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Myocardial Infarction
Molly Chaffin Denielle Saitta Claire Holladay Lauren Mitchell Karly Childress

What is a myocardial infarction?

A heart attack occurs when blood flow to the heart muscle is decreased or blocked completely, keeping the heart from getting enough oxygen, which can damage or destroy part of the heart muscle.
Heart attacks are most often caused by the buildup of plaque in the arteries that lead to the heart. Plaque is the accumulation of calcium and fatty acids such as cholesterol and triglyceride.

What are the symptoms?

Most

common warning symptoms of a heart attack:

Chest pain or discomfort Upper body discomfort Shortness of breath

Other

possible symptoms of a heart attack include:

Breaking out in a cold sweat Feeling unusually tired for no reason, sometimes for days (especially if you are a woman) Nausea and vomiting Light-headedness or sudden dizziness

What is angioplasty?

Angioplasty is a nonsurgical procedure to open narrowed or blocked coronary arteries that supply blood to the heart. A coronary artery stent is a small, metal mesh tube with a balloon that expands inside a coronary artery which is placed during or after an angioplasty. The stent helps prevent blockages in the artery in the future.

+ Meet James Klosterman

Client History (CH)

Personal

History

61 y.o. male Occupation: Lutheran Minister Marital Status: Married, with grown children Tobacco use: 1 ppd for 40 years Alcohol use: 1 glass of wine per day

Patient

Medical History

Brought to emergency room by his wife after having severe chest pain returning home from work. He described having pressure-like pain radiating to his jaw and left arm and had an episode of emesis and nausea

Client History (CH)

Medical

History cont

Surgical History: Appendectomy Cholecystectomy (10 years prior) Allergies: none

Family

History

Father: Coronary Artery Disease; MI age 59

Client History (CH)

Treatments/

Therapy Alternative Medicine

Surgical treatment Diagnosed as myocardial infarction Angioplasty of distal right coronary artery Stent placement to stabilize patient

Anthropometric Measurements (AD)

Height:
Weight: BMI:

5 feet 10 inches
185 pounds

26.6 kg/m2 Weight Loss: N/A

Unplanned

Nutrition-Focused Physical Findings (PD)

Overall Appearance

Slightly overweight, pale, distressed

Nerves

and Cognition

Alert and focused

Vital

Signs

Temp: 98.4 BP: 118/78 Pulse: 92 bpm Respiratory rate: 20 bpm

Biochemical Data, Medical Tests and Procedures (BD)

Day 1 20 L Day 2 24 Day 3 26 Ref. Range 23-30

Chemistry Carbon Dioxide (CO2, mEq/L)

Glucose (mg/dL)
ALT (U/L) AST (U/L) CPK (U/L) CPK-MB (U/L) Lactate Dehydrogenase (U/L)

136 H
30 25 75 0 325

106
215 H 245 H 500 H 75 H 685 H

104
185 H 175 H 335 H 55 H 365

70-110
4-36 0-35 55-170 (M) 0 208-378

Biochemical Data, Medical Tests and Procedures (BD)

Day 1 2.4 H 2.1 H 235 H Day 2 2.8 H 2.7 H 226 H 32 L 150 H 4.7 H 80 L 110 12.6 214 H 33 L 141 H 4.3 H 98 105 12.4 Day 3 Ref. Range <0.2 <0.03 120-199 > 45 (M) <130 <3.55 (M) 94-178 (M) 63-133 (M) 12.4-14.4

Chemistry Troponin I (ng/dL) Troponin T (ng/dL Cholesterol (mg/dL)

HDL-C (mg/dL) 30 L LDL-C (mg/dL) LDL/HDL ratio Apo A (mg/dL) Apo B (mg/dL) PT (sec) 160 H 5.3 H 72 L 115 12.6

Food and Nutrition-Related History (FH): Food and Nutrient Intake

Drug-Nutrient

Interactions
Lisinopril Blood Pressure Nitro-Bid Chest Pain Vasodilator Avoid alcohol NTG Chest Pain Vasodilator Avoid alcohol Aspirin Blood thinner COX inhibitor Vitamin K affects thickness of blood, Calcium decreases absorption

Lopressor Purpose Mechanism Nutritional Interaction Blood Pressure

Beta blocker ACE inhibitor Calcium interferes with absorption, avoid licorice Avoid high potassium

Unclear as to why Mr. Klosterman was not prescribed a statin drug

Food and Nutrition-Related History (FH): Food and Nutrient Intake

Previous nutrition therapy:

Year prior with community dietitian

Hospital medical treatment:

Nitroglycerin and morphine until pain recession IV Heparin: 5000 bolus units; 1,000 unit/hr continuous infusion Chewable aspirin: 160 mg continued daily Lopressor: 50mg twice daily Lidocaine: as needed

Current dietary prescription:

Pre-surgery: NPO Post-surgery: High protein (1g/kg body weight) Low saturated fat (5-6%) Moderate cholesterol

New guidelines supported by AHA suggest no specific limit for dietary cholesterol

Food and Nutrition-Related History (FH): Food and Nutrient Intake

24

hour recall:
None 1 large cinnamon raisin bagel 1 tbsp fat-free cream cheese 8 oz orange juice coffee 1 cup canned vegetable beef soup Sandwich (4oz roast beef, lettuce, tomato, dill pickles, 2 tsp mayonnaise) 1 small apple 8 oz 2% milk 2 lean pork chops (3 oz each) 1 large baked potato (2 tbsp margarine) cup green beans cup coleslaw 1 slice apple pie 1 oz pretzels 8 oz 2% milk

Breakfast Morning snack

Lunch

Dinner

Snack

Mid-Morning Snack
Carbohydrate (g) 60g Protein (g) (0-12)g Fat (g) (0-4)g Calories 320

Food List Large Cinnamon Raisin Bagel (4 carb exchanges) 1 tbsp fat free cream cheese (1 free exchange) 8 oz orange juice (2 fruit carb exchange) coffee TOTAL

30g

120

90g

0-12g

0-4g

=440

Lunch
Carbohydrate (g) 15g Protein (g) (0-3)g Fat (g) (0-1)g Calories 80

Food List 1 c. canned vegetable beef (1 carb exchange) Sandwich

bread (2 carb) 4oz roast beef lettuce, tomato, pickels 2 tsp mayo

30g
30g

28-34g
(0-6)g 28g

10-15g
(0-1)g (0-4)g

434
160 184

10g

90

1 small apple (1 15g fruit exchange)

60

8 oz 2% milk
TOTAL

12g
72g

8g
36-45g

5g
15-21g

120
=694

Dinner
Carbohydrate (g) Protein (g) 42g Fat (g) (0-18)g Calories 600

Food List
2 lean pork chops (6 meat exchanges) Large baked potato (4 starch exchange) cup green beans (2 low carb exchanges) cup coleslaw (1 carb + 1.5 fat exchanges)

60g

(0-12)g

(0-4)g

320

10g

4g

50

15g

(0-3)g

7.5g

147.5

1 slice apple pie (3 carb + 1 fat exchange)

45g

(0-9)g

(5-6)g

285

TOTAL

130g

46-70g

12.5-35.5g

=1,402.5

Snacks

Food List

Carbohydrate (g)

Protein (g)

Fat (g)

Calories

1oz pretzels (1.25 carb exchange)

8 oz 2% milk (1 milk exchange) TOTAL

18.75 g

(0-3.75)g

(0-1.25)g

100

12g

8g

5g

120

30.75g

8-11.75g

5-6.25g

=220

Food and Nutrition-Related History (FH): Food and Nutrient Intake

Current dietary intake (according to online nutrition database)

Dietary Intake (according to food exchange list)

Calories= 2,201 Carbs = 280 g (54% )

Calories = 2,756.5 Carbs = 322.75 g Protein = 90-138.75 g Fat = 65-66.75 g

Protein = 106 g (19%)

Fat = 89 g (36%)

Sat. Fat 12% = 30 g (rec. <56%)

Fiber 19 g (recommended 30g) Sodium 5,064 mg (recommended < 1,500mg)

Food and Nutrition-Related History (FH): Food and Nutrient Intake

History:

Appetite good Recent diet changes Corn oil instead of butter Less fried foods

Food Allergies: Physical

none

Activity

15 minute walk dailywalking dog, leisurely pace

Comparative Standards (CS):

Resting

Energy Requirements (using Mifflin St. Jeor)

REE= (10 * 84kg) + (6.25 * 178cm) (5 * 61yr) + 5 = 1,652 kcal

Total

Energy Requirements

Normal activity factor: 1.4 (low activity) 1,652 kcal/day x 1.4 = 2,313 kcal/day Hospitalized factor: 1.2 (surgery) 1,652 kcal/day x 1.2 = 1,982 kcal/day

Comparative Standards (CS):

Macronutrient
Normal

needs

protein needs (67-84 g/day) 84 kg x 0.8-1.0= 67.2-84 g protein/day Post-op protein needs (84-126 g/day) 84 kg x 1.0-1.5= 84-126 g protein/day

Nutrition Diagnoses
PES

#1:

Altered nutrition-related laboratory values related to high saturated fat diet as evidenced by total cholesterol >200mg/dL, HDL <45mg/dL, and LDL >130mg/dL

PES

#2:

Physical inactivity related to sedentary lifestyle as evidenced by only walking 15 minutes each day

Nutrition Intervention

PES #1: Altered nutrition-related laboratory values related to high saturated fat diet as evidenced by total cholesterol >200 mg/dL, HDL <45 mg/dL, and LDL >130 mg/dL
Nutrition Rx: Modify diet to consume less than 5-6% of daily calories from saturated fats; this translates to between 99.1-118.92 calories from saturated fat or 16 grams of saturated fat per day for Mr. Klosterman Nutrition Intervention: This can be done by decreasing dietary consumption of saturated fats by choosing a lower fat milk option. Provide nutrition education to promote healthy cooking and appropriate portion sizes. Also, continue to replace butter with oil when cooking and reduce fried foods. Participate in the DASH diet to reduce sodium intake and have a better heart healthy diet and help reduce BMI.

Nutrition Intervention

PES #2 Physical inactivity related to sedentary lifestyle as evidenced by only walking 15 minutes each day
Nutrition Rx: Increase physical activity to 150 minutes per week of moderate intensity physical activity.

Nutrition intervention: From Nutrition Care Manual, increase walking to 30 minute per day, five or more times per week. Discuss other options for physical activity to decrease sedentary time. Gradually increase daily activity time to walking the dog for 30 minutes twice daily two times per week. Also, meet with a personal trainer to set and achieve specific goals.

Monitoring and Evaluation

Evaluate the effectiveness of the nutrition interventions in meeting the nutrition goals
Monitor the patients Cholesterol (>200mg/dL), HDL (<45 mg/dL) and LDL (>130 mg/dL) levels for changes through laboratory values Monitor Anthropometrics by checking weight, BMI, and waist circumference Have patient keep track of a food diary so dietary intake can be monitored Monitor his daily physical activity to see an increase from only walking 15 minutes per day Monitor the patients progress in his cardiac rehab program Monitor the patients progress in cessation of smoking

ADIME Notes

Client History (CH):

Age 61

Gender Male

Race/Ethnicity White

Living/housing situation- living with wife Smokes 1 PPD Dx: Myocardial Infarction s/p angioplasty

ADIME Notes, cont.

Food- and Nutrition- Related History (FH):

Meal type: clear liquids, no caffeine History: Appetite good. Has been trying to change diet. Wife indicates that she has been using corn oil instead of butter and has tried not to fry foods as often. 24-hour recall: Breakfast- none Midmorning snack- 1 large cinnamom rasiin bagel with 1 tbsp. fat-free cream cheese, 8 oz orange juice, coffee Lunch- 1 c canned vegetable beef soup, sandwich with 4 oz roast beef, lettuce, tomato, dill pickles, 2 tsp mayonnaise, 1 small apple, 8 oz 2% milk Dinner:- 2 lean pork chops (3 oz each), 1 large baked potato, 2 tsp margarine, c green beans, c coleslaw (cabbage with 1 tbsp. salad dressing), 1 slice apple pie Snack- 8 oz 2% milk 1 oz pretzels Food allergies/intolerances/aversions: none Previous nutrition therapy? Yes, last year with community dietation Food purchase/ preparation: spouse Vitamin/mineral intake: none

ADIME Notes, cont.

Anthropetric Data (AD):

Height and Weight: 510 and 185 pounds: BMI: 26.6 kg/m2
Cholesterol214mg/dL HDL 30mg/dL LDL 141mg/dL VLDL 40mg/dL HDL/LDL ratio 4.8 ApoA 98mg/dL

Biochemical Data (BD):

Physical Findings (PD):

Vital signs Blood Pressure 118/78 mm Hg Temperature 98.4 F Pulse 92 bpm Respiratory rate 20 bpm

Comparative Standards (CS):

Total Energy estimated needs: 2300 calories Total Protein estimated needs: 67.2 84 g protein/day Total Fat estimated needs: 25-35%

ADIME Notes, cont.

Diagnosis:

PES #1: Altered nutrition-related laboratory values related to high saturated fat diet as evidenced by total cholesterol >200mg/dL, HDL <45mg/dL, and LDL >130mg/dL PES #2: Physical inactivity related to sedentary lifestyle as evidenced by only walking 15 minutes each day

ADIME Notes, cont

Intervention PES #1:

Nutrition Rx: Modify diet to consume less than 5-6% of daily calories from saturated fats; this translates to less than 162 calories or 18 grams of fat for Mr. Klosterman. Nutrition intervention: This can be done by decreasing dietary consumption of saturated fats by choosing a lower fat milk option. Provide nutrition education to promote healthy cooking and appropriate portion sizes. Also, continue to replace butter with oil when cooking and reduce fried foods. Participate in the DASH diet to reduce sodium intake and have a better heart healthy diet and help reduce BMI.

PES #2:

Nutrition Rx: Increase physical activity to 150 minutes per week of moderate intensity physical activity (1).
Nutrition intervention: Increase walking to 30 minute per day, five or more times per week. Discuss other options for physical activity to decrease sedentary time. Gradually increase daily activity time to add up to 300 minutes per week until healthy weight is reached.

References

Nahikian-Nelms, Marcia, and Sara Long. Roth. Medical Nutrition Therapy: A Case Study Approach. Belmont, CA: Wadsworth/Thomson Learning, 4th ed., copyright 2014. Print.
Internet Resources

American Heart Association: http://www.heart.org/

Academy of Nutrition and Dietetics: http://www.eatright.org Nutrition Care Manual: http://www.nutritioncaremanual.org National Heart, Lung, and Blood Institute: http://www.nhlbi.nih.gov/health/health-topics/topics/heartattack/