Cardiac Cachexia - from a Nursing Perspective
Preben Ulrich Pedersen, R.N., Ph.D., Bettina Rasmussen, R.N., Lene Hested, R.N.
The Heart Center, Copenhagen University Hospital, Rigshospitalet, Denmark
phone +45-3545-8320, fax +45-3545-2496, e-mail: prebenup@rh.dk
Learning Objectives
 To describe the role of the nurse in clinical nutrition
 To describe the factors of importance for nutritional intake
 To review the methods to assess the nutritional risk of the patient
 To review the most frequently experienced nursing problems regarding clinical nutrition
Introduction
Nutrition must be considered as of major importance in an individual’s treatment and thus
providing the basis for all other treatments, the success of which may depend almost entirely upon the nutritional status of the individual. The nurse’s role is primarily that of prevention, early detection, treatment and liaison with other members of a multi-disciplinary
team [1].
The imbalance between intake and requirements results in wasting of muscle, a negative
nitrogen balance and multi system dysfunction, ultimately promoting clinical complications
such as infection, poor wound healing and increased mortality [2]. The length of the rehabilitation is extended as the patient continues to lose weight, muscle tissue and performance status after discharge. During the last decade complications arising as a result of
malnutrition are considered to have increased hospital costs and costs for rehabilitation
after discharge [1].
Clinical malnutrition can result from a variety of reasons, such as the underlying medical
condition and treatment of the patient, inability to eat, and the lack of knowledge concerning recommended nutrients [3]. Regarding the health care institution poor mealtime routines, planning and assistance, lack of knowledge among the staff, the eating milieu and of
course the quality of the food prepared by the caterer are relevant factors.
High Quality Nursing
The primary concern in nursing is the delivery of services for the purpose of managing current health problems, preventing untoward conditions, and promoting proper functioning
and well-being. To be successful in achieving these goals, the nursing services should be
of the highest quality. Broadly, this can be defined as the delivery of care that results in the
best health outcome for the patient [4].
To benefit the patients’ health, the care planned and implemented by professionals should
be based on an adequate understanding of the patients’ problems. To comply with the
patients’ basic physiological needs by ensuring a sufficient diet during a hospital stay and
also after discharge from hospital requires a care given and advice that support the
patient’s own health promotion activities.
Patients that are activated positively to look after their health will choose activities three
months after discharge from hospital which are appropriate for their continued health [5]. In
this connection it means that during a hospital stay and after discharge at home the patient
preferably chooses food that is rich of energy and protein.
The main role for the nurse is therefore to prevent the occurrence of malnutrition during
the hospital stay and after discharge and by doing so preserve the patients’ functional level.
Nursing can not influence nutrient requirements, which are a function of the metabolic
stress or the disease, but nursing can deal with methods to optimize nutritional intake of
patients.
The patients’ intake of energy and protein can be increased passively either by a
supplement to the hospital diet with energy- and protein-enriched drinks, by tube feeding
or by a specially enriched hospital diet [6-9].
These methods may, however, supply the patient with the required amount of energy and
protein but do not deal directly with the reasons for the occurrence of malnutrition.
Another method is to actively involve the patient in his own nutritional care with the
perspective to avoid malnutrition and improve nutritional status of the patient not only
during the hospital stay but also after discharge. This method is based on fitting the
nursing actions to the actual situation and requires that the nurse is constanly assessing
and evaluating the daily care and that the nurse changes and chooses the method that will
most likely benefit the nutrition of the patient at the moment.
Activating Patients
Cumulative evidence from decades of research in education and other fields demonstrates
that the durability of cognitive and behavioural changes depends on the degree of active
rather than passive participation of the learner [10]. If the patient is given the responsibility
of and is encouraged to look after his own health then he becomes motivated to take
initiatives to solve his own problems as motivation is something that happens within the
person and not something that is done to the person [10].
The target is a constant personal development by availability of alternatives and selfdetermination [5]. This implies that patients are able to make an appropriate judgement of
their own situation and know how and what they can do to promote their health. Patient
motivation is increased if the institution creates the proper physical and psycho-social
frames which encourage the patient’s options to do this. To encourgae the patient to look
after his own health presupposes that the staff knows each patient well and that this
activation is based on the patient’s realisation of his own situation. Direct involvement is
obtained by guidance, teaching, information, assisting and observation of the patient [5].
Factors Influencing Patient Activities
Factors that influence health promotion activities for the patient may be categorized into
the following three main subjects [11]:
 The pre-disposing factors include a person’s knowledge, attitudes, beliefs, values and
perceptions that can facilitate or hinder motivation for change. In this context this
means adequate knowledge of patient regarding the appropriate food to eat during
illness and the influence of proper food on rehabilitation.
 The enabling factors are those skills, resources, or barriers that can help or hinder the
desired behavioural changes. It is a question of the patient’s options and ability to have
and to eat sufficient food. Thus, observations of the staff are necessary regarding the
patient’s eating skills, need for utensils and special diet, and the consistency (liquid,
solid, etc.) of the food.

The reinforcing factors deal with information from the staff, information and guidance of
the patients, the patient’s wishes as to the hospital environment, the routines in
connection with the meals in the ward and the social environment oft the department.
Daily Nursing Care
The nursing care comprises the following elements:
 Writing a nutritional chart based on the interview on admission and daily dialogue to be
available to all caregivers for consultation on the patient’s bed table. The nutritional
chart should specify: eating problems, eating habits, need for assistence at the meals,
figures on the patient’s requirements of energy and protein.
 Daily evaluation of the amount of food consumed during the past 24 hours based on
information given by the patient and/or staff. On this basis the nurse guides the patient
as to the proper composition of a sufficient diet for the coming 24 hours. Together they
plan the need for assistance during the mealtimes, counseling is given and the last 24
hours intervention is evaluated.
The Case
A 60 years old male living alone admitted with mitral valve incompetence. His heart disease has been increasingly symptomatic over a period of 5-7 years. In the same period
the patient has had an undesired weight loss of at least 15 kg. The last 6 months before
admission his functional level has decreased significantly.
Status on admission
Weight
Height
BMI
60,0 kg
1,75 m
19,6 cm²
Haemoglobine
Albumine
Leucocytes
Lymphocytes
6.1 mmol/l
585 µmol/l
10,0 GP/L
0,6 GP/L
normal: 8.4 – 11.0
normal: 600 – 830
normal: 3.0 – 9.0
normal: 0.7 – 4.8
Functional level
NYHA* class IV
Hardly able to perform basic Activities of Daily Living (ADLs)
* New York Heart Association classification of heart failure
Nutritional status
Very slim patient with thin upperarms and legs, low muscle
strength. Able to eat normal food, no difficulty with chewing or
swallowing. Can eat by himself. It is not possible to assess his
knowledge of proper food choices.
Medical management
Mitral valve replacement is considered necessary and
performed after a few days. After two weeks, myocardial
function does not recover and heart transplantation is
considered necessary and performed at week 4.
The postoperative period is complicated by various infections
(candidiasis of the oral mucosa and cytomegalovirus infection),
nausea, decreased appetite, weight loss of 6.6 kg, bedsores.
The patient was totally immobile for several weeks.
Nutritional intervention
Assessment of energy and protein requirement, daily food
record, assessment of eating difficulties, adequate nursing
assistance, counseling, intermittent tube-feeding, energy and
protein enriched food and sip-drinks.
Medication on day 70
Cyclosporine A
Azathioprine
Prednisolone
antithymocyte globuline
Cotrimoxazole
Ranitidine
Amphotericine B
Outcome:
150 mg
125 mg
15 mg
150 mg
400 mg
150 mg
15 ml
b.i.d.
q.i.d. by mouth
The patient was discarged after 6 months.
Weight 62 kg, NYHA II, able to perform all basic ADLs.
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Recommended Reading

Freeman LM, Roubenoff R. The nutritional implications of cardiac cachexia. Nut Rev 1994; 52: 340-7

Anker SD, Coats AJS. Cardiac Cachexia - A syndrome with impaired survival and immune and neuroendocrine
activation. Chest 1999; 115: 836-47

Anker SD, Rauchhaus M. Heart failure as a metabolic problem. Eur J Heart Fail 1999; 1: 127-131

Anker SD, Ponikowski P, Varney S, et al. Wasting as independent risk factor for mortality in chronic heart failure.
Lancet 1997; 349: 1050-3. Erratum in Lancet 1997; 349: 1258