Myocardial Infarction

Ischemic necrosis

of part of the heart

muscle.

Daniel Lewis, Ariel Lebert, Courtney Kousser, Sarah Fecco11/28/2012

Mr. Klosterman

• Symptoms: Sudden onset of severe precordial pain

• Medical Diagnosis: Myocardial Infarction

• Medical Treatment: Emergency Angioplasty

Physical Findings @ 1354 3/25

• 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

Client History (CH)

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

Anthropometric Data (AD)

• 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

Biochemical Data

Day One Day Two Day Three Optimal Values

Total Cholesterol 235 mg/dl H 226 mg/dl H

214 mg/dl H <200 mg/dl

LDL-C 160 mg/dl H 150 mg/dl H

141 mg/dl H <100 mg/dl

HDL-C 30 mg/dl L 32 mg/dl L 33 mg/dl L >/= 60 mg/dl

LDL-C/HDL-C ratio 5.3 H 4.7 H 4.3 H < 3.55

CPK 0 u/l 75 u/l H 55 u/l H 0 u/l

ALT 30 u/l 215 u/l H 185 u/l H 4-36 u/l

AST 25 u/l 245 u/l H 175 u/l H 0-35 u/l

LDH 325 u/l 685 u/l H 365 u/l 208-375 u/l

Troponin I 2.4 ng/ml H 2.8 ng/ml H -- < 0.2 ng/ml

Troponin T 2.1 ng/ml H 2.7 ng/ml H -- < 0.03 ng/ml

Biochemical Data Interpretation

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

Medications

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 cont…

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 acid—aspirin) 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 & Dietary Supplements

Medication Possible Food-Nutrient Interactions

Lopressor 50 mg daily Avoid natural licorice. Take 2 hours before or 6 hours after calcium supplements and/or fortified orange juice. Calcium salts may decrease absorption.

Lisinopril 10 mg daily Avoid salt substitutes. Caution with K and Mg supplements. Decreased Na and Ca may be recommended.

Nitro-Bid 9.0 mg twice daily Avoid alcohol. May result in dangerously low blood pressure.

NTG 0.4 mg sl prn chest pain Avoid alcohol.

ASA 81 mg daily (acetylsalicylic acid-aspirin)

Taking with food can decrease absorption and diminish drug effects.

Lipitor 10 mg daily Avoid grapefruit juice- increase risk of toxicity. Fibers such as oat bran and pectin may diminish drug effect.

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, ½ c green beans, ½ 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, ½ c

green beans, ½ 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, ½ c

green beans, ½ 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

Intake Analysis (NutriCalc)

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

Comparative Standards

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

Intake Problems

• 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)

Other Possible 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

Diagnoses

• 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.

Prescriptions

• Reduction in total cholesterol (<200) and LDL-cholesterol (<100); Increase in HDL-cholesterol (>60).

• Increase amount of physical activity to 30 minutes/day minimum.

Interventions

• 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)

Nutritional Therapy

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

TLC: Nutrient Composition

Nutrient Recommended Intake

Saturated Fat Less than 7% of total kcal

Polyunsaturated fat Up to 10% of total kcal

Monounsaturated fat Up to 20% of total kcal

Total Fat 25-35% of total kcal

Cholesterol <200mg/day

Fiber 20-30g/day

Protein Approx. 15% of total kcal

Sodium <2400 mg/day

Stanol esters 3-4 g/day

TLC: Foods to Eat More

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 Choose Less

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: Weight Reduction

Self-Monitor• Record weight, BMI & waist circumference

Gradual weight loss• Goal: lose 10% of body weight in 6 months• Lose ½ to 1 lb per week

Increase Physical Activity• Make PA part of daily routines and recreational activities

Cardiac Rehabilitation

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

Monitoring & Evaluation

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?

ADIME

Domain 1Medication: 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 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, ½ c green

beans, ½ 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 HLDL: 150 mg/dl HHDL: 32 mg/dl LLDL/HDL: 4.7 HTroponin I: 2.8 ng/ml HTroponin T: 2.7 ng/ml HALT: 215 u/l H AST: 245 u/l HLDH: 685 u/l HCPK: 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 5Smokes (1 pack/day) for 40 yearsPatient Hx:

Emphysema/lung problems Angina/chest pain

Family Hx: CAD (Father) – MI age 59Cancer (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 (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)

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?

References

• 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/

Questions?