Clinical Case Study: Acute
Onset Heart Failure
AMY LOFLEY
CASE STUDY #2
Objectives
 Overview of Acute Heart
Failure
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Physiology
Pathophysiology
Treatment
 Multidisciplinary team
 Case Study
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Medical Hx
Nutrition Assessment
Nutrition Intervention
Prognosis
Conclusion
Acute Heart Failure
CLINICAL UPDATE
Normal Physiology
 The heart pumps blood
throughout the body to
deliver oxygen and
nutrients and bring back
carbon dioxide and
waste.
 A normal heart is able to
pump this blood
effectively throughout
the body.
http://filer.case.edu/dck3/heart/intro.html
Pathophysiology (1)
 In heart failure the heart isn’t able to pump
adequate blood supply to the rest of the body.

This is indicated by a low ejection fraction and a high Bnatriuretic peptide (BNP).
 It does not mean that an individual has had a heart
attack or that the heart is no longer working.
 The beginning stages of HF are usually
asymptomatic and can progress if not treated.
http://www.annerporterco.com/is-your-heart-failure-systolic-diastolic-or-both.html
Pathophysiology
http://www.annerporterco.com/is-your-heart-failure-systolic-diastolic-or-both.html
Pathophysiology
http://oyiabrown.com/2013/03/20/
Stages of Heart Failure (2)
Classification of Heart Failure (1)
 Class I – No undue symptoms associated with
ordinary activity and no limitation of physical
activity
 Class II – Slight limitation of physical activity;
patient comfortable at rest
 Class III – Marked limitation of physical activity;
patient comfortable at rest
 Class IV – inability to carry out physical activity
without discomfort; symptoms of cardiac
insufficiency or chest pain at rest
Risk Factors
 Hypertension
 DM
 Coronary Heart Disease
 Left ventricular hypertrophy
 Age
 Dyslipidemia \Obesity
 Atherosclerosis
Practice Recommendations
 Primary treatment
 Treated with IV lasix
 Primary intervention
 MNT
Fluid restriction
 1500 mg Na restriction

Evidence-Based Practice (3)
 Referral to a RD for MNT when an individual has
HF. An initial visit lasting 45 minutes and up to
three planned follow up visits lasting 30 minutes to
improve diet and quality of life.
 Protein needs for patients are based on their
nutrition status. Patients that are clinically stable
but protein depleted should have at least 1.37 g/kg
and patients with a normal nutrition status should
have 1.12 g/kg actual body to preserve body
composition and limit hypercatabolism.
Evidence-Based Practice (3)
 Energy needs are best determined with indirect
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calorimetry but if not possible usual predictive
equations should be used adjusting with increased needs
for a catabolic state.
Fluid should be limited to between 1.4 and 1.9 L per day,
depending on symptoms of edema, fatigue, and
shortness of breath.
Sodium intake should be limited to less than 2000 mg
per day from AND and 1500 mg from the AHA.
Patients with HF should consume the DRI for folate, B6,
and B12.
A multi-vitamin/mineral should be recommended that
contains B12, B6 and folate.
Evidence-Based Practice (3)
 Thiamine status should be monitored closely
because of diuretic use. Encouraging the patient to
consume the DRI of thiamine is important until
further research is conducted.
 Magnesium should be consumed at the DRI because
of the increased risk for HF patients to have an
irregular heart beat.
Multidisciplinary team
 Physician
 Hospitalist
 Cardiologist
 Registered Dietitian
 Nurses
 PCT
 RN
 HF RN
Case Study
Mr. F
 Age: YOM, Caucasian
 Presents to hospital with shortness of breath, weakness, and chest pain
 Medical Diagnosis
 Acute episode of heart failure
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UTI
Past Medical/Surgical/social History
 Past Medical History
 Stage 4 CKD
 HTN
 UTI
 Hypothyroidism
 CHF
 Severe mitral
regurgitation
 Non-ST elevation
myocardial infarction with
possible (A1)
 Paroxysmal atrial
fibrilation
 Past Surgical History
 No significant hx
 Social History
 Lives with wife at home
Clinical Data
 Physical Exam
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Appears to be at a normal
weight
Resting comfortably in the
bed
Stage 2 decubitus ulcer on
bottom
Heels red
Decreased appetite
 Nutrition Assessment
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Height: 64 inches
Weight: 68.9 kg
No wt changes pta
BMI: 26.07
Labs/Medications
Lab
Lab Value
Normal Value
Albumin
2.6
3.5-5
Creatinine
1.7
.6-1.2 mg/dL
FSBS
94-106
Medications: lasix
Dietary data
 According to patient, he follows a no added salt diet
at home.
Nutrition Assessment
 Calorie Needs
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25-29 kcals/kg/d
1725-2000 kcals needed
 Fluid Needs
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2000 mL Fluid Restriction
 Protein Needs
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1-1.2 g/kg/d
69-80 g needed
Nutrition diagnosis
 Increased nutrient needs (protein/kcals) RT
increased demands for wound healing AEB skin
breakdown, delayed wound healing, decreased
intake x 2 days.
 Food and nutrition related knowledge deficit RT lack
of prior diet education AEB lacks understanding of
prescribed diet
Nutrition Intervention
 PO intake at least 50% in 5 days.
 50% intake of supplement next 5 days.
 Add berry magic cup BID and pb grahams BID
 Maintain wt within 1 kg of 68.9 kg over next 5 days.
 Prevent further skin breakdown and help heal
decubitus ulcers next 5 days.
 Pt will identify high fat/chol/sodium foods within
the next 5 days.
 HF nutrition education to caregiver. Good
comprehension and expect good compliance
Nutrition Monitoring and Evaluation
 Monitor and evaluate:
 GI tolerance
 Labs
 PO intake
 Skin integrity and wound healing
 Weight
 Monitor 2 times weekly
Follow Up Assessment
 Diet order: 1500 mg Na,
 Tolerating food with no
2000 FR
 New PES: Inadequate
oral intake RT decreased
appetite AEB <50% PO
intake.
 PO intake 50-75%, < 240
ml fluid per meal
 Assessment
complaints
 Labs
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Wt. 54.9 kg
No change in skin noted
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Alb 2.6, Cr 1.9, FSBS 93124
 Hospice is being
consulted
 Goal: Intake to meet >
50% of needs next 3-4
days ( met and continue)
 Monitor GI, labs, PO
adequacy, skin and wt
Expected Outcomes
 Prognosis is good
 A full recovery from Acute episode of HF should
occur within the next week
 Wound healing will take time.
References
Mahan LK, Escott-Stump S. Medical nutrition therapy
for heart failure and transplant. Krause. 2008: 884897.
2. Jessup M, Abraham WT, Case DE, et al. 2009 focused
update: ACCF/AHA guidelins for the diagnosis and
management of heart failure in adults. Journal of the
American College of Cardiology. 2009; 53(15):134382.
3. Academy of Nutrition and Dietetics. Evidence Analysis
Library. Available at:
http://andevidencelibrary.com/topic.cfm?cat=2800
1.