Definitions

• Angioplasty: surgical repair or unblocking of a blood vessel, especially a coronary artery
• Stenosis: the abnormal narrowing of a passage in the body
• Cardiac Catheterization: a procedure used to diagnose and treat cardiovascular conditions; a long thin tube (catheter) is inserted in an artery or vein in the groin, neck or arm and threaded through the blood vessels to the heart
• Pulmonary Edema: a condition caused by excess fluid in the lungs; this fluid collects in the numerous air sacs in the lungs, making it difficult to breathe; in most cases, heart problems cause pulmonary edema
• Syncope: temporary loss of consciousness caused by a fall in blood pressure
• CABG: Coronary Artery Bypass Graft – it is a form of bypass surgery that can create new routes around narrowed and blocked coronary arteries, permitting increased blood flow to deliver oxygen and nutrients to the heart muscle; it is one of the most commonly performed major operations
• LVAD: Left Ventricular Assist Device – a mechanical pump that is implanted inside a person’s chest to help a weakened heart pump blood

Interventions

For each of the following disorders, describe the etiology and recommended MNT.

CAD “Coronary Artery Disease”

Etiology:

• The usual cause is the buildup of plaque on the inner walls or lining of the arteries, which causes the coronary arteries to narrow and harden, limiting blood flow and lowering oxygen supply to the heart.

MNT:

• Therapeutic Lifestyle Changes Diet (TLC Diet)
  • Reduced intake of cholesterol-raising nutrients
    • Saturated fats < 7% of total calories
    • Dietary cholesterol < 200 mg per day
  • LDL-lowering therapeutic options
    • Plant stanols/sterols (2 g per day)
    • Viscous (soluble) fiber (10–25 g per day)
  • Mediterranean diet, emphasizes:
    • Eating primarily plant-based foods, such as fruits and vegetables, whole grains, legumes and nuts
    • Replacing butter with healthy fats such as olive oil and canola oil, and nuts
    • Using herbs and spices instead of salt to flavor foods
    • Increased fruit and vegetable intake
    • Limiting red meat to no more than a few times a month
    • Eating fish and poultry at least twice a week
    • Enjoying meals with family and friends
    • Drinking red wine in moderation (optional)
    • Getting plenty of exercise
  • While the above diets are good MNT for CAD, an individualized approach that focuses on positive life changes such as a healthy diet and increased exercise should be taken
  • Weight reduction encouraged

CHF “Congestive Heart Failure”

Etiology:

• Caused by conditions that damage the heart muscle, it is when the heart can’t pump enough blood because the muscle is so badly damaged or is not working anymore

MNT:

• Sodium restriction (<2,000 mg sodium/d)
• Fluid restrictions – typically 1mL/kcal or 35mL/kg – if patient is fluid overloaded limit fluid to 1500-2000 mL/d – strict I/Os, need to monitor their weight to make sure they are not gaining too much too quickly because that is fluid weight – extra strain on the heart
• Aim to improve nutrition status
  • Significantly higher protein needs
  • Increased calorie needs
    • There is a dilemma between sufficient calories and a restricted diet, recommend small, frequent feedings
  • Correct/avoid any nutrient deficiencies
    • Recommend a daily multivitamin
    • Additional supplementations may be necessary
  • Important to be aware of drug-nutrient interactions – diuretics, such as furosemide, deplete potassium
  • Nutrition education is really important, want to encourage increasing nutrient density and making food choices that enhance oral intake

Hypertension

Etiology:

• Primaryhypertension– idiopathic, but thought to be the result of a variety of factors, including lifestyle factors (poor diet, lack of exercise, smoking, stress, and obesity)
• Secondaryhypertension– occurs as a result of another primary problem (renal disease, other cardiovascular disease, endocrine disorders, or neurogenic disorders)

MNT:

• DASH Diet (Dietary Approaches to Stop Hypertension)
  • Decreased sodium intake (<2,300 mg/d)
  • Emphasizes fruits, vegetables, and low-fat dairy
  • Includes whole grains, poultry, fish and nuts
  • Larger amounts of potassium, calcium, magnesium, dietary fiber, and protein than the typical diet
  • Smaller amount of red meat, sweets, sugar-containing beverages
  • Smaller amount of total and saturated fat and cholesterol
• Lose weight when overweight
• Limit alcohol consumption (<2 alcoholic drinks/d for men and <1/d for women)
• Increased aerobic physical activity
• Discontinue smoking

Metabolic Syndrome

Etiology:

• Metabolic syndrome is when several risk factors (e.g. dyslipidemia, hypertension, hyperglycemia) occur (or cluster) together, increasing your risk of cardiovascular disease and Type II Diabetes
• Diagnosis of metabolic syndrome occurs when there are >3 risk factors present
• Risk factors include:
  • Abdominal obesity, given as waist circumference
    • Men: > 40 in
    • Women: > 35 in
  • Triglycerides>150 mg/dL
  • HDL cholesterol
    • Men: < 40 mg/dL
    • Women: < 50 mg/dL
  • Blood pressure >130 / >85 mm Hg
  • Fasting glucose >110 mg/dL

MNT:

• Weight loss through lifestyle changes – improved diet and increased physical activity
• The Dietary Approaches to Stop Hypertension (DASH) diet or the Mediterranean diet are encouraged, both diets:
  • Limit unhealthy fats (saturated and trans fats) and encourage increased consumption of healthy fats such as omega-3 PUFA and MUFA, especially from olive oil
  • Emphasize fruits, vegetables, fish, and whole grains
  • Limit sodium intake
• Increased physical activity – 30 minutes or more of moderate-intensity exercise daily
• Discontinue smoking

List and discuss the three most prevalent modifiable risk factors associated with cardiovascular disease.

Tobacco use

• Smoking is the number-one preventable cause of CVD in the U.S.
• Smoking damages the cardiovascular system in the following ways:
  • Damages the lining of arteries
  • Reduces HDL levels
  • Raises triglycerides and LDL levels
  • Nicotine increases blood pressure and heart rate
  • The carbon monoxide in cigarette smoke replaces oxygen in the blood – this reduces the amount of oxygen available to the body
  • Causes platelets to stick together in the blood-stream (leads to clotting)
  • Speeds up the development of fatty deposits in the arteries
• Smoking one pack per day doubles your risk of having a heart attack and stroke, and when a smoker has a heart attack they are three times more likely to die from them than nonsmokers
• Non-smokers are also affected – the risk of developing heart disease increases up to 30% among those exposed to environmental tobacco smoke at home or work

High blood pressure (hypertension)

• Risk factor for several forms of CVD, including heart attacks and strokes
• It is the most prevalent form of CVD
• Often called a silent killer because it usually has no symptoms
• High blood pressure damages vital organs and increases the risk of heart attack, congestive heart failure, stroke, kidney failure, and blindness
• Primary hypertension cannot but cured but it can be controlled with certain lifestyle changes, such as:
  • Weight reduction
  • Regular exercise
  • A healthy diet – the DASH diet
  • Moderate alcohol consumption

High cholesterol

• Excess LDL cholesterol is deposited in the blood vessels and accumulates, this can clog arteries and increases the risk of CVD (blocked coronary arteries can result in a heart attack; if an artery that carries blood to the brain is blocked a stroke can occur)
• Elevated LDL and total cholesterol and triglycerides, along with low HDL levels, are associated with a higher risk for CVD – reduce this risk by lowering LDL, total cholesterol, and triglycerides
  • Following a Mediterranean style diet can help to lower cholesterol levels
• It is also important to raise HDL levels because high HDL levels have been shown to protect against CVD, even if total cholesterol is high, especially in women
• It is also important to note that the risk of CVD is greater if the persons cholesterol level is elevated and they have another risk factor (e.g., smoker, hypertension, diabetes, etc.)

What is the relationship between body composition and CVD risk? What measure(s) of body composition would be most practical to use in a clinical setting?

Excess body fat is strongly associated with CVD. In a clinical setting, it would be most practical to use BMI, waist circumference, waist to high ratio, or triceps skinfold to measure body composition. As your weight increases, and subsequently your BMI, your risk of CVD increases – for every 5-unit increase in BMI, the risk of death from CAD increases by 30%. Obese individuals (BMI >30) are 2-3x more likely to die from CVD than individuals with a normal BMI (BMI 18.5-24.9). Increased levels of visceral fat, especially in the abdominal area, are strongly associated with hypertension, high cholesterol levels, insulin resistance, and diabetes. Waist circumference and waist to hip ratio are two of the simplest methods for measuring body fat distribution. A waist circumference > 35 inches in women and > 40 inches in men indicates an increased risk of metabolic syndrome. A waist to hip ratio > 0.8 in women and > 1 in men is associated with an increased risk of cardiovascular disease. Triceps skinfold is used to assess body composition based on the amount of subcutaneous fat.

What role, if any, do omega-3 fatty acids play in the management of CAD? What are the recommended amounts of omega-3 fatty acids?

Omega-3 fatty acids reduce blood clotting and inflammation, inhibit abnormal heart rhythms, lower triglyceride levels, may lower blood pressure in some people, and may reduce the risk of fatal heart attack and stroke. It is recommended to eat a 3.5 oz serving of omega-3 fatty acid containing fish 2-3 times per week.

Explain the role of plant stanols in the management of CHD. What are the recommended amounts of stanols?

Plant stanols and sterols reduce the absorption of cholesterol in the body and help lower LDL levels. They do this by competing with dietary and biliary cholesterol for absorption in the intestine. For people with high LDL levels, the recommended intake of plant stanols is 2 grams per day.

What is the relationship of trans fats in the diet to serum cholesterol?

Trans fat raises total cholesterol and LDL cholesterol and lowers HDL cholesterol. Some food sources of trans fat include deep-fried fast foods, stick margarines, packaged cookies and crackers, and processed snacks and sweets.

What precautions must be taken when recommending salt substitutes?

Salt substitutes are composed of potassium chloride instead of sodium chloride, so overconsumption of potassium-containing salt substitutes can lead to hyperkalemia. Individuals that do not have normal kidney function are especially at risk since their kidneys cannot adequately excrete potassium. Symptoms of hyperkalemia include muscle weakness, paralysis, paresthesias, and cardiac dysrhythmias. Severe hyperkalemia can lead to cardiac arrest.

Discuss the use of the following drugs.

	Classification	Mechanism of action	Indication for use with the cardiac patient	Effect of the drug on nutrient absorption and utilization	Effect of nutrients on drug absorption and utilization
Digoxin	Digitalis   Cardiac glycoside   Antiarrhythmia	Increases the heart muscles force of contraction by inhibiting the activity of ATPase (enzyme that controls the movement of calcium, sodium, and potassium into heart muscle)   Increases the efficiency of heart contractions by slowing the electrical conduction between the atria and ventricles of the heart, which helps to control and normalize the rhythm of the heart	Heart failure   Atrial fibrillation	Potassium and magnesium depletion	Take one hour before or two hours after eating because foods high in fiber may decrease digoxin levels in the body Avoid taking with senna and St. John’s wort – both may decrease the amount and action   Natural black licorice can greatly enhance the activity, resulting in the heart not beating properly   Excess potassium consumption can reduce the effectiveness of digoxin, resulting in heart failure
Aspirin	Salicylate   Nonsteroidal anti-inflammatory drug (NSAID)	Acts by inhibiting the activity of the cyclooxygenase (COX) enzyme   Helps prevent blood clots from forming and helps prevent heart attack or stroke   Relieves pain, fever, and inflammation	Prevent stroke and myocardial infarction in patients with cardiac history or history of previous stroke	If aspirin causes stomach irritation, take with water or milk   Folic acid, iron, potassium, sodium, and vitamin C depletion can occur with long-term high-dose aspirin intake	Alcohol consumption leads to an increased risk of stomach bleeding   Avoid or limit natural products which affect coagulation such as garlic, ginger, ginkgo, ginseng, or horse chestnut   Taking aspirin with food limits its absorption
Coumadin	Anticoagulant	Treats blood clots and prevents new clots from forming – it helps to keep blood flowing smoothly by decreasing the amount of clotting proteins in the blood	Prevention and treatment of venous thrombosis and pulmonary embolism   Prevention and treatment of thromboembolic complications associated with atrial fibrillation and/or cardiac valve replacement Reduction in the risk of death, recurrent myocardial infarction, and thromboembolic events such as stroke or systemic embolization after myocardial infarction	N/A	Excessive alcohol consumption leads to an increased risk of stomach bleeding or clot formation   Excess vitamin K decreases its efficacy (especially if it’s a dramatic increase) – the goal is to take in the same amount of vitamin K each day   coQ10 and St. John’s wort could decrease its efficacy   Garlic, ginger, glucosamine, ginseng, and ginkgo can increase the risk of excessive bleeding   Large amounts of vitamin C (more than 5 grams) can interfere with its efficacy   Vitamin E is also an anticoagulant, so combined with this the blood may thin too much, causing bruising and possibly excessive bleeding
Aldactone	Aldosterone antagonist   Diuretic   Antihypertensive	Interrupts aldosterone, which increases sodium and water excretion, and increases potassium retention	Hypertension   Heart failure   Edema due to heart failure	May increase serum potassium   Take with meals or milk to improve absorption and decrease GI irritation   Reduces serum sodium (discontinue sodium restriction if hyponatremia occurs)	Avoid excessive potassium intake and supplementation   Avoid salt substitutes composed of potassium chloride   Avoid natural licorice
Mevacor/Lovastatin	Statin	Decreases the risk of heart disease and helps prevent stroke and heart attack by lowering LDL cholesterol and raising HDL cholesterol – it reduces liver cholesterol production by inhibiting HMG-CoA reductase (a liver enzyme necessary for cholesterol production)	Primary prevention of CVD   Primary hypercholesterolemia   Hyperlipidemia   Coronary heart disease (used to slow progression of coronary atherosclerosis)	Can decrease coenzyme Q10 levels   Take with meals to increase absorption – works best when taken with evening meals	Excessive alcohol consumption may increase the risk of liver damage   Large amounts of grapefruit juice can increase levels in the body and increase the chance of side effects   Niacin enhances its cholesterol-lowering effects
Lasix	Diuretic	Decrease blood volume by increasing urinary output; inhibit renal sodium and water reabsorption	Edema due to heart failure   Hypertension	Can decrease levels of calcium, magnesium, potassium, vitamin B1, vitamin B6, and zinc	Avoid natural licorice   Food decreases its bioavailability – best to take on an empty stomach
Streptokinase	Thrombolytic (fibrinolytic) agent	Forms a complex with plasminogen which releases plasmin, a protease capable of breaking apart fibrin molecules, thereby dissolving clots	Acute myocardial infarction   Pulmonary embolism   Arterial and venous thrombosis	N/A	N/A
Tissue plasminogen activator	Thrombolytic (fibrinolytic) agent	Binds to the surface of the clot and activates plasminogen, releasing plasmin, which breaks apart the clots fibrin molecules, thereby dissolving the clot	Acute myocardial infarction   Acute ischemic stroke   Pulmonary embolism	N/A	N/A