Case Report

Nutritional Management of Atrial Fibrillation Alyssa Peterson 11/24/2013

Disease Description

Atrial Fibrillation (AF)

Most common form of an arrhythmia Irregular heartbeat rate or rhythm Rapid signals cause the atria to fibrillate

(contract irregular)

AF with RVR

rapid ventricular response, (RVR) Common tachyarrhythmia Requires hospitalization Defined as having greater than 100 bpm plus symptoms of:

Lightheaded Hypotension Chest pain

Comorbidities

Stroke

A blood clot forms due to an extra pool of blood in the atria. If the clot breaks off it could travel to the brain and cause a stroke.

Heart Failure

Caused from not enough blood being available

Risk Factors

High blood pressure Coronary heart disease

Congenital heart defects Hyperthyroidism

Heart failure
Rheumatic heart disease Structural heart defects Pericarditis

Obesity
Diabetes Sleep apnea Lung disease

Evidence Based Nutrition Recommendations

Dietary factors and incident of

atrial fibrillation1

Purpose:

Evaluate associations between consumption of alcohol, caffeine, fiber and polyunsaturated fatty acids (PUFA) and the incidents of AF1

Methods:

Comparison to the Framingham Heart Study longitudinal study Men and women with mean age of 62 years 177 men and 119 women developed AF1

Dietary factors and incident of

atrial fibrillation

Results:

No significant associations1

P trends:

0.48 for alcohol

0.84 for caffeine

0.16 for fiber 0.57 for PUFA

Fish Intake and risk of

Atrial Fibrillation2

Purpose:

How does adherence to the Mediterranean diet relate to development of atrial fibrillation?

Methods:

Case-control study Both men and women Mean age = 54years

Total of 400 volunteers2

Fish Intake and risk of

Atrial Fibrillation

Diet includes2

Moderate consumption of wine Low consumption of meat High consumption of

Vegetables
Fruits Legumes

Nuts
Olive oil

Fish Intake and risk of

Atrial Fibrillation

Results2:

Strong adherence to diet

AF incidence lower 22 cases compared to 27 in control group

High intake of antioxidants

AF incidence lower P value: 0.001

AND Evidence Based Library

Consumption of fatty fish at least twice a week:

lowers the risk of developing a cardiovascular disease3

In 2005, the Dietary Guidelines Advisory Committee showed not enough evidence for:

consumption of PUFA protecting against cardiovascular disease.3

Case Presentation

77-year old retried Caucasian male Visiting wife in the hospital and fell down in hallway Admitted into the Intensive Care Unit (ICU) with atrial fibrillation with RVR

Client History

Family history of heart disease

Previously been diagnosed with:

Diastolic heart failure Type 2 Diabetes (T2DM) Acute renal failure Hypertension Sleep apnea Chronic obstructive pulmonary disease (COPD) Gastroesophageal reflux disease (GERD) Coronary artery disease Hyperlipidemia

Food/Nutrition-Related History

No previous problems swallowing or chewing Diet in the hospital

Nothing by mouth (NPO) and clear liquids due to surgeries and testing

Nasogastric (NG) tube was placed

Total parenteral nutrition (TPN) Clinimix 5/25 with the goal rate of 50mL/hr and 10mL/hr 20% lipids

1740kcal (29kcal/ IBW kg) ( IBW= Ideal Body Weight)

60g protein (1g/ IBW kg)

Nutrition-Focused Physical Findings

Small bowel obstruction and gastritis Underwent an exploratory laparotomy and small bowel resection Eventually began hemodialysis

due to a decrease in kidney function from surgery

Anthropometric Measurments

Weight- 254.6# BMI 43.7 (morbidly obese) Weight dropped 17.1# due to hemodialysis and Lasix after two weeks.

Biochemical Data

Labs:

BUN 39.9- 70.8 GFR 67- 11 Phosphate levels range from 30-38 mg/dL

Electrolytes within normal range

Average glucose 175mg/dL

Nutrient Needs

Estimated needs based on Ideal body weight (IBW) (130#) due to weight being greater than 125% of his IBW Energy needs: 25kcal/kg= 1477kcal

Protein needs: 1g/kg= 59g protein

Protein needs increased to 1.2g/kg= 71g once he began hemodialysis

Fluid requirements: 25mL/kg= 1477 mL

ARAMARK nutrition status

Upon admittance:

Level 2 mildly compromised due to:

BMI greater than 40, albumin ranging from 3.0-3.4

5 days later:

Level 4 severely compromised due to:

Eating and chewing problems, recent TPN, unintentional weight loss 1-2% in one week, BMI of 3539.9 and a GI obstruction

Malnutrition Identification

Chronic disease related to malnutrition for majority of hospital stay Moderate Malnutrition

Po intake of 50-75% for one month prior to admission Less than 5% weight loss in one month

Nutritional Diagnosis

Inadequate oral intake (NI-2.1) related to decreased ability to consume sufficient energy and protein as evidence by weight loss of 12% in 1 week. Altered GI function (NC1.4) related to alteration in gastrointestinal tract structure and function as evidence by bowel obstruction, lack of bowel movements.

Interventions

1. Parenteral Nutrition (ND 2.2):

REC Clinimix 5/25 with goal rate of 50mL/hr and 10mL/hr 20% lipids to provide a total of 1740 kcal (29kcal/IBW kg) and 60 g protein (1g/IBW kg). Start TPN at half rate of 25mL/hr and titrate to goal rate to prevent refeeding syndrome.

2. Parenteral Nutrition/IV Fluids (ND-2.2.7):

Start TPN protocol and additional additives per MD.

3. Referral to other providers (RC 1.5):

Refer patient to Gastroenterologist for further recommendations and procedures.

Interventions cont.

4. Discharge and transfer to community agencies/programs (RC 2.2):

When appropriate, discharge patient to Good Samaritan nursing home.

5. Carbohydrate-modified diet: (ND 1.2 (4)):

REC patient advance diet to an 1800 American Diabetes Association diet once appropriate due to the diagnosis of T2DM and use of rapid-acting insulin.

6. Commercial Supplements: (ND 3.1.1):

REC patient to begin Nepro BID to provide an additional 850kcal and 38.2g protein if consumed to promote adequate intake for nutritional needs.

Monitoring and Evaluation

1. Parenteral nutrition intake (1.3.2):

Nutritional needs are met with parenteral nutrition intake.

2. Amount of food (1.2.2.1):

Monitor amount of food eaten with goal of po intake greater than 75%.

3. Liquid meal supplement (1.2.1.3):

Monitor amount of supplement intake with goal of 100% po intake.

Monitoring and Evaluation cont.

4. Skin (PD1.1.8):

Maintain skin integrity.

5. Weight change- (1.1):

Maintain weight and prevent weight change while in house.

6. Electrolyte and renal profile (1.2):

Nutrition related lab values stay within normal limits.

Short Term Goals

1. Tolerate TPN feeding with little to no residuals

2. TPN feeding will provide adequate nutrition to meet his estimated nutritional requirements.
3. Maintain weight and skin integrity throughout admission.

Long Term Goals

1. Patient will advance diet as tolerated to an ADA 1800 kcal diet once medically able to. 2. Po intake will be greater than 75% and supplements 100% intake. 3. Prevent further worsening of symptoms and promote healthy well-being.

Conclusion
Nutritional intervention is individualized
Depends on patients history and underlying diseases

No specific medical nutrition therapy for AF treatment

Studies have looked at ways to prevent

Conclusion
Our patient went from:
o o o o o o o o o o Admittance to ICU on 10/25/13 Small bowel obstruction Began TPN Clinimix 5/25 Small bowel resection Discontinued TPN and began clear liquids Used Ensure Clear to help supplement Transition to regular diet Began hemodialysis Used Nepro to supplement Discharged to nursing home 11/22/13

References
1. Shen J., Johnson V., Sullivan L., et al. (2010) Dietary factors and the incident atrial fibrillation: Framingham heart study. American Journal of Clinical Nutrition; 93 (2) 261-266. 2. Mattioli AV, Miloro C, Pennella S, Pedrazzi P, Farinetti A. (2011) Adherence to Mediterranean diet and intake of antioxidants influence spontaneous conversion of atrial fibrillation. Nutrition, Metabolism & Cardiovascular Disease; (23) 115-121. 3. What is the relationship between consumption of seafood n-3 fatty acids and the risk of developing cardiovascular disease? (2010). Academy of Nutrition and Dietetics Evidence Analysis Library. Retrieved from http://andevidencelibrary.com/evidence.cfm? evidence_summary_id=251259&highlight=Atrial%20fibrillation&home=1

Questions?

Thank you for all your help with this project and patient!