Libby Sells
Professor Matuszak
KNH 411
5 September 2013
Case Study 5:Myocardial Infarction
I. Understanding the Disease and Pathophysiology
1.Mr. Klosterman has a myocardial infarction. Explain what happened to his heart.
a. A myocardial infarction is more commonly known as a heart attack. The heart needs its
own supply of oxygen in order to survive, and the coronary arteries are responsible for the task
of delivering oxygen to the heart. If one or both of these arteries become blocked, the heart
cannot get adequate oxygen; this is called an ischemia. If an ischemia continues to occur, cardiac
muscle begins to die due to lack of oxygen-this is a myocardial infarction.
i. From American Heart Association
2.Mr. Klosterman’s chest pain resolved after two sublingual NTG at 3-minute intervals and 2
mgm of IV morphine.In the cath lab he was found to have a totally occluded distal right coronary
artery and a 70% occlusion in the left circumflex coronary artery.The left anterior descending
was patent. Angioplasty of the distal right coronary artery resulted in a patent infarct-related
artery with near normal flow. A stent was left in place to stabilize the patient and limit infarct
size. Left ventricular ejection fraction was normal at 42% and a postero-basilar scar was present
with hypokinesis. Explain angioplasty and stent placement. What is the purpose of this medical
procedure?
a.In an angioplasty, arteries that are too narrow or blocked are opened up so that blood flow
to the heart is improved, and so cardiac cells can get the oxygen they need to survive. The
procedure is done by inserting a small balloon into the clogged part of the artery and then
blowing it up, thus opening up the artery. A stent (small, mesh tube) is then placed in the artery to
keep it open to prevent future clogging or narrowing of the arteries.
i. From American Heart Association
3.Mr. Klosterman and his wife are concerned about the future of his heart health. What role
does cardiac rehabilitation play in his return to normal activities and in determining his future
heart health?
a. Recommended by the American Heart Association, cardiac rehabilitation plays an
important role in recovery and the return f a patient to their normal lives. It includes important
components of exercise and education. Goals for the program are: regain strength and stamina,
prevent worsening of heart condition, and reduce future risk for cardiovascular complications.
Aspects of the program include nutritional counseling, monitored and controlled exercising, and
support and education about changes necessary to improve cardiac condition.
I. From the American Heart Association
II. Understanding the Nutrition Therapy
4.What risk factors indicated in his medical record can be addressed through nutrition
therapy?
a.Mr. Klosterman has high total cholesterol and LDL levels, as well as low HDL levels.This
lipid profile can end up in resulting in atherosclerotic development and heart disease. The patient
is also overweight as evidenced by his BMI of 26.6 kg/m^2. From high 24 hour recall, it can be
seen that he consumes a number of high fat, processed, and high sodium foods such as roast beef,
cream cheese, 2% milk, canned goods, and pretzels. While smoking and a family history of heart
disease are risk factors, they would not be part of his nutrition therapy but could be addressed.
5.What are the current recommendations for nutritional intake during a hospitalization
following a myocardial infarction?
a. Mr. Klosterman will be on an NPO, or nothing per orem diet until after his angioplasty.
This means he cannot consume any food or liquid. Following a myocardial infarction, areas of
dietary focus include sodium intake and saturated fat intake, which should be reduced.After
surgery, initial intake is limited to intake of clear liquids with no caffeine. This gradually
becomes a diet with soft, chewable foods and patient should start to following
the TLC or Therapeutic Lifestyle Changes diet. Some aspects of this diet include: limiting total
fat intake to 25-35% of total calories, limiting saturated fat to 7% of total calories, limit sodium
intake to less than 2400 mg/day,add 5-10 grams of fiber per day, consume less than 200 mg of
cholesterol per day, and increase physical activity.
i.From DHHS Guide to Lowering your Cholesterol with TLC
III Nutrition Assessment
6.What is the healthy weight range for an individual of Mr. Klosterman’s height?
a. Using the Hamwi method,106 lbs. for the first 5 ft of ht; add 6 lbs for every inch over 5
ft. for males, the patients recommended weight is 106 + [6(10))]=166 pounds. Using a BMI
chart, a healthy weight range for a 5’10 male is (149-183 pounds).
i. From Rush University Medical Center BMI Chart
7.The patient is a Lutheran minister. He does get some exercise daily. He walks his dog
outside for about 15 minutes at a leisurely pace. Calculate his energy and protein requirements
a.Using the Mifflin St. Jeor equation: Patient’s REE is about 1650 kcal per day. For weight,
185 lbs x .4536 kg=83.92 kg and height is 70 inches x 2.54 cm=177.8 cm. Plugging these
numbers into the formula:[(10W + 6.25H – 5A +5) or (10*83.92 kg + 6.25 * 177.8 cm – 5*61
+5)]=1650.4. REE is multiplied by 1.2 for a sedentary lifestyle. I chose a sedentary lifestyle over
a lightly active lifestyle, because walking a dog for 15 minutes is a hard activity to categorize,
but since patient is overweight anyway, airing on the side that would give a less caloric
requirement would be better, so 1650.4 x 1.2 =1980.5 or 1981 kcal. Often times, energy needs
increase after surgery. By using either a factor or 1.0 or 1.1 for post surgery caloric needs: 1980.5
x 1.0=1980.1 kcals or 1980.5 x 1.1=2178.6 kcals would give a range of about 1980 to 2179
kcals.
b. For his protein requirements, Mr. Klosterman should have been consuming 0.8 g per kg
of body weight or 0.8 g x 83.92 kg=67.1g or 67 g of protein. After surgery, 1.0 g protein per kg
of body weight is suggested because the extra protein is important for post-surgery wound
healing. So, 1.0 g x 83.92 kg=83.92g or 84 g of protein during recovery time after surgery.
8.Using Mr. Klosterman’s 24 hour recall, calculate the total number of calories he consumed as
well as the energy distribution of calories for protein, carbohydrate, and fat using the energy
exchange system.
a.Using FitDay, the patient’t 24 hour dietary recall was entered and analyzed.
According to the program, Mr. Klosterman consumed 2663 calories for the day.
When the percentage of calories from Mr. Klosterman’s diet analysis are used, the following are
the total number of grams from each macronutrient that the patient consumed:
Fat: (2663 x .34) / 9 = 100.6 grams of fat
Carbohydrates: (2663 x .46) /4 =306.3 grams of carbohydrates
Protein: (2663 x .20) / 4=133.2 grams of protein
Using more appropriate percentages of macronutrient intake of total calories, it would be more
ideal for the patients macronutrient consumption distribution to be:
Fat: (2663 x .3) / 9 = 88.8 grams of fat
Carbohydrates: (2663 x .55) /4 =366.2 grams of protein
Protein: (2663 x .15) / 4=99.9 grams of carbohydrates
9.Examine the chemistry results for Mr. Klosterman. Which labs are consistent with the
diagnosis? Explain. Why were the levels higher on day 2?
a. Troponin 1 and T are used to diagnose Mr. Klosterman with a MI diagnosis. These levels
were both high (2.4 I and 2.1 T). These numbers are indicative of the structural components of
cardiac muscle that are much higher when there has been an injury to the heart. Cholesterol
levels (total, LDL, LDL/HDL ratio,and HDL) are also used. The patient’s high total cholesterol
and LDL levels combined with low HDL (indicated by low Apo A) levels can be indicative of
plaque build up that can lead to MI. High triglyceride levels are also indicative of cardiac issues.
Levels were higher on day 2 because more cardiac cells were being deprived of oxygen and
destroyed as evidenced by high AST levels and creatine phosphate levels.
10. What is abnormal about his lipid profile? Indicate the abnormal value.
Abnormal Lab Result For
Normal Range
Patients Value 12/1 1957
Cholesterol (mg/dL)
120-199
235
HDL-C mg/dL
>55 F; >45 M
30
LDL
<130 mg/dL
160
LDL/HDL ratio
<3.22 F or <3.55 M
5.3
Apo-A mg/dL
101-199 F
94-178 M
72
Triglycerides mg/dL
35-135 F
40-160 M
150
11. Mr. Klosterman was prescribed the following medications on discharge. What are the foodmedication interactions for this list of medications?
Medication
Possible Food-Medication Interactions
Lopressor 50 mg daily
Should be taken with meal or right after
meal for best absorption. Works to slow
heart rate and relax blood vessels, so avoid
alcohol which may increase drowsiness
and cause dizziness. If taken close to
consumption of multivitamin, certain
minerals in vitamin may decrease effects
of Lopressor.
Lisinopril 10 mg daily
Can increase amount of potassium in body.
High potassium foods include bananas,
oranges, green leafy vegetables, and salt
substitutes containing potassium.
Nitro-Bid 9.0 mg twice daily
Can take on full or empty stomach.Avoid
alcohol, which can add to blood vessel
relaxing affect and may cause harmfully
low blood pressure.
NTG 0.4 mg sl prn chest pain
Avoid alcohol
ASA 81 mg daily
Avoid alcohol, as it could cause stomach
bleeding. Could cause nausea and
vomiting.
i. From the Food and Drug Administration: Avoiding Food-Drug Interactions
12.You talk with Mr. Klosterman and his wife, a math teacher at a local high school. They are
friendly and seem cooperative. They are both anxious to learn what they can do to prevent
another heart attack. What questions will you ask them to assess how to to best help them?
a.Do you know which foods are high in cholesterol and saturated fats?
b.Do you know which foods are effective in reducing cholesterol?
c.Do you know how to read a nutrition label?
d.What is a typical day like for you? What times do you usually eat/exercise?
e.How willing are you to change your dietary habits and get more exercise?
f. Who does the grocery shopping/food preparation?
g. How often do you eat out?
h.What methods are commonly used to prepare your meals?
i. What issues would you like to see altered regarding your health and lifestyle?
13.What other issues might you consider to support successful lifestyle changes for Mr.
Klosterman?
a.Patient is a smoker who has been smoking for over 40 years. I would speak to Mr.
Klosterman about possible smoking cessation programs and assess his motivational level for
change since smoking is a major risk factor for heart disease.
b.Patient also gets inadequate physical activity, since his sole form of exercise is dog walking
at a leisurely pace for 15 minutes/day. I would speak to him about the importance of physical
activity in improving his health and reducing risk for further cardiac complications.
c.Patient is also overweight. I would speak to him about proper nutrition and exercise needed
to reduce his BMI.
d. I would also consider patient’s motivational level and that of his wife as well. I would discuss
possible changes in both their routines (exercise, grocery shopping, meal preparation) that would
be most helpful in lifestyle changes.
14. From the information gathered within the assessment, list the possible nutrition problems
using the correct diagnostic terms.
a.Excessive fat intake NI-5.6.2
Inappropriate fat intake:excessive saturated fat NI-5.6.3
Overweight/obesity NI-3.3
Food a nutrition related knowledge deficit NB-1.1
Undesirable food choices NB-1.7
Possible Food-Medication Interaction NC-2.4
IV.Nutrition Diagnosis
15.Select two of the identified nutrition problems and complete the PES statement for each.
a.Excessive fat intake related to regular consumption of red meats, fried foods, and foods
high in saturated fats as evidenced by 24 hour diet recall and high overall and LDL cholesterol
levels.
b. Excessive caloric intake related to lack of knowledge of caloric content of food and
inadequate physical activity as evidenced by a BMI of 26.6 kg/m^2.
16.For each of the PES statements you have written, establish an ideal goal (based on the signs
and symptoms) and an appropriate intervention (based on etiology).
a. Lower LDL and overall cholesterol levels to < 70 mg/dL for LDL and <200 mg/dL for
total cholesterol by reducing intake of red meats, processed foods, and other foods high in
saturated fat and cholesterol:consume <200 mg total cholesterol for day, with total fat of 25-35%
total calories from fat and saturated fat to 7% of total calories.
b. Reduce BMI to appropriate range of 18.5-24.9 kg/m^2 by decreasing caloric intake by
500 kcal/day and increasing duration and intensity of physical activity to thirty minutes five
times a week after patient has fully recovered.
17.Mr. Klosterman and his wife ask about supplements. “My roommate here in the hospital
told me I should be taking fish oil pills.” What does the research say about omega-3-fatty acid
supplementation for this patient.
a. Omega-3 fatty acids are essential fatty acids that the body needs, and can lower
inflammation the body and triglycerides. The American Heart Association recommends that
healthy people get adequate nutrients by eating a variety of foods rather than taking supplements.
The American Heart Association suggests that those without heart disease eat a variety of fish
(ex. salmon, herring, and trout) at least twice a week to get the essential omega-3-fatty-acids.
People with heart problems and heart disease are advised to intake about 1 gram of
EPA+DHA/day preferably from fish; supplements may be taken but a doctor should be consulted
first. For those with high triglycerides, 2-4 grams EPA+DHA/day in the form of capsules and
under a doctor’s supervision are recommended.
i. From American Heart Association
V. Nutrition Monitoring and Evaluation
18.What would you want to assess in three to four weeks when he and his wife return for
additional counseling?
a. Upon a return visit, I would assess any lab values available, including triglyceride and
cholesterol levels and especially LDL and LDL/HDL ratio levels. Since Mr. Klosterman is
overweight, I would also like to see whether or not he was losing weight, and what his current
BMI is. Before coming into the counseling session, I would have Mr. Klosterman perform a 3day or 24 hour dietary recall, to see if his eating habits were improving. Additionally, I would
find out if Mr. Klosterman had been getting any additional exercise. I would also assess the
couple’s relationship, and ask Mrs. Klosterman what she has been doing and could possibly
additionally due to help her husband improve his health. Since Mr. Klosterman is a smoker, I
would want to assess his motivation level for smoking cessation, and if he has not already begun
a program, I would talk to him about his smoking cessation options.
Resources
Food and Drug Administration, (n.d.). Avoid food-drug interactions. Retrieved from website:
http://www.fda.gov/downloads/Drugs/ResourcesForYou/ConsumerBuyingUsingMedicineSafely
EnsuringSafeUseofMedicine/GeneralUseofMedicine/UCM229033.pdf
U.S. Department of Health and Human Services, (n.d.). Your guide to lowering your cholesterol
with tlc. Retrieved from website: http://www.nhlbi.nih.gov/health/public/heart/chol/chol_tlc.pdf
The American Heart Associate. (2013). Retrieved from http: www.heart.org/HEARTORG
GettingHealthy/NutritionCenter/Vitaminand-Mineral-Supplements_UCM_306033_Article.jsp
What is a healthy weight? Rush university medical center. (n.d.). Retrieved from http:
www.rush.edu/rumc/page-1108048103230.html