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Heart Failure A Case Study

HMD 570 Summer 2014 Final Project Presented by Angela Wolfenberger. Heart Failure A Case Study. Heart Failure Introduction. Definition, Etiology, and Diagnosis Symptoms Risk Factors and Public Health Implications Complicating Factors Nutritional Significances Treatment Algorithm.

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Heart Failure A Case Study

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  1. HMD 570 Summer 2014 Final Project Presented by Angela Wolfenberger Heart FailureA Case Study

  2. Heart Failure Introduction • Definition, Etiology, and Diagnosis • Symptoms • Risk Factors and Public Health Implications • Complicating Factors • Nutritional Significances • Treatment Algorithm

  3. Heart Failure: Definition Heart Failure (HF) is a chronic, progressive, clinical syndrome wherein the pumping action of the heart is insufficient to meet the metabolic demands of the body. The heart muscle enlarges, stiffens, and weakens, resulting in inefficient filling and pumping. Blood flow is reduced, causing Insufficient perfusion of organs and extremities. Congestive Heart Failure (CHF) is a type of HF with pulmonary and peripheral (abdominal, leg/ankle) edema. CHF and HF are often used interchangeably.

  4. Heart Failure: Definition, cont’d 2 Types of Heart Failure: Diastolic- The heart cannot fill properly during the rest period; preserved Ejection Fraction (EF) Systolic- The weakened ventricle cannot squeeze hard enough to pump fluid properly; Decreased EF Heart Failure generally results in: • Cardiomegaly (enlarged heart) • Increased Heart Rate • Vasoconstriction as the body attempts to compensatefor the weakened heart tissue

  5. Heart Failure: Definition- Stages Stage Definition Stage AEvidence of heart failure risk factors; no heart disease, asymptomatic Stage B Heart disease present (structural changes); asymptomatic Stage C Structural heart disease evident;symptoms present Stage DAdvanced heart disease; progressive HF
 symptoms require aggressive medical therapy Source: The American College of Cardiology and the American Heart Association Stages of Heart Failure

  6. Heart Failure: Etiology What Causes Heart Failure? • Coronary Artery Disease (CAD)- Arteries narrow, decreasing blood flow to heart • Myocardial Infarct (Heart attack)- One or more blocked coronary arteries, heart muscle becomes damaged (cardiomyopathy) • Hypertension(HTN)- High blood pressure weakens heart muscle over time • Abnormal Heart Valves- Valves that don’t open/close properly disrupt blood flow through heart, causing muscle to work harder • Arrhythmias- Abnormal heart rhythms or fibrillations damage heart muscle • Heart Defects- Abnormal heart structure can reduce muscle function • Pulmonary Disease- Fluid in lungs causes pulmonary hypertension, resulting in enlarged left ventricle • Diabetes Mellitus (DM I or II)- High blood sugar weakens the heart muscle • Hypothyroidism- Low thyroid activity increases LDL cholesterol and atherosclerosis • Drugs (ex. Cocaine, alcohol, etc.)-Dugs have various negative effects on the heart muscle

  7. Heart Failure: Diagnosis • How is Heart Failure diagnosed? • Elevated Brain Natriuretic Peptide (BNP) Blood Levels • Dyspnea-Shortness of breath • Cheyne-Stokes Respiration- Periodic breaths • S3 Gallup- Extra heart sounds • Echocardiogram • Ventricular Ejection Fraction (LVEF) <45% • Chest X-ray- Showing Cardiomegaly • Edema-Peripheral (legs/ankles/feet), Abdominal, and Pulmonary • Rales- Fluid sounds in lungs, wheezing, coughing • Hepatomegaly- Fluid retention causes liver swelling • Stasis Dermatitis-Peripheral swelling causes epidermal tissue breakdown *No single test can diagnose heart failure

  8. Heart Failure: Symptoms • What are the Symptoms of HF? • Dyspnea (shortness of breath), especially when supine • Edema (swelling of ankles/legs/feet, abdomen, lungs) • Fatigue • Cough (dry, hacking, unproductive) • Nausea, anorexia • Syncope • Sudden weight gain (>3 lbs./day or 5 lbs./week) • Angina • Elevated heart rate and/or blood pressure • Anxiety, confusion, decreased alertness • Nocturia (need to urinate at night)

  9. Heart Failure Symptoms, cont’d

  10. Heart Failure: Symptoms, cont’d • Stages of HF: • NYHA Class I: Asymptomatic; patient is not short of breath or fatigued with any activity • NYHA Class II: Patient is short of breath or fatigued after moderate activity (such as climbing two flights of stairs, golfing nine holes, or carrying a load of wash up from the basement) • NYHA Class III: Patient is short of breath or fatigued even after very mild exertion (such as walking around the house or up half a flight of stairs) • NYHA Class IV: Patient is exhausted, short of breath, or fatigued at rest (just sitting still or lying in bed). • New York Heart Association Functional Classification (NYHA)

  11. Heart Failure: Risk Factors • CAD (75% of HF is caused by CAD) • HTN (2nd leading cause of HF) • Myocardial Infarct • Diabetes Mellitus (DM I or II) • Some diabetes medications • rosiglitazone [Avandia] • pioglitazone [Actos] • Sleep Apnea- Improper breathing while asleep decrease blood oxygen levels and increases risk of abnormal heart rhythms. • Congenital heart defects, Arrhythmias • Viruses- Someviral infections damage heart muscle. • Alcohol/Drug Use

  12. Heart Failure: Public Health Implications • 5.8 Million Americans suffer from HF • 2.8% of the general population (2010), • Will rise to 3.5% by 2030 • 10% of people >65 years old (2010) • 1 in 5 adults over 40 will suffer from HF in their lifetime • 400,000+ new cases of HF each year in the US • 1 in 5 HF patients die in 1 year, 50% die within 5 years • Major HF risk factors are rising each year: • Diabetes • Obesity • Aging Population • HF costs $24.7 Billion per year (2010), and is projected to escalate to $77.7 Billion by 2030

  13. Heart Failure: Complicating Factors • Kidney Damage/Failure-HF reduces blood flow to kidneys, which can cause kidney failure. Some HF medications can cause kidney damage. • Heart Valve Damage- Valves may not function properly if heart is enlarged, or if the pressure inside the heart is very high. • Liver Damage-HF can cause abdominal edema, putting pressure on the liver, causing scarring. • Stroke-Blood flow in HF through the heart is slower than normal, making blood clots more likely.

  14. Heart Failure: Nutritional Significance • Restrict Sodium Intake to <2000mg/day (about 1 teaspoon) • Sodium causes fluid retention and increased blood pressure • Restrict Fat Intake, Especially Saturated Fats (if hyperlipidemia is involved) • 30% of daily Kcal should come from fats, >10% from Sat fats • Modify Fluid Intake- • Restrict fluids to <1.5 Liters, because of fluid retention/edema • Consume Adequate Protein • 1.12-1.37g protein/kg of weight per day may be necessary to prevent cachexia (wasting) in HF • Micronutrients- Some HF medications cause accumulation or depletion of essential minerals like K, Mg, and/or Ca • Taking a daily Multi-vitamin/Multi-mineral supplement may ameliorate the effect of medications

  15. Heart Failure: Drug Therapy Algorithm

  16. Heart Failure Case Study:Joseph Himm • Patient Information • Patient History • Symptoms • Risk Factors • Diet (24-hour Recall) • Lab Values

  17. HF Case Study:Joseph Himm, Patient Information • Age: 79 years • Height: 65” • Weight: 209 lbs. • BMI: 34.8, obese (class I) • Normal weight range (BMI 18.5—24.9) is 110 to 149 lbs. • Blood Pressure: 119/71 mmHg (without medication: 220/170 mmHg or higher) • Pulse: 60 bpm • LVEF: 27% (normal=55-70%, HF<45%) • Diagnosis: NYHA Class III Heart Failure • Medications: Lasix (120mg/d), Nitroglycerin (.4mg/prn), Carvedilol (25mg/d), Allopurinol (300mg/d), Ramipril (5 mg/d), Plavix (75 mg/d), Isocitrate (90 mg/d) • Caucasian • Physical Activity: No exercise tolerance

  18. HF Case Study: Joseph Himm, Patient History Mr. Himm was diagnosed with HTN in 1972, and has taken medication to control his blood pressure since that time. Mr. Himm suffered an MI in 1982, and another in 1994. He also suffered a CVA (stroke) in 1997, and another in 1999. He has suffered many TIAs (transient ischemic attacks). Mr. Himm had coronary bypass surgery (CABG) with 4 bypasses, (5th blockage could not be bypassed) in 2002, with Carotid Endarterectomy (CEA) at the same time. He had an Implantable Cardioverter Defibrillator (ICD) implanted in 2012. He has had multiple heart catheterizations over the years. Mr. Himm was an athlete in his youth, but has led a sedentary lifestyle for the last 45 years. Mr. Himm was counseled about the DASH diet (Dietary Approaches to Stop Hypertension) by his cardiologist upon his initial HTN diagnosis. He stopped cooking with added salt and adding salt to cooked foods at that time (as did his wife). His diet is otherwise uncontrolled, and he has weighed in excess of 200 lbs. for 15+years. Mr. Himm has difficulty with ADLs (dressing, shaving) because of CVA damage, so he leaves the house infrequently. He sits and watches television for the large part of each day. He also does not like to leave the house because of urinary incontinence fears from his Lasix (diuretic). Mr. Himm has had difficulty sleeping for many years, and takes naps throughout the day and night. He does not sleep for more than 2-3 hours at a time. Mr. Himm’s father died of MI in 1945, at age 45 years.

  19. HF Case Study: Joseph Himm,Symptoms • Angina upon rising and with any effort (stairs, walking, lifting, etc.) • Dyspnea with any physical activity (limits activity due to dyspnea and angina) • Edema in legs, ankles, feet, and abdomen • Stasis Dermatitis in lower legs • Nocturia (2x/night) • Bradycardia (pacemaker controlled) • Memory and Speech deficit, occasional confusion, and anxiety • Bowel Movements loose, 3-4x/day • Sleep Apnea

  20. HF Case Study: Joseph Himm,Risk Factors • Age- Mr. Himm’s HF risk is exacerbated by his advanced age (79 years). 8% of men in this age group have HF. • Obesity- Mr. Himm’s BMI is 34.8. Some of his weight can be attributed to water retention, but his wife states that his weight does not decrease more than 2-3 pounds when he takes Lasix. • Unhealthy diet- Mr. Himm consumes many processed foods at meals and snacks, which have high saturated fat and salt content. He consumes few vegetable-especially green leafy vegetables. He consumes too little fiber. • Genetic Predisposition- Mr. Himm’s father died at age 45 from CVD (cardiovascular disease). • Anxiety- Mr. Himm suffers from anxiety and mental confusion. The stress puts significant strain on his heart, and he occasionally forgets to take his medications. • LVEF- Mr. Himm is in danger of sudden cardiac death from ventricular fibrillation due to his low ejection fraction (27%).

  21. HF Case Study: Joseph Himm,Diet- 24 Hour Recall

  22. HF Case Study: Joseph Himm, Diet- 24 Hour Recall, cont’d Analysis

  23. HF Case Study: Joseph Himm, Diet- 24 Hour Recall, cont’d Analysis, cont’d • Kcal- 2161 Empty Calories- 839 Kcal • Sat Fat- 66g (limit 22g) PRO- 84g (AI for HF 75.68g) • CHO- 215g (AI 100g) • Fiber- 16g (target 25g) • Ca- 1283mg (RDA 1200mg) Vit. C -43mg (RDA 90mg) • K-2035mg (AI 4700mg) Vit. D-15ug (RDA 20ug) • Mg-252mg (RDA 420mg) Vit. K- 43ug (AI 120ug) • Na- 2475mg (AI 1200mg)Vit. E- 8mg (RDA15mg) Mr. Himm consumed adequate amounts of other vitamins and minerals

  24. HF Case Study: Joseph Himm,Significant Lab Values

  25. EAL: Guidelines and Supporting Evidence Relevance to Mr. Himm

  26. EAL Guidelines

  27. EAL Guidelines

  28. EAL Guidelines

  29. EAL Guidelines

  30. EAL Guidelines Mr. Himm has adequate blood levels of Mg, Ca, and K, so the correlating guidelines do not apply at this time. His blood chemistry should be monitored and guidelines Implemented as necessary (if serum levels fall). Mr. Himm does not consume alcohol, so the corresponding guideline does not apply. Mr. Himm does not like taking a lot of pills, So additional bionutrient therapy (per guidelines) is not supported at this time.

  31. Nutrition Care ProcessSubjectiveObjectiveAssessmentPlan Joseph Himm

  32. SOAP: Joseph Himm • S: Mr. Himm reports long Hx of HTN, and CAD, with multiple coronary artery bypass, carotid endarterectomy, 2 MIs and 3 CVAs. Patient suffers dyspnea with walking, stairs, lifting, etc. Patient consume high fat, high energy, high salt diet (per 24-hour recall). He reports taking his medications sporadically in the past, but regularly now that he feels poorly (fatigue, angina, edema, dyspnea). Patient has been obese for approx. 15 years and tolerates no physical activity. Patient suffers anxiety, periodic mental confusion, slow speech, and muscle weakness (from previous CVAs). Father died at age 45 of MI (1945). • O:Age: 79 years, Ht: 65” Wt.: 209# BMI: 34.8 BMI Class: Obese, Class I Dx: Cardiomyopathy (425.1), Edema (782.3), Stable Angina (412.9), Carotid Stenosis (433.1), Heart Failure (428.0) BP (unmedicated): 220/170, BP (medicated): 119/71 Pulse: 60 (with pacemaker working 3-7%). Medications: Lasix (120mg/d), Nitroglycerin (.4mg/prn), Carvedilol (25mg/d), Allopurinol (300mg/d), Ramipril (5 mg/d), Plavix (75 mg/d), Isocitrate (90 mg/d)

  33. SOAP, cont’d: Joseph Himm • A:NI-1.3 Excessive Energy Intake related to Kcal/ fat/CHO consumption above TEE as evidenced by BMI of 34.8 (obese, class I) and 24 hour diet recall NB-2.1 Physical Inactivity related to sedentary lifestyle and heart failure as evidenced by exercise intolerance, excessive TV. watching, and obese BMI. NB-1.1 Food-and Nutrition-Related Knowledge Deficit related to excessive in take of saturated fat and salt as evidenced by24-hour food recall, edema, and adiposity whilst claiming to follow a DASH dietary pattern. • P: Intervention ND-1 Meals and Snacks.Pt. to follow DASH dietary pattern to decrease salt and saturated fat intake and increase fruit and vegetable intake. Pt. to receive printout of DASH guidelines to post in kitchen E-1 Nutrition Education.Pt. will learn to read labels to avoid processed foods with high salt and saturated fat content. Use cognitive behavior theory to instruct Pt. to prepare and include fruits and vegetables in meals and snacks Monitor/Evaluate: F-1.1 Energy Intake. Pt. will keep food log. BE-1.1 Beliefs/Attitudes. Monitor actual fat/salt/energy/vegetable intake vs. Pt. perceived intake S-1.4 Weight/Weight ChangeFollow up with Pt. weight/BMI S2.3Creatinine. Monitor Pt. Lab Values to ensure diet maximizes HF/renal outcomes.

  34. Treatment Plan: Joseph Himm After our initial 45-minute consultation, Mr. Himm will embark on a lifestyle modification plan to include healthy eating (and keeping a food diary), body weight/BMI reduction and increased Physical Activity. Dietary changes will include: (5-10 servings/day) of fruits and vegetables (emphasis on variety and color), daily multivitamin to maintain to comply with recommendation for Folate, Thiamin, B6, B12, Ca, Mg, and Potassium (K). Lab values will be monitored on subsequent visits to ensure adequate intake. Diet will consist of low-Na, Low-fat DASH style dietary pattern to lower BP and ameliorate HTN, lower edema, and maintain cardiovascular integrity. The diet will include 1.12g/kg/day of Protein, <30% Fat with <10% Sat Fat,<100-130g CHO, <2000mg Na, and <1.4-1.9L of fluids. Fiber levels will be monitored and adjusted as necessary due to Mr. Himm’s report of frequent, loose stools. Mr. Himm’s therapeutic prescriptions and lab values will be monitored to ensure no or food/nutrient-drug interactions. For example, Mr. Himm’s diuretics lower serum Potassium while his ACE-inhibitors raise serum Potassium levels. Kcal content of food will be adjusted and monitored to support weight loss while conserving muscle and preserving body composition as indicated for HF. I will suggest that Mr. Himm attempt to decrease TV. watching while increasing physical activity as recommended by his physician for his ability. I will schedule at least 3 monthly 30 minute follow-up visits to evaluate Mr. Himm’s food/nutrient intake based on his Food Diary, and lab values (to include Creatinine/BUN, eGFR, serum mineral levels, serum lipids, glucose, etc.), and to monitor and support his continued healthy diet and physically active lifestyle.

  35. Sample Menu: Joseph Himm

  36. EAL: Lessons Learned I have thoroughly enjoyed becoming familiar with the Evidence Analysis Library this Semester. I love to research topics of interest, especially in nutrition and preventive medicine. The EAL is a handy reference for current knowledge about common health conditions and their nutrition implications. I now feel comfortable looking up guidelines for dietary treatments, and feel confident that the material that I am reading comes from thoughtful analysis of peer-reviewed literature. I especially appreciate the information about the quality and amount of research behind each guideline, together with the ratings and grades. I also feel that the knowledge I glean from the EAL will help me with interview questions when I apply for internships next year. The EAL also helps the practitioner understand the importance of motivational interviewing. There were many guidelines for Heart Failure that I was unsure whether they were applicable until I spoke at length with the subject (Mr. Himm). I asked him questions, then I read through the EAL guidelines, and I thought of many more questions to ask. This helped me gain a far deeper understanding of his diagnosis, symptoms, etc. The news media is filled with “sound bytes” and fad diet “factoids” with little, if any, scientific basis. The EAL helps me separate fact from fiction quickly and efficiently, which will not only be of great use in my future practice, but is very informative for me as a dietetics student, since I constantly field questions from friends and family concerning nutrition “information” in the media. Finally, I am studying dietetics as a second career. I am am following my passion while, hopefully, contributing to society. My first career has provided me with enough disposable income that I can pursue whatever field of dietetics I desire without worrying about supporting my family with the income. I think that I would enjoy participating in the analysis for future EAL topics, as I love scouring peer-reviewed articles for information about interesting topics. What an exciting way to contribute to the future of the profession!

  37. Bibliography: • Academy of Nutrition and Dietetics Evidence Analysis Library. (2008). Heart Failure Guideline. Retrieved July 24, 2014 from http://www.andeal.org/topic.cfm?menu=5289&cat=3249 • Academy of Nutrition and Dietetics Evidence Analysis Library. (2008). Hypertension Guideline. Retrieved July 27, 2014 from http://andevidencelibrary.com/topic.cfm?cat=3248 • American Heart Association (2014). Heart Failure, Retrieved July 24 from http://www.heart.org/HEARTORG/Conditions/HeartFailure/AboutHeartFailure/About-Heart-Failure_UCM_002044_Article.jsp • Amirkalali, B., Hosseini, S., Heshmat, R., & Larijani, B. (2008). Comparison of harris benedict and Mifflin-ST Jeor equations with indirect calorimetry in evaluating resting energy expenditure. Indian journal of medical sciences, 62, 283. doi: 10.4103/0019-5359.42024 • Chobanian, A. V., Bakris, G. L., Black, H. R., Cushman, W. C., Green, L. A., IzzoJr, J. L., ... & National High Blood Pressure Education Program Coordinating Committee. (2003). The seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure: the JNC 7 report. Jama, 289, 2560-2571. doi:10.1001/jama.289.19.2560 • Institute of Medicine (2014). Dietary Reference Intakes,, Retrieved July 28, 2014 from http://www.iom.edu/Activities/Nutrition/SummaryDRIs/~/media/Files/Activity%20Files/ Nutrition/DRIs/5_Summary%20Table%20Tables%201-4.pdf • Mayo Clinic (2014). Heart Failure, Retrieved July 24, 2014 from http://www.mayoclinic.org/diseases-conditions/heart-failure/basics/definition/con-20029801. • National Heart, Lung, and Blood Institute (2014). Heart Failure. Retrieved July 24, 2014 from http://www.nhlbi.nih.gov/health/health-topics/topics/hf/ • Shamsham, F., & Mitchell, J. (2000). Essentials of the diagnosis of heart failure. American Family Physician, 61(5), 1319-1330. • USDA (2014). SuperTracker. Retrieved July 28, 2014 from https://www.supertracker.usda.gov/foodtracker.aspx

  38. Addendum: Patient Education Materials: Allegheny Gen’l Hospital, Pittsburgh, PA.

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