CVD HTN Case Study

Understanding the Disease and Pathophysiology

3. Hypertension is persistently high arterial blood pressure. Essential HTN is when there is no
single known cause, usually due to poor life style choices or gene expression. The etiology like I
said, could be poor life style choices (high intake of sodium, low amounts of f/v, smoking,
physical inactivity, stress, obesity, etc.) or gene expression
4. Common symptoms of essential hypertension include frequent headaches, impaired vision,
SOB, nosebleeds, chest pain, dizziness, failing memory, snoring and sleep apnea, and GI
distress.
6. Risk factors for developing hypertension include: dietary high salt/processed food/ fat intake
along with low intake of fruits and vegetables, PUFAs, and omega-3’s; lifestyle: obesity,
physical inactivity, alcohol use, smoking; Metabolic: LDL cholesterol, high BP and glucose
concentrations, also age, race, family hx, being overweight, and physical inactivity. The risk
factors currently pertaining to Mrs. Moore are that she has 2-4 drinks a week, eats out with
husband Friday and Saturday nights meaning she consumes high amounts of sodium and
saturated fat from high kcal foods. Her mother also had HTN and died due to MI related to
uncontrolled HTN.
7. The four major modes of treatment for HTN are: dietary, lifestyle, metabolic, pharmaceutical
(drug) First I would use dietary measures to reduce heath risks and lower weight. This includes:
reduce caloric intake, reduce portions of highly processed foods, increase MUFA, fiber,
fruit/vegetable, micronutrients, plant proteins, adopting DASH or Mediterranean dietary pattern.
For lifestyle alcohol use can be lowered and smoking should stop. With a better diet the
metabolic risk factors will be reduced (better LDL-C, BP, and lower blood glucose). If the
dietary pattern and nutrition therapy doesn’t work I would then resort to pharmacological
interventions (loop diuretics, thiazides, etc.)
8. Metabolic syndrome is an array of conditions that occur together to increase one’s risk of
heart disease, stroke, and diabetes. Have to have 3 of the conditions to be diagnosed.

9. Factors that are pertinent for determining Mrs. Moore’s coronary heart disease risk category
found in her medical and social history are that she drinks 2-4 times per week, eats out 2 nights a
week, has attempted to follow a low sodium diet but gave up on it due to food being too bland,
she is African-American, and sometimes resorts to fast food/ high sugar foods late at night after
skipping dinner due to her volunteer work. Her mother also died of uncontrolled HTN.
10. Hypertension is a disease that is part of a larger group of interrelated CVD diseases. Possible
complications of uncontrolled or untreated HTN include: organ damage, heart failure, stroke,
CKD, retinopathy, atherosclerosis, stroke, renal failure, and MI.
II. Understanding the Nutrition Therapy
13. Dietary sodium is positively associated with blood pressure, and ecological and animal
studies both have suggested that high dietary sodium intake increases stroke mortality. In the
result section of this study, overweight individuals had increased risk of cardiovascular disease,
but dietary sodium intake was not significantly associated w/ cardiovascular disease risks in non-
overweight persons.
https://jamanetwork.com/journals/jama/fullarticle/192154

14. The Mediterranean diet consists of eating primarily plant-based foods: fruits, veggies, whole
grains, legumes, and nuts; replacing “unhealthy fats with better options like olive oil; using herbs
and spices in place of salt; having red meat very sparingly; eating fish and poultry at least 2x a
week; and drinking red wine in moderation (optimal).
15. Life style modifications that have been shown to lower BP include: reducing caloric intake,
increasing MUFA/PUFA, fiber, and macronutrients; reducing intake of highly processed foods,
sodium, saturated fats; adopting the DASH or Mediterranean diet pattern; adding physical
activity; cutting out smoking and consumption of large amounts of alcohol.
III. Nutrition Assessment
16. Mrs. Moore’s BMI is 25.8 suggesting that she is slightly overweight. Since she is
overweight her risk factors go up for CVDs so weight loss would be critical for normalizing risk
factors.

17. Calculate Mrs. Moore’s energy and protein requirements.

 Recommended kcal intake: 1500-1800 kcal/kg BW (20-25 kcal/kg BW)
Recommended protein intake: 58-72 g/kg BW (.8-1.0)

18. Major sources of sodium: Campbell’s tomato bisque soup, diet soda, saltine crackers, salt
seasoning, butter, buttered popcorn. Major sources of fat: margarine, glazed donut, butter, ranch
dressing *also consumes a large amount of added sugar. She should up her fruits by 3-4 servings
since she doesn’t consume a lot normally, she should also up her grains and veggies by 1-2
servings per day. She should cut out the extra salt, sugar, and fat
19. Tools I would use to asses her diet would be a food diary/log with a 24-hour log included
and energy and micronutrient tracker.
 20. Excessive energy, fat, protein, CHO intake; Inadequate fiber, mineral (potassium, calcium,
zinc) intake
21. Dr. Evans ordered the laboratory tests listed in the following table. Complete the table with
Mrs. Moore’s values from 6/25 and the potential cause of any abnormalities.
Parameter Normal Value Pt’s Value Reason for Abnormality
Glucose 70-99 mg/dL 101 High sugar and CHO intake
BUN 6-20 mg/dL 20 High protein
Creatinine 0.6-1.1 mg/dL 0.9 WNL (could indicate kidney
issue)
Total cholesterol <200 mg/dL 270 High fat and animal protein
intake
HDL- cholesterol >59 mg/dL 30 Physical inactivity and
overweight
LDL- cholesterol <130 mg/dL 210 Consumption of foods high in
saturated fats and cholesterol
Apo A 80-175 mg/dL 75 Due to low HDL concentrations
Apo B 45-120 mg/dL 140 High fat consumption and higher
concentrations of LDL in blood
Triglycerides 35-135 mg/dL 150 High consumption of fats, being
overweight

23. From 6/25 to 3/15 Mrs. Moore lowered her cholesterol, LDL-C, and raised her HDL-C. She
also put her Apo A, B, and triglycerides WNL. Factors that could have had an impact on this is
that she began a walking program resulting in a 10# weight loss that she has been able to keep
off and she quit smoking cold turkey when she was diagnosed.

24. Indicate the pharmacological differences among the antihypertensive agents listed below.
Medications Mechanism of Action
Diuretics Lowers blood volume by
increasing urine output;
inhibits sodium and water
reabsorption
Beta-blockers Blocks beta-receptors which
decrees heart rate and
cardiac output
Calcium-channel blockers Blocks movement of
calcium, reduces blood
Nutritional Side Effects and
Contraindications
Constipation, diarrhea, anorexia,
hypokalemia, hyperlipidemia,
hypercholesterolemia
Gas, bloating, upset stomach,
nausea, diarrhea, dry mouth,
stomach pain, heartburn
Heartburn, edema, nausea
 vessels to relax further
causing vasoconstriction
ACE inhibitors Acts as a vasodilator, Hypotension, hyperkalemia,
lowering blood pressure, dysgeusia
interfering with the
production of Angiotensin
II
Angiotensin II receptor They interfere with rennin- Increases in serum potassium, upset
blockers angiotensin system without stomach/pain, diarrhea, vomiting,
inhibiting the breakdown of dysgeusia
bradykinin
Alpha-adrenergic blockers Blocks the response to Dryness of mouth, vomiting,
sympathetic stimulation, diarrhea, nausea
reduces stroke volume

25. Hydrochlorothiazide inhibits absorption of sodium, chloride and potassium which causes a
fluid and electrolyte imbalance. It’s considered a diuretic and is used with edema; as a quick
solution to removing excess fluid from the body. Inhibition of potassium absorption can cause
dizziness, lightheadedness, and irregular heartbeats. It also can cause constipation, increase in
glucose, TG, Ca+, cholesterol, and uric acid levels.
26. The ACE inhibitor would reduce vascular resistance and increase cardiac output further
increasing her blood pressure. HMG-CoA reductase inhibitor works to prevent CVD by lowering
LDL cholesterol and raising HDL cholesterol
27. A possible nutrition problem would be she is overweight indicated by her high BMI
IV. Nutrition Diagnosis
28. Select two nutrition problems and complete the PES statement for each.
 Limited adherence to nutrition-related recommendations r/t poor food choices AEB 24-hr
recall and high cholesterol concentrations
 Excessive sodium and fat intake r/t high intake of commercially prepared and packages
foods AEB BP of 160/100 mm Hg, dietary history, and lab values
V. Nutrition Intervention
29. For Mrs. Moore, her ideal body weight would be 130 lbs. I would want to talk to her about
having a lower BMI to put her in a healthy range and then address further weight loss. I would
suggest that she tries to lose a pound per week as a reasonable goal. After a few weeks I would
want to follow up with her to check her progress and her mind set on her weight loss.
30. Goals would include her changing her negative outlook on her condition and changing her
life style to help her become healthier. I would want to educate and counsel her on why diet and
excessive is so important with her current health and why she needs to make a change, making
her aware of the negative outcomes if she doesn’t. Another goal would be for her to cut out high
fat foods she usually eats. I would educate her on the effects of a high fat diet on weight and
HTN and provide examples of food substitutes that would still taste great.
31. Major recommendation for Mrs. Moore would be to switch out coffee for green tea (less
antioxidant effects), use skim milk instead of 2% (cutting out fat), substitute soda for water,
suggest drinking a light beer or no alcohol, season with salt less seasonings (Mrs. Dash; to
reduce salt intake). Cut out any salt crackers, no added sugar or margarine (donut, veggies,
oatmeal), substitute ranch salad dressing for a vinaigrette or olive oil, and try low fat options of
sweets (ice cream) along with cutting down on amounts.
32. I would want to reevaluate Mrs. Moore in 3-4 weeks to check up on her progress with
lowering her lipid panel concentrations, on her eating pattern, and weight loss goals.
 ADIME Chart Note

Assessment: Pt, MM, 57 y/o African American, female, in for evaluation and treatment for Stage
2 (essential) hypertension and hyperlipidemia. Pt was diagnosed 1 year ago with treatment thus
far focused on nonpharmacological measures. Family hx: mother died of MI related to
uncontrolled HTN. Mrs. Moore began walking program 30 mins 4-5x week missing when she
volunteers, from this she has lost 10# that she has kept off. She has been educated by MD w/
nutrition information pamphlet outlining a low sodium diet and is familiar w/ the content due to
her prior practice as an RN. Mrs. Moore describes her appetite as “very good” doing a majority
of the grocery shopping and cooking, often binging on ice cream when home late. Pt and
husband usually eat out 2x week at pizza restaurants or steakhouses, where she usually consumes
2 glasses of wine or regular beers. Pt states that she and her husband have tried to comply with
the diet guidelines, but found food bland, soon abandoning the effort. Dx: heart disease, early
COPD (pt stopped smoking when HTN was diagnosed), R/O metabolic syndrome. Current
medication/supplements include: daily multivitamin/mineral; 25 mg hydrochlorothiazide daily;
2.5 mg Altace daily 1 week; 5 mg Altace daily 3 weeks and then 10 mg Altace daily thereafter;
evaluate for initiation of HMG-CoA reductase inhibitor therapy. All labs reviewed and noted. Pt
current consumes ~2300 kcal per day based off of her 24-hr recall.
Ht: 5’ 6”, Wt: 160#, BMI: 25.8 kg/m2, BP: 160/100, Weight loss of 10# over past year
Recommended kcal intake: 1500-1800 kcal/kg BW (20-25 kcal/kg BW)
Recommended protein intake: 58-72 g/kg BW (.8-1.0)
Diagnosis:
Limited adherence to nutrition-related recommendations r/t poor food choices and high intake of
commercially prepared and packages foods AEB BP of 160/100 mm Hg, 24-hr recall, and lab
values
Intervention:
RD recommends pt decrees kcal intake by 300 kcal per day, along with limiting sodium intake to
1500 mg daily.
RD provided education and counseling on the effects of a high fat and sodium diet on weight and
HTN with provided examples of food substitutes that would still taste great; and on why diet and
exercise is so important with her current health and why she needs to make a change, making her
aware of the negative outcomes if she doesn’t.
RD educated pt on the DASH diet eating pattern.
Monitor & Evaluation:
RD will monitor pt’s food choices and adherence to low sodium/fat diet by providing pt with
food log. RD will follow up with pt in 3 months when in for check-up to evaluate lab
concentration and diet adherence.
1-Day Meal Plan
AM: 1 c tea (of preference), 1 pack plain instant oatmeal w/ ½ c dried or fresh fruit, 1 c pure
squeezed orange juice
Snack: 2 c water or tea, 1 medium apple w/ 2 tbsp. peanut butter
Lunch: Veggie burger on whole wheat bun w/ mustard and veggies of choice, side salad w/
balsamic vinaigrette or olive oil (1-2 tbsp)—lettuce, spinach, croutons, sliced cucumbers
PM: 6 oz chicken (white meat, no skin; seasoned w/ McCormick salt-free seasoning blends or
Mrs. Dash, pepper, garlic), 1 c steamed carrots, ½ cup whole grain brown rice *seasoned w/ salt
free options, 1 c skim milk, 1 c tea
HS snack: 2 c air popped popcorn w/ a dash of olive oil and salt free seasoning (McCormick or
Mrs. Dash)