Cardiovascular Disorders

Cardiovascular disease (CVD) is a collective term referring to a group of diseases affecting the heart and blood
vessels. These include cerebrovascular disease, hypertensive disease, and coronary heart disease.

I. Definition
1. Coronary Heart Disease (CHD) or Coronary Heart Disease (CAD) disease involving the network of blood
vessels surrounding and serving the heart; manifested in clinical end points of myocardial infarction and
sudden death

2. Atherosclerosis
*a form of arteriosclerosis; a complex process of thickening and narrowing of the arterial walls caused by
accumulation of lipids, primarily oxidized cholesterol, in the intimal or inner layer in combination with
connective tissue and calcification
*A term denoting number of different processes resulting in atheroma or patchy deposits of various
materials in the intima of the arteries. These deposits are produced by an accumulation of fatty substances
(cholesterol, phospholipids, and triglycerides), complex carbohydrates, lipoproteins, calcium and calcified
plaques, fibrin, and the formed elements of the blood

3. Arteriosclerosis cardiovascular disease characterized by thickening, loss of elasticity, and hardening
(calcification) of the walls of the arteries

4. Hypertension (HPN) also called high blood pressure; persistent elevation of blood pressure above
normal. For adults, the average systolic/diastolic pressure is about 120/80 mm HG

5. Hypercholesterolemia condition in which blood cholesterol is above the normal limits (200 mg or more). It
is associated with atherosclerosis and other cardiovascular diseases, obstructive jaundice, hyperlipidemia,
and excess adrenocorticotropic hormone

6. Myocardial Infarction (MI) also called coronary thrombosis; commonly called heart attack
*ischemia in the coronary arteries resulting in necrosis, tissue damage, and sometimes, sudden death

7. Cerebrovascular accident (CVA) commonly called stroke
*an event in which the blood flow to a part of the brain is cut off
*partial brain damage as a result of a constricted blood supply caused either by ruptures, clots, or blood
vessel spasms

II. Etiology

CHD is caused by a narrowing of the coronary arteries resulting in an impeded blood flow to the network of
blood vessels surrounding the heart and serving the myocardium. CHD is brought about by atherosclerosis.
Atherosclerosis in the coronary arteries causes myocardial infarction and angina (chest pain); in the cerebral
arteries it causes strokes.

Pathogenesis of Atherosclerosis
*the pathogenesis is multifactorial
*lesions develop due to:
1. Proliferation of smooth-muscle cells, macrophages, and lymphocytes
2. Formation of smooth-muscle cells into a connective tissue matrix
` 3. Accumulation of lipid and cholesterol in the matrix around the cells: these build up in the initimal
layer and are called plaque or atheroma

Major Risk Factors for CHD that cannot be modified:
1. Increasing age
2. Male gender
3. Heredity

Modifiable Risk Factors for CHD:
1. Tobacco smoke
2. Elevated blood cholesterol (LDL)
3. Hypertension
4. Physical inactivity
5. Excess body weight and body fat, especially abdominal fat
6. Diabetes Mellitus

Standards of CHD Risk Factors
Standard Values Interpretation
LDL Cholesterol <130 mg/dL
130-159 mg/dL
160 mg/dL
Desirable
Borderline high
High
HDL Cholesterol 35 ng/dL Indicates risk
LDL to HDL Ratio
Men
Women

>5.0
>4.5

Indicates risk
Indicates risk
Total Cholesterol <200 mg/dL
200-239 mg/dL
240 mg/dL
Desirable
Borderline high
High
Triglycerides (Fasting) <200 mg/dL
200 400 mg/dL
400 1000 mg/dL
>1000 mg/dL
Desirable
Borderline high
High
Very High
Blood pressure Systolic Pressure | Diastolic Pressure
<120 and <80
<130 and <85
130-139

140-159 or 90-99
160-179 or 100-109
180 or 110

Optimal
Normal
High-normal
Hypertension
Mild (Stage 1)
Moderate (Stage 2)
Severe (Stage 3)
Body Mass Index 25-29.9
30
Overweight
Obese

III. Prevention and Treatment of CHD
A. Prevention: Dietary Factors
1. Types of fatty acids
a. Saturated Fatty Acids (SFA) tend to elevate blood cholesterol
*The most hypercholesterolemic or atherogenic are lauric (C12:0) and myristic (C14:0) acids
*Sources: butter fat, coconut, and palm-kernel oils
b. Polyunsaturated Fatty Acids (PUFA)
*Omega-6 Lower LDL-C and raise HDL-C; major source: vegetable oils
*Omega-3: EPA and DHA do not affect total cholesterol, increase LDL-C and decrease TG
*MUFA lower serum cholesterol, LDL-C and TG
**oleic acid (C18:1) is the more prevalent cis-MUFA in the diet; from olive oil & peanut oil
2. Amount of dietary fats and oils fat intakes are related to obesity
The American Heart Association (AHA) recommends for a safe and prudent diet that restricts total fat,
saturated fat and cholesterol. Acceptable oils include canola, corn, cottonseed, olive, safflower,
sesame, soybean and sunflower.

3. Dietary cholesterol raises total cholesterol and LDL-C
Sources: animal fat, organ meats, eggyolk, whole milk, cream, butter, fatty cuts of meat, cold cuts

4. Fibers effect depends on type and quantity
a. Soluble fiber pectins, gums, mucilages, algal polysaccharides and some hemicellulose in
legumes, oats, fruits and psyllium lower serum cholesterol and LDL-C
Proposed mechanism for the hypocholesterolemic effect of soluble fiber:
*The fiber binds bile acids which lower serum cholesterol to replete the bile acid pool
*Bacteria in the colon ferment the fiber to compounds (such as acetate, propionate, and
butyrate), which inhibit cholesterol synthesis
b. Insoluble fibers cellulose and lignin have no effect on serum cholesterol level
Recommended fiber intake: 20-30 grams daily for adults, approximately 6 grams from soluble
fiber, can be achieved with the recommended five or more servings of fruits and/or vegetables
per day and six or more servings of grain

5. Alcohol increases total triglyceride (TG) and HDL-C

6. Coffee heavy consumption of regular coffee (<720ml/day) causes minor increases in total cholesterol
and LDL-C and HDL-C

7. Antioxidants do not affect serum lipids, except for vitamin E/palm oil combination

8. Calcium supplementation produces small decreases in LDL-C among hypercholesterolemic men

9. Soy protein a daily intake of 25g of soy, with isoflavones intact, can lower LDL-C among
hypercholesterolemic persons

10. Trans-fatty acids
-elaidic acid, the trans-isomer of oleic acid, increases blood cholesterol
-increased intakes of trans-fatty acid can lower HDL-C

B. Prevention/Recommendations
Diet and lifestyle changes:
1. Diet
2. Exercise
3. Weight reduction

The American Heart Association and the National Cholesterol Education Program (NCEP) have established dietary
recommendations designed to decrease risk of Coronary Heart Diseases (CHD). A high HDL level is associated
with decreased risk of CHD, and a high LDL increases CHD risk. Increasing the proportion of HDL cholesterol is
protective and the amount (or ratio) of LDL to HDL cholesterol is an indicator of cardiovascular risk. Major causes of
reduced HDL cholesterol include the following:
*cigarette smoking
*obesity
*lack of exercise
*androgenic and related steroids, androgens, progestational agents, and anabolic steroids
*beta-adrenergic blocking agents
*hypertriglyceridemia
*genetic factors, primary hypoalphalipoproteinemia

The NCEP established guidelines for lowering LDL-cholesterol to below 130mg/dL if other risk factors are present
or to 160 mg/dL if no other risk factors are present. Treatment begins with Step 1 diet; if that does not improve blood profile,
the Step 2 diet and individual therapy counselling are introduced. If Step 2 does not lower cholesterol enough, drug therapy
is used.

National Cholesterol Education Program
Step 1 and Step 2 Diets

Nutrient Recommended Intake
Step 1 Diet Step 2 Diet
Total fat <30% total kcal <30% total kcal
Saturated fatty acids <10% total kcal <7% total kcal
Polyunsaturated fatty acids Up to 10% total kcal 10-15% total kcal
Monounsaturated fatty acids 10-15% total kcal 10-15% total kcal
CHO 50-60% total kcal 50-60% total kcal
Protein 10-20% total kcal 10-20% total kcal
Cholesterol <300 mg/day <200 mg/day
Total kcal To achieve & maintain desirable weight To achieve & maintain desirable weight

Nutritional Guidelines for the Prevention of Heart Disease and Diabetes Mellitus (FNRI)
1. Eat foods low in fat and cholesterol
2. Increase intake of fiber-rich foods in the daily diet
3. Limit intake of salty foods
4. Maintain desirable body weight
5. Follow a regular exercise program
6. Stop smoking
7. Regulate alcohol intake
8. Have a regular medical check-up

American Heart Association Dietary Guidelines
1. Total fat intake less than 30% of calories
2. Saturated fat intake less than 10% of calories
3. Polyunsaturated fat intake not to exceed 10% of calories. Monounsaturated fat should provide the remaining
calories from fat
4. Cholesterol intake not to exceed 300mg/day
5. Carbohydrate intake constituting 50% or more of calories, with emphasis on complex carbohydrates
6. Protein should provide the remaining calories
7. Sodium not to exceed 3g/day
8. Alcoholic consumption should not exceed 1 to 2 oz of ethanol/day. Two ounces of 100 proof whisky should be
sufficient to maintain the individuals recommended body weight
9. A wide variety of foods should be consumed

Recommended diet modification to lower blood cholesterol based on the Step 1 diet
Food Group Choose Decrease
Fish, chicken, turkey, & lean meats Fish; white-meat poultry without skin;
lean cuts of beef, lamb, pork or veal;
shellfish
Fatty cuts of beef, lamb, pork; spare
ribs; organ meats; regular cold cuts;
sausage; hot dogs; bacon; sardines;
roe
Food Group Choose Decrease
Skim and low-fat milk, cheese, yogurt,
& dairy substitutes
Skim or 1% fat milk; buttermilk;
substitute nonfat dry-milk powder for
whole milk (for consistency in cooking);
nonfat (0% fat) or low-fat yogurt
Low-fat cheeses, farmer, or pot
cheeses (all of these should be labelled
no more than 2-6 g fat/oz)
Sherbet, sorbet
Whole-milk yogurt, whole-milk cottage
cheese (4% fat), all natural cheeses
(e.g. blue, Roquefort, Camembert,
Cheddar, Swiss) Low-fat or diet
cream cheese, low-fat or diet sour
cream, cream cheese, sour cream, ice
cream
Eggs Egg whites (2 whites = 1 whole egg in
recipes), or mix together 1 egg white, 2
tsp nonfat milk powder @ 2 tsp
acceptable oil; cholesterol-free; egg
substitutes
Egg yolks
Fruits & vegetables Fresh, frozen, canned, or dried fruits
and vegetables
Vegetables prepared in butter, cream,
or other sauces
Breads & cereals Homemade baked goods using
unsaturated oil sparingly, angel food
cake, low-fat crackers, low-fat cookies;
Rice, pasta, barley, bulgur, legumes;
Whole-grain breads & cereals
(oatmeal, whole wheat, rye, bran,
multigrain, etc.)
Commercial baked goods: pies, cakes,
doughnuts, croissants, pastries,
muffins, biscuits, high-fat crackers,
high-fat cookies; Egg noodles; Breads
in which eggs are a major ingredient;
cereals with coconut oil, palm oil, or
palm kernel oil
Fats & oils Acceptable unsaturated vegetable oils;
reduced-fat margarine
Mayonnaise, salad dressings made
with acceptable unsaturated oils, low-
fat dressings; seeds and nuts;
nonhydrogenated, old-fashioned style
peanut butter (100% peanuts)
Butter, coconut oil, palm oil, palm
kernel oil, bacon fat, hydrogenated
vegetable shortening; dressings made
with egg yolk; coconut, hydrogenated
peanut butter


Atherosclerosis

A. Etiology: exact origin unknown; risk factors include hypertension, obesity, smoking, elevated blood lipids, heredity
B. Nutritional Care Objectives: to lower blood elevated blood lipids and possibly help prevent coronary artery disease
1. Low cholesterol: <300 mg/day
2. Low fat: 20-25% of TER
3. P:S ratio of 1:1 to 2:1 PUFA helps lower serum cholesterol by promoting its excretion
4. Kilocalories restricted for weight reduction
5. Increased complex CHO intake
*complex CHO is more slowly absorbed thus controlling the rise of blood serum lipids
6. Decreased refined CHO
7. High fiber
*this lowers cholesterol level by reducing transit time in the GI tract

Hyperlipoproteinemia
*an abnormally high level of one or more of the circulating lipoproteins in the blood
Hyperlipidemias: hypercholesterolemia, hypertriglyceridemia, hyperlipoproteinemia

Lipoproteins composed proteins formed when a simple protein unites with a lipid; complexes composed of blood lipids
(cholesterol, phospholipids, triglycerides) bound to specific proteins that transport the lipids into and out of the blood plasma

A. Types of Lipoproteins
1. Chylomicrons consist of triglycerides absorbed from the diet; have the lowest density since they have the
smallest amount of protein; these are synthesized in the intestines and they transport dietary triglycerides
from intestines to plasma
2. Prebeta lipoprotein or very low density lipoprotein (VLDL) composed largely of triglycerides; it transports
triglycerides of endogenous origin, largely from the liver
3. Beta lipoprotein or low-density lipoprotein (LDL) it carries two-thirds of the total plasma cholesterol; it is
45% cholesterol and 25% protein by weight
4. Alpha lipoprotein or high-density lipoprotein (HDL) the smallest group among the lipo-proteins with a large
protein content
*Chylomicrons primarily contain triglycerides; serum cholesterol is a component of HDL, LDL, and VLDL
*A high HDL-cholesterol level correlates with decreased risk for CHD whereas a high LDL-cholesterol level
correlates with increased risk.

Types of Lipoproteins and Their Dietary Management
Type I characterized by hyperchylomicronemia or an extremely high triglyceride level (TG>1000), with
normal or slightly elevated cholesterol levels
Diet: Restrict fat intake to 20% of calories (30g/day for adults)
MCT may be used as source of calories
Cholesterol intake is normal; caloric level is adjusted to attain a healthy weight
Alcohol is not allowed

Type IIa and IIb characterized by increased serum cholesterol levels since LDLs are elevated
Type IIa: VLDL and TG levels are normal
Type IIb: VLDL and TG levels are increased
Diet: Restrict cholesterol intake (150-200 mg/day)
Adequate calories with 30% or less supplied by fats (1:1 ratio of PUFA to SFA)
Alcohol allowed, but in moderation

Type III characterized by presence of elevated prebetalipoproteins, elevated plasma cholesterol, and
elevated triglycerides; individuals with this disorder are at risk of developing early coronary disease
Diet: Reduce caloric intake if weight reduction is indicated
A maximum of 30% provided by fats with low SFA or a PUFA/SFA ratio of 1:1
Restrict cholesterol to 200mg/day
Limit alcohol to 25 g/day
Consume complex carbohydrates with dietary fiber
Use non-nutritive sweeteners for calorie-restricted diets

Type IV characterized by elevated prebetalipoproteins, elevated TG, and normal or slightly elevated
cholesterol levels; also called carbohydrate-induced hyperlipidemia
Diet: Caloric restriction to reduce weight and to lower TG levels and normalize glucose tolerance
Limit cholesterol, saturated fats, and sugars
No alcoholic beverages

Type V with a plasma lipoprotein pattern of hyperchylomicronemia and elevated prebetalipoproteins
indicating intolerance to both endogenous and exogenous fat sources; glucose tolerance and uric levels
are abnormal
Diet: Reduce weight for obese individuals
Restrict calories: 25% should be provided by fats and oils
Limit cholesterol to 300 mg/day
Alcohol and concentrated sweets not allowed

B. Nutritional Care Objectives
General:
1. To reduce the hyperlipidemia and keep the patient asymptomatic
2. To achieve or maintain DBW because weight loss itself will cause a lowering of the serum triglyceride
levels in overweight patients

Specific:
1. All: normalize body weight. Keep cholesterol levels lower than 200 mg/dL and triglyceride levels lower than 250
mg/dL; keep HDLs high and LDLs low. Elevated triglyceride levels can be atherogenic. A Mediterranean diet
(olive oil, red wine, fruits & vegetables, fish) probably is beneficial for most people.
2. Type I: minimize chylomicron formation. Lower triglyceride levels. Prevent abdominal pain resulting from fat
ingestion. MCTs are tolerates.
3. Type IIa: lower intake of saturated fats. Lower serum cholesterol.
4. Type IIb: or III: reduce weight: lower serum cholesterol
5. Type IV: reduce weight. Restrict intake of carbohydrate and alcohol. Intake of cholesterol should be moderate.
6. Type V: reduce weight. Modify intake of cholesterol. Keep fat intake low.

Hypertension (HPN)
*characterized by elevated blood pressure (>140/90 mmHg); a symptom that accompanies many cardiovascular
and renal diseases
*it can occur at any age, most frequently above 40 years
*excessive smoking and emotional disturbances are contributory factors
*it increases the risk of developing coronary heart disease
*it is positively correlated with obesity, psychological stress, and a high sodium intake, but all HPN is not responsive
to sodium reduction

Classification of HPN based on diastolic pressure:
1. Mild: 90-104 mm Hg
2. Moderate: 105-119 mm Hg
3. Severe: 120-130 mm Hg or above

A. Types
1. Primary or Essential the cause is unknown; approximately 85-90% of cases belong to this category; can be
controlled
2. Secondary 10% of cases result from renal disease, tumor of the adrenal gland, or brain lesion

B. Treatment
1. Medical
a. Diuretics thiazides (hydrochlorothiazide, chlorothiazide), furosemide (Lasix)
*may induce hypokalemia
b. Antiandregenic agents methyldopa (Aldomet), clonidine (Catapers)
c. Drugs acting on the sympathetic nervous system (beta-blockers) and vasodilators

2. Diet/Treatment
*Low-sodium diet
*Kilocalories restricted to reduce weight if patient is obese/overweight
*Exercise
*Relaxation therapy to decrease stress
Aggressive diet and drug therapy are required for severe hypertension.

Sources of Sodium in the Diet
a. Natural (inherent) Na foods of animal origin are naturally high in Na such as meat, poultry, egg, milk, and
cheese
Organ meats have more Na than muscle meats
Shellfish are high in Na
b. Na added in foods
1,000 mg salt or NaCl contains 400mg Na
1 tsp salt provides 2,000 mg Na
Sodium carbonate in baking soda; sodium benzoate as a preservative in relishes; sodium
propionate in cheeses and breads; monosodium glutamate (MSG) as seasoning; sodium alginate
used to smoothen texture of ice cream

Food labelling (sodium):
Sodium-free less than 5 mg (0.2mEq) of Na per serving
Very low sodium 35 mg (1.5mEq) or less of Na per serving
Low sodium 140mg (6mEq) or less of Na per serving
Reduced sodium foods are altered to reduce the usual level of Na by at least 25%
Without added salt; Unsalted; No salt added processed without salt
Lite or light may be reduced in calories, fat or sodium; Na content reduced by at least 50%

Nutritional Care Objectives:
1. Lose weight if obese. In men, there is a 6.6mm-rise in blood pressure for every 10% weight gain
2. Control blood pressure to lessen the likelihood of CHF or stroke. Lower BP to a safe level.
3. Induce negative Na balance in the body only when this is absolutely required to lower BP rapidly. The
average diet contains 6-15g of Na. A low Na diet (10mEq) increases vascular and lymphocyte beta-
andrenergic responsiveness, thereby lowering BP.
4. Reduce excessive intake of caffeine and alcohol, which may increase BP.
5. Increase calcium by 400 mg/day. Increase magnesium, vitamins D, E, And K
6. Force fluids unless contraindicated
7. Increase potassium intake to increase the need for hypertensive medications
8. Increase physical activity

Sodium-restricted diets are used in the management of essential hypertension, impaired liver function,
cardiovascular disease, renal disease, and renal or cardiac failure.
The aim of sodium restriction is to restore normal Na balance to the body by promoting the loss of excess
sodium from extracellular fluid components, thus reducing HPN, edema, and/or ascites. Sodium is the major cation
of extracellular fluid. Normally, moderate Na loads are excreted in urine. In certain pathologies, a breakdown in the
bodys normal homeostatic mechanism results in Na and water retention in cells and an increased resistance to
blood flow.

Diseases of the Heart

Myocardial Infarction (MI) or Coronary Thrombosis or Heart Attack
*results in the death of part of the heart muscles

Cerebrovascular Accident (CVA) or stroke
*partial brain damage due to constricted blood supply caused by either ruptures, clots, or blood vessel spasms

Nutritional Care Objective: to reduce cardiac workload and initiate modification of diet-related risk factors


Diet:
Phase I (inpatient)
Liquids during the first 24 hours
Restrict caffeine-containing beverages
Low Na (2000 mg or 90 mEq) to reduce cardiac workload and control HPN
Small frequent meals
Low fat
Low cholesterol
Restricted kcal if obese or overweight

Phase II (outpatient-monitored)
Approximately 8 weeks duration
Review and reinforce diet modification in Phase I
Exercise

Phase III (outpatient-lifelong, nonmonitored)
Minimum of 6 months beyond Phase II
Emphasis on education, prevention, support, and rehabilitation

Specifics Objectives for Acute MI:
1. Promote rest to reduce heart strain. Avoid the distention of heavy meals
2. Prevent arrhythmias by serving food at body temperature
3. Avoid both constipation and flatulence
4. Avoid excessive heart stimulation from caffeine
5. Reduce elevated levels of lipids: keep cholesterol below 210-230mg/dL, triglycerides
6. Prevent death from arrhythmia or asystole
7. Decrease energy required to chew, prepare meals, etc.
8. Initiate healing and promote convalescence
9. Decrease excess weight to reduce stress on the heart

Congestive Heart Failure
*CHF results in reduced heart pumping efficiency in the lower two chambers, with less blood circulating to body
tissues, congestion in lungs or body circulation, ankle swelling, abdominal pain, ascites, hepatic congestion, jugular
vein distention and breathing difficulty.
*It can be caused by coronary or another heart disease, lung disease, severe anemia, or low thyroid function
Right-sided CHF yields pitting edema of extremities and fatigue
Left-sided CHF affects the lungs, with pulmonary edema, rales, and dyspnea
*Stages:
a. Compensation heart is slightly damaged, near normal circulation is maintained
b. Decompensation heart is no longer able to maintain normal circulation to supply nutrients and oxygen
to the tissues or to dispose carbon dioxide and other wastes

Characteristics:
1. Weakened heart is unable to sustain normal circulation, thus there is decreased cardiac output
2. Presence of edema due to shift of body water from circulatory plasma and interstitial spaces
3. Reduced renal blood flow triggers ADH and aldosterone mechanism resulting in edema formation
4. Chest pains, dyspnea, weakness, nausea
5. Digitalis increases strength of heart contraction
6. Diuretics reduce abnormal fluid retention
7. Nutrient losses, glucose intolerance, hyperuricemia


Dietary Recommendations:
1. Restrict Na (500 mg at first; then progress to 1000mg as edema subsides). Not all patients require the strict
limitations; 4 to 6 g of Na may be satisfactory. Increase salt in the dinner meal rather than in the lunch
2. Diet should provide adequate potassium to replace potassium losses. Also monitor K supplementation
3. Provide five to six small meals a day, with no more than 3L fluid per day
4. If patient is obese, a calorie-controlled diet is necessary
5. Restrict caffeine intake at first, no caffeine is allowed; later, coffee intake should be limited to 4 to 5 cups of
coffee/day
6. Use bland, low-roughage foods to lessen heartburn, distention, and flatulence. Beans, cabbage, onions, cauliflower,
and Brussels sprouts may cause these problems.
7. Use soft textures to reduce the amount of chewing. Add soluble fiber from apples or oat bran if tolerated
8. If TPN is used, ensure adequate nutrient intake (including selenium, etc.)
9. If fat intolerance occurs, try MCT
10. Ensure adequate intakes of vitamins E, B6, and B12, folic acid, and riboflavin. Thiamine levels also tend to be low
and should be supplemented.