of the electrical signals as well as the pace of the hearts beating. Blood Tests measure
the amount of protein in the blood, higher protein suggests a myocardial infarction as proteins
are released into the blood during a myocardial infarction for necrosis of muscle cells. Another
test option is the Coronary Angiography, which is a test that uses dye to show the inside of the
coronary arteries. The test helps find blockages in the arteries (How is a Heart Attack
Diagnosed). For patient M.K, serum albumin and prealbumin were at normal levels throughout
his three-day stay. His blood pressure is also normal at 118/78.Troponin tests were used to
diagnose a myocardial infarction upon admittance. In addition CPK-MB was used to also
distinguish cardiac damage. More information regarding his diagnosis are included under
laboratory findings.
How disease affects Nutrition Status
As dyslipidemia is a contributing factor to a myocardial infarction, nutrition implications are
to normalize lipid levels. The American Heart Association recommends an intake of 5-6% of
total dietary kcals from saturated fat to reduce LDL cholesterol levels as well as an intake of less
than 200mg/day of dietary cholesterol. Interestingly, a study done by Pennsylvania State
University concluded that the amount of adipose tissue in a patient would effect the amount of
lipid response to dietary intervention. Diets that lower saturated fat and cholesterol are less
effective in improving the lipid profile in obese patients than in that of lean patients. The altered
lipid response to dietary changes is due in part to the suppression of hepatic LDL receptors in
obese individuals, which reduces hepatic LDL uptake. An applicable take away from this study is

MNT Case Study Myocardial Infarction

the reduction of adipose tissue can improve the lipid response to dietary interventions (Flock et
al. 2011).
Further effects on nutrition status include the consumption of fiber. Fiber is well known to
help correct dyslipidemia by reducing LDL and total serum cholesterol levels. Soluble fiber, in
particular, is known to decrease total LDL cholesterol levels.The TLC dietary recommends a
total of 20-30g/day of dietary fiber. A study published in the Journal of the Academy of Nutrition
and Dietetics supports the TLCs diet recommendation. Their study concluded that soluble fiber
(B-Glucan) can reduce serum cholesterol and LDL levels by increasing bile acid production. This
mechanisms allows bile acids to bind to soluble fiber which favorable affects LDL receptor
status (Horn et. al 2008).
The TLC diet encompasses the wide range of nutrition implications for people with heart
disease as well as other chronic disease states such as diabetes, obesity, and hypertension. In
addition to dietary fiber and fat intake recommendations, it also provides sodium intake and plant
sterol recommendations. The TLC diet recommends less than 2,300mg/day for sodium. This
recommendation is based off the evidence that reduced sodium intake is associated with reduced
blood pressure. A study from the trails of hypertension concluded that a 25 to 35% reduction in
salt intake was associated with a 25% decrease in cardiovascular disease characterized by
myocardial infarction, atherosclerosis and stroke (Can Lifestyle Modifications). The TLC diet
also encourages consumption of 2g per day of plant sterols, which are derived from soybean and
tall- pine tree oils. They are recommended because of their ability to reduce dietary and biliary
cholesterol absorption, which can reduce LDL cholesterol levels. Plant sterols can be found in
orange juice, yogurt, some cereals and soft gel capsules (Horn et al. 2008).

MNT Case Study Myocardial Infarction

Laboratory Findings
Relevant Lab Data
Patients had an abnormally high ALT and AST level after admission. ALT levels on the
second and third day at the hospital range from 185-215 U/F, normal range is 4-36U/L. AST
levels on the second and third day at the hospital range from 175-245U/L, normal range is 035U/L. Patients labs indicate dyslipidemia which low HDL and high LDL levels. Within the
three days at the hospital the patients HDL levels range from 30-33mg/dL, normal range is above
45 for males. Patients LDL levels range from 141-160mg/dL, normal range is below 130. The
patients troponin levels were abnormally elevated. Troponin I levels range from 2.4-2.8ng/dL,
normal range is below .2ng/dL. Troponin T levels range from 2.1-2.7ng/dL, normal levels are
below.03ng/dL.. Another cardiac biomarker that was elevated is CPK-MB, which ranged from
55-75U/L.
How labs relate to Disease
Patient M.Ks elevated troponin I & T levels are indicative of a heart attack. Elevated levels
indicate damage to the heart as these proteins found in the heart muscles are released into the
blood when myocardial damage has occurred. After a myocardial infarction, a rise is results are
typical after several hours and can remain elevated 10- 14 days after the cardiac event
(Troponin). This is shown in patient M.K as evidence by his elevated troponin levels from day
two to day three of admittance. This lab result also has implications for cardiomyopathy and
kidney disease. Another cardiac biomarker of this patient is elevated CPK-MB levels. Elevated
levels, distinguish heart muscle damage from skeletal damage.
Cardiac damage may present with noncardiac symptoms like hepatic dysfunction. In this
patient, liver dysfunction is suggested from their abnormally high ALT and AST levels. The

MNT Case Study Myocardial Infarction

mechanism by which liver dysfunction results from cardiac diseases involves the decrease in
cardiac output from myocardial damage, which can lead to hepatocellular necrosis. A study
published in the Journal of Angiology suggest that hepatic dysfunction due to cardiac diseases is
associated with the development of congestive hepatomegaly. The study also concludes that
bilirubin levels will be elevated with impaired hepatic function due to reduced cardiac output
(Alvarez, Mukherjee, 2011). This information calls to question whether patient M.K is in fact
experiencing hepatic dysfunction because he only has elevated ALT and AST levels while
maintaining normal bilirubin levels.
Evidence has shown the role LDL cholesterol plays in atherosclerosis and myocardial
infarction. Evidence shows a positive correlation between elevated LDL levels and increase risk
for atherosclerosis and myocardial infarction. People with low LDL cholesterol levels are found
to have minimal atherosclerosis, whereas people with high LDL cholesterol levels are found to
lead to atherosclerosis (Nabel, Braunwald 2012 ). Interestingly, Brown and Golsteins discovered
genetic cause for myocardial infarction. It is found that people with family history of
hypercholesterolemia are prone to develop atherosclerosis. It is shown that statins lower LDL
cholesterol levels in the blood, which reduces the risk of myocardial infarction (Brown,
Goldstein 1986). This evidence shows the relationship between dyslipidemia and myocardia
infarction in patient M.K as well as incorporates his family history implications on the disease.
Analysis of Diet
Analysis of 24-Hour Recall
This patients 24 hour recall provides insight to his heart condition and weight status. First, his
total intake is well above his calorie needs at 2,766calories. Within those calories, his distribution
of nutrition can use improvement, but does have some positive aspects. The TLC dietary

MNT Case Study Myocardial Infarction

guidelines recommend daily fiber intake of 20-30g, which aligns well with M.Ls diet intake of
26g. His total fat intake is above desirable at 35%, with total saturated fat above the ideal amount
at 11% of kcals. His protein is within range at 19% as well as carbohydrates at 47%. Because
there was presence of ketones in the urea I would suggest increasing carbohydrates. One aspect
of this 24 hour recall that needs attention in the sodium intake. His sodium intake is well above
the recommendation at 2,300mg/day at 4,395mg/day! This will be one aspect of his diet that will
need intervention and possible coordination with his wife, who makes the food, to decrease
sodium use while preparing food. This may be challenging in maintain the foods appeal and
palatability but will be discussed further in the intervention section.
Estimated Needs
To calculate total calorie needs I chose to use the Harris benedict equation to account for his
age and activity level. The calculations are as follows: 66.5 + (13.8*84.09kg) + (5*177.8cm)(6.76*61)= 1703kcal. 1703kcal * 1.2 activity factor= 2,044kcal
This results in a total calorie need of 2,044kcals per day. There was no addition kcals subtracted
to promote weight loss at this time, as that would only provide 1,544kcal/day and would not
provide enough nutrients to recover from his myocardial injury. Also, the new prescribed kcals of
2,044 is already a 722kcal deficit from his usual 2,766kcal intake. The TLC diet recommends
15% total kcals from protein, however the Nutrition Care Manual recommends high protein
following a myocardial infarction. I decided to combine the two recommendations and provide
the patient with 17% protein to promote weight loss and recovery from myocardial injury.
Protein requirements at 17% come out to 347kcals and 86g. Total fat intake will be estimated at
28%, which accounts for 575kcals and 64g.Total carbohydrate intake recommendation is 55%
which accounts for 1130kcals and 282g. Because the patients urinalysis presented with clear

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10

appearance and no evidence of fluid retention such as ascites, I decided to provide the
recommended 30mL/kg of fluid. This accounts for 2,520ml or 10 cups. The Nutrition Care
Manual recommends 35mL/kg which would account for about 12cups of water which I thought
would be too much for this patient to consume since he is currently adequately hydrated as seen
in his urinalysis.
Pros and Cons
There are strengthens in the 24 hour recall. First, does consume 2% milk, which is much
better for his health than whole milk as 2% has less saturated fat. In addition, he also does
consume some fruits and vegetables. He also does not consume sweetened beverages or fried
foods. Some weaknesses in the diet are his high sodium and saturated fat consumption. Another
weakness in the diet is the high overall calorie intake as well as low vitamin D and E
consumption. To conclude weaknesses in the diet, missing breakfast is an important aspect of the
diet that can be modified to decrease hunger and aid in lower calorie consumption throughout the
day.
Dietary Instruction Provided
After slowing progressing the patient from clear liquids to solid foods, I would provide him
with dietary guidelines to follow while at home. The Nutrition Care Manual suggests a weight
loss diet that is high in protein and low in carbohydrates. This recommendations conflicts the
TLC diet recommendation for low protein, but is consistent on the weight loss diet. Because of
the patients overweight status and presence of ketones in the urea on the first day at the hospital,
I am going to provide a weight loss diet which is not too high in protein at 17% with a moderate
amount of carbohydrates at 55% of the total kcal. Another reason for the weight loss diet is
because of its association with improvement in lipid profiles, which is necessary for this patients

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11

recovery and prevention from another myocardial infarction. This will leave total fat intake at
28%. Saturated fat intake and cholesterol will be lowered to the goal of <6% total intake to
lower serum lipid levels. I will encourage the patient to continue consuming their favorite
beverage which is 2% milk. In addition, to improve their sodium intake I will instruct the patient
to consume homemade soup instead of canned, if possible, as that will significantly improve
sodium consumption.
Nutrition Care Process
PES Statements
1. Less than optimal intake of saturated fat related to large servings of animal protein as
evidence by 24 hour recall and saturated fat representing 11% of calories as compared to
references values: total saturated fat <6% of total kcal
2. Excessive sodium intake related to intake of canned soup and high fat animal protein as
evidence by sodium intake <4395mg/day as compared to reference values: <2300mg/day
3. Physical inactivity related to busy work schedule as evidence by patient interview
Interventions
Excessive fat intake.
Abnormal lipid profile and saturated fat intake exceeding 6% of total calories supports the
need for decreased fat intake, specifically saturated fat. Intervention will focus on switching from
high fat animal protein to lean protein. I will begin this intervention by asking the patient what
their preferences are with protein sources, with his permission, I will also include his wife in the
discussion as she does the food preparation in their household.

Excessive sodium intake.

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Sodium intake exceeding 2300mg/day is a nutritional indicator for cardiovascular disease.

Intervention will focus on consumption of fresh soup instead of canned soup as well as
consumption of a low sodium diet in general. Education will be given on reading food labels to
recognize high sodium foods. Education will also be given on low sodium cooking to retain
palatability
Physical Inactivity.
Physical inactivity is associated with overweight and obesity, which is a risk factor for
myocardial infarction. Too increase physical activity in accordance with his individual needs,
post myocardial infarction, I will refer him out to a physical therapist. Increased physical activity
can aid in weight loss and increase the effectiveness of nutrition therapy on lipid profiles.
Patient Goals
1. Promote recovery and strength through diet modifications given by dietitian and
physical activity regimen given by physical therapist
2. Correct dyslipidemia through lowering saturated fat intake to promote lowering of low
density lipoprotein
Nutrition Prescription
1. Decrease saturated fat to account for <6% total kcals and bring total fat intake to 28% of
total kcals
2. Decrease consumption of high sodium foods and bring sodium intake to <2300mg/day
3. To promote weight reduction and recovery participation in physical activity regimen
prescribed by physical therapist

References
Alvarez, Mukherjee. (2011) Liver Abnormalities in cardiac Disease and Heart Failure.
International Journal of Angiology Vol.3 135-142

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Brown, M. S. and Goldstein, J. L. (1986), A Receptor-Mediated Pathway for Cholesterol

Homeostasis (Nobel Lecture). Angew. Chem. Int. Ed. Engl., 25: 583602.
doi:10.1002/anie.198605833
Can lifestyle modifications using theraputic lifestyle ... (n.d.). Retrieved November 8, 2016, from
http://www.cdc.gov/nutrition/downloads/R2P_life_change.pdf
Flock., Green., Etherton. (2011) Effects of Adiposity on Plasma Lipid Response to Reductions in
Dietary Saturated Fatty Acids and Cholesterol. Advances in Nutrition Vol 2, 261-274
Fuller MD., Alemu MD., Harper MD., Feldman MD. (2009) Relation of Nausea and Vomiting in
Acute Myocardial Infarction to Location of the Infarct, The American Journal of
Cardiology Vol 104, Issue 12 1638-1640
Horn., McCoin., Etherton., urke., Carson., Champagne., Karmally., Sikand. (2008) The Evidence
for Dietary Prevention and Treatment of Cardiovascular Disease. Journal of the
Academy of

Nutrition and Dietetics Vol. 108, Issue 2, 287-331

How Is a Heart Attack Diagnosed? - NHLBI, NIH. (n.d.). Retrieved October 10, 2016, from
https://www.nhlbi.nih.gov/health/health-topics/topics/heartattack/diagnosis
Lewine, (2013). Heart attack (Myocardial Infarction). In HarvardMedicalSchool, Harvard
Medical School Health Topics A-Z. Boston, MA: Harvard Health Publications.
Nabel., Braunwald (2012) A Tale of Coronary Artery Disease and Myocardioal Infarction New
England Journal of Medicine. Vol 366 No.1 54-63
Nahikian-Nelms, M. (2011). Nutrition therapy and pathophysiology. Belmont, CA: Wadsworth,
Cengage Learning.
Troponin. (n.d.). Retrieved November 08, 2016, from
https://labtestsonline.org/understanding/analytes/troponin/tab/test

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What Are the Symptoms of a Heart Attack? - NHLBI, NIH. (n.d.). Retrieved October 10, 2016,
from https://www.nhlbi.nih.gov/health/health-topics/topics/heartattack/signs
Nahikian-Nelms, M., & Roth, S. L. (2014). Medical nutrition therapy: A case study approach.
Stamford, CT: Cengage Learning.