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Medical Nutrition Therapy in

Cardiovascular Disease






A Nation at Risk
 49 million Americans smoke
 42 million have total cholesterols
>240 mg/dl
 63 million have total cholesterols
 17 million Americans have diabetes
 61 million Americans are obese; 68
million are overweight

obesity found to increase the risk of heart disease  1970: High blood pressure found to increase the risk of stroke . and EKG abnormalities found to increase the risk of heart disease  1967: physical activity found to reduce the risk of heart disease.Framingham Milestones  1960: cigarette smoking found to increase the risk of heart disease  1961: Cholesterol level. blood pressure.

Framingham Milestones  1976: Menopause found to increase the risk of heart disease  1978: Psychosocial issues found to affect the risk of heart disease  1988: High levels of HDL found to reduce risk of death  1994: Enlarged left ventricle found to increase the risk of stroke  1996: Progression from hypertension to heart failure described .

structural and compositional changes in the inner wall of the arteries  Manifested in clinical end points of myocardial infarction (MI) and sudden death .Coronary Heart Disease (CHD) or Coronary Artery Disease  (CAD)impeded blood flow to Disease involves the network of blood vessels surrounding and serving the heart  Major cause is atherosclerosis.

and calcium (rate depends partly on level of LDL-C in the blood) → . protein. incorporating cholesterol.Pathophysiology of Atherosclerosis  Vessel lining is injured (often at branch points) →  Plaque is deposited to repair injured area →  Plaque thickens. muscle cells.

Pathophysiology of
Atherosclerosis (cont)
 Arteries harden and narrow as
plaque builds, making them less
elastic →
 Increasing pressure causes
further damage →
 A clot or spasm closes the
opening, causing a heart attack

Pathophysiology of
 Proliferation of smooth-muscle
cells, macrophages, and
 Formation of smooth muscle cells
into a connective tissue matrix
 Accumulation of lipid and
cholesterol in the matrix around
the cells

Endothelial Injury
Caused by
 Hypercholesterolemia
 Oxidized low-density lipoprotein
 Hypertension
 Cigarette smoking
 Diabetes
 Obesity
 Homocysteine
 Diets high in saturated fat and cholesterol

Philadelphia: W. Fundamentals.B. 2000) .Natural Progression of Atherosclerosis (From Harkreader H. Saunders.

Heart Attack (Myocardial Infarction) .

the heart is damaged  May cause the heart to beat irregularly or stop altogether  25% of people do not survive their first heart attack .Heart Attack (Myocardial Infarction)  When blood supply to the heart is disrupted.

neck and shoulder pain (especially women)  Irregular heartbeat . prolonged chest pain or pressure  Shortness of breath  Sweating  Nausea and vomiting (especially women)  Dizziness (especially women)  Weakness  Jaw.Symptoms of a Heart Attack  Intense.

high-fat meal (increases risk of clotting) .Factors That May Bring On Heart Attack (in at- risk)  Dehydration  Emotional stress  Strenuous physical activity when not physically fit  Waking during the night or getting up in the morning  Eating a large.

Cerebrovascular Accident (CVA) or Brain Attack .

Brain Attack (Stroke) or Cerebrovascular Accident .

phospholipid. and density  Consist of varying amounts of triglyceride.Functions of Lipoproteins  Lipids are transported in the blood bound to protein  Lipoproteins vary in composition. cholesterol. and protein  The ratio of protein to fat determines the density (HDLs have more protein than LDLs) . size.

Lipoproteins combine  Lipids (triglycerides. cholesterol)  Protein  Phospholipids .

Functions of the Plasma Lipoproteins  Chylomicron—Transport of dietary triglyceride  VLDL—Transport of endogenous triglyceride  IDL—LDL precursor  LDL—Major cholesterol transport lipoprotein  HDL—Reverse cholesterol transport .

Lipoprotein Summary .

and triglyceride level after fasting .Lipoprotein Assessment  Includes measurement of total cholesterol. HDL cholesterol. LDL cholesterol.

Total Cholesterol  Captures cholesterol contained in all lipoprotein fractions  60%-70% is carried on LDL  20%-30% is carried on HDL  10%-15% on VLDL .

positive association between TC and CHD risk  Diets high in saturated fats raise total cholesterol and CHD incidence and mortality  ATP-III Guidelines: lowering total cholesterol and LDL-C reduces CHD risk  10% reduction in TC decreases CHD risk by about 30% .Total Cholesterol  Direct.

thiazide saturated fat.Factors Affecting Total Cholesterol  Age  Drugs (beta  Diets high in fat. blockers.  Season of the year menopause)  Diseases  Exogenous steroids . diuretics) cholesterol  Body weight  Genetics  Glucose tolerance  Endogenous sex  Physical activity hormones (pre.

↑ risk of pancreatitis  Can be evidence of metabolic syndrome .Total Triglycerides  Triglyceride-rich lipoproteins include chylomicrons. VLDL. remnants or intermediary products  Are atherogenic  At very high levels.

triglycerides are hydrolyzed by lipoprotein lipase (LPL) in muscle and adipose tissue  When 90% of triglyceride is hydrolyzed.Chylomicrons  Largest particles  Transport dietary fat and cholesterol from the small intestine to the liver  In the bloodstream. released into blood as a remnant  Liver metabolizes remnants. but some deliver cholesterol to the arterial wall  Absent in fasting studies .

but TG in them is measured in total triglyceride .Very-Low-Density- Lipoproteins  Manufactured in the liver to transport endogenous triglyceride and cholesterol  60% is triglyceride  Large VLDL may be nonatherogenic  VLDL remnants or IDL appear to be atherogenic  Not routinely measured.

Intermediate-Density Lipoprotein  Formed with catabolism of VLDL. though components can be . a precursor of LDL  Rich in cholesterol and apo E  High concentrations of IDL and VLDL remnants directly related to lesion progression and coronary events  Not routinely measured.

adrenals. other tissues. rest is metabolized via alternative pathways  Number and activity of receptors determines LDL cholesterol levels in the blood .Low-Density Lipoprotein  Primary cholesterol carrier in blood  Total cholesterol and LDL-cholesterol are strongly correlated  95% of apolipoproteins in LDL are apo- B-100  LDL is formed in VLDL catabolism. 60% is taken up by LDL receptors in liver.

density. cholesterol depleted. predictive of CHD risk in men and women . not associated with disease risk  Phenotype B typified by small. triglyceride rich. LDL-C  Particles heterogeneous in size. dense LDL particles. lipid components  Phenotype A: large particles.

VLDL remnants. dense LDL .High Density Lipoproteins (HDL)  Contain more protein than the other lipoproteins  Apo A-1 is involved in tissue cholesterol removal  High HDL is associated with low levels of chylomicrons. and small.

LDL- cholesterol. and triglycerides  8-12 hour fast allows chylomicrons to clear  Friedenwald formula for calculating LDL-C = (TC) – (HDL-C) – (TG/5) . HDL-cholesterol.Lipoprotein Profile  Measures total cholesterol.

Lipoprotein Profile  If nonfasting. can measure total and HDL cholesterol  If TC>200 mg/dl or HDL-C is <40 mg/dl. get fasting analysis .

accessed 2-2005 . Evaluating Blood Lipids: Total Cholesterol <200 mg/dL Desirable 200-239 Borderline high mg/dL ≥240 mg/dL High Source: ATP-III Guidelines. NHLBI.

NHLBI. accessed 4-2005 . Evaluating Blood Lipids: Triglycerides <150 mg/dL Normal 150-199 Borderline high 200-499 High >500 mg/dl Very high Source: ATP-III Guidelines.

Evaluating Blood Lipids: LDL <100 mg/dL Optimal 100-129 Near optimal 130-159 Borderline high 160-189 High ≥190 Very high Source: ATP-III Guidelines. accessed 2-2005 . NHLBI.

Evaluating Blood Lipids: HDL < 40 mg/dL Low ≥ 60 mg/dL High Source: ATP-III Guidelines. accessed 2-2005 . NHLBI.

independent risk factors  Life-habit risk factors  Emerging risk factors .Risk Factors affect Lipid Targets  Major.

Major Risk Factors That Modify LDL Goals  Cigarette smoking  Hypertension (BP 140/90 mmHg or on antihypertensive medication)  Low HDL cholesterol (<40 mg/dL)†  Family history of premature CHD – CHD in male first degree relative <55 – CHD in female first degree relative <65 – Age (men 45 years. women 55 † years) .

Life-Habit Risk Factors
 Obesity (BMI  30)
 Physical inactivity
 Atherogenic diet

Emerging Risk Factors
 Lipoprotein (a)
 Homocysteine
 Prothrombotic factors
 Proinflammatory factors
 Impaired fasting glucose
 Subclinical atherosclerosis

Risk Assessment
Count major risk factors*
 For patients with multiple (2+) risk factors
– Perform 10-year risk assessment
 For patients with 0–1 risk factor
– 10 year risk assessment not required
– Most patients have 10-year risk <10%

 *HDL cholesterol 60 mg/dL counts as a “negative” risk
factor; its presence removes one risk factor from the total

CHD Risk Equivalents  Risk for major coronary events equal to that in established CHD  10-year risk for hard CHD >20% Hard CHD = myocardial infarction + coronary death .

Diabetes In ATP III. . diabetes is regarded as a CHD risk equivalent.

Diabetes as a CHD Risk Equivalent  10-year risk for CHD  20%  High mortality with established CHD – High mortality with acute MI – High mortality post acute MI .

CHD Risk Equivalents  Other clinical forms of atherosclerotic disease (peripheral arterial disease. and symptomatic carotid artery disease)  Diabetes  Multiple risk factors that confer a 10-year risk for CHD >20% . abdominal aortic aneurysm.

htm s/cholesterol/atglance.nhlbi.Calculate Your 10-Year Risk of Heart Attack  Risk Calculation http://hp2010.asp?usertype=pub  At-A-Glance treatment guidelines: http://www.nih.

Three Categories of Risk that Modify LDL-C GOALS Risk Category LDL Goal (mg/dL) CHD and CHD risk equivalents <100 Multiple (2+) risk factors <130 Zero to one risk factor <160 .

ATP III Guidelines Goals and Treatment Overview .

Primary Prevention With LDL-Lowering Therapy Public Health Approach  Reduced intakes of saturated fat and cholesterol  Increased physical activity  Weight control .

and corticosteroids) .Causes of Secondary Dyslipidemia  Diabetes  Hypothyroidism  Obstructive liver disease  Chronic renal failure  Drugs that raise LDL cholesterol and lower HDL cholesterol (progestins. anabolic steroids.

major coronary events. coronary mortality. Secondary Prevention W/ LDL-Lowering Therapy  Benefits: reduction in total mortality. coronary procedures. and stroke  LDL cholesterol goal: <100 mg/dL  Includes CHD risk equivalents  Consider initiation of therapy during hospitalization (if LDL 100 mg/dL) .

2004 . Factors consider drug (10-year risk options) 10-20%) ATP-3 update. Circulation.LDL-C Goals in Different Risk Categories LDL for Total LDL for Lifestyle Drug Therapy LDL Goal Change (TLC) Risk Category (mg/dL) (mg/dL) (mg/dL) CHD or CHD <100.  100 Risk optional (<100: Equivalents  100 goal <70 consider drug (10-year risk mg/dL options >20%) Moderately high risk >130 mg/dL (100-129 2+ Risk <130  130 mg/dL.

2004 . Circulation. <160 mg/dL >160 mg/dL >190 mg/dL 1 risk factors) (160-189 mg/dL. drug optional) ATP-3 update.LDL-C Goals in Different Risk Categories LDL for Total LDL for Lifestyle Drug Therapy LDL Goal Change (TLC) Risk Category (mg/dL) (mg/dL) (mg/dL) Moderate risk: <130 mg/dL >130 mg/dL >160 mg/dL 2+ risk factors (10 year risk<10%) Lower risk (0.

shortness of breath. and congestion .Congestive Heart Failure (CHF)  A clinical syndrome characterized by progressive deterioration of left ventricular function. fatigue. inadequate tissue perfusion.

Compensated—Lack of O2 to tissues causes increase in heart rate and enlargement of heart 2.Congestive Heart Failure (CHF) —cont’d Gradual failure of heart 1. Decompensated—Heart no longer adjusts .


medication noncompliance. muscle. infection. arrhythmias. anemia can precipitate complete CHF . dietary sodium excess. pulmonary embolism. vessels. myocardial infarction. arteries) and vasculature (hypertension) cause left ventricular systolic dysfunction  Once established.Causes of Heart Failure  Diseases of the heart (valves.

Risk Factors  Hypertension (91% of Framingham cohort had hypertension before CHF)  Left ventricular hypertrophy  Coronary heart disease (causes 60- 65% of cases)  Diabetes  Mean age of onset is 70 years .

12 Ed. low EF. diabetes. without syx or using cardiotoxins. refractoryth awaiting transplant Krummel in Krause. metabolic structural damage syndrome B Structural heart LVH or fibrosis. reduced exercise or prior syx of HF tolerance D Advanced structural Frequently hospitalized. with HF but no asymptomatic valve disease. CAD.Stages of Heart Failure A High risk of HF HBP. left ventricular disease associated dilatation. alcohol because of presence abuse. symptoms . signs/syx previous MI C Structural heart Dyspnea or fatigue due to LV disease with current dysfunction. of risk factors but family hx cardiomyopathy. hx rheumatic fever. damage.

patient comfortable at rest Class Inability to carry out physical . patient comfortable at rest Class Marked limitation of physical III activity.Classifications of Heart Failure Class I No undue symptoms associated with ordinary activity. no limitations Class II Slight limitation of physical activity.

Congestive Heart Failure Symptoms  Dyspnea  Orthopnea  Nausea  Fullness  Pulmonary edema  Cardiac edema  Cardiac cachexia .

fluid in lungs. pulmonary disease .CHF DIAGNOSIS  EKG or electrocardiogram – measures the rate and regularity of the heartbeat – May indicate whether there has been heart damage or changes in anatomy  Chest X-ray – Shows whether heart is enlarged.

CHF DIAGNOSIS  Echocardiogram – Most useful test in diagnosis of heart failure – Uses sound waves to create a picture of the heart – Evaluates heart function: cardiac output and areas of the heart that are not contracting normally .

Other Cardiac Tests  Holter Monitor: ambulatory electrocardiography – Worn for 24 hours and provides a continuing recording of heart rhythm during normal activity  Cardiac Blood Pool Scan (radionuclide ventriculography or nuclear scan) – Uses radioactive imaging agent injected into a vein to outline chambers of the heart and blood vessels – Shows how well heart is pumping blood to the rest of the body .

collect blood samples  Coronary angiography: usually done along with cardiac catheterization – Dye injected into coronary arteries and/or chambers of the heart – Allows angiographer to visualize flow of blood .Other Cardiac Tests  Cardiac Catheterization – Flexible tube passed through vein in the groin or arm to reach the coronary arteries – Allows physician to visualize the arteries. check pressure and blood flow in coronary arteries.

Cardiac Tests  Exercise Stress Test – EKG and blood pressure readings are taken before. and after exercise to determine how the heart responds to exercise – Patient exercises on a treadmill or stationary bike until reaches a heartrate established by the physician – Echocardiogram often included . during.

and to LVH  Used to grade the severity of heart failure .BNP and NT-proBNP Blood Test  Measure the concentration of BNP (hormone made by the heart) or NT- proBNP (both formed when pro-BNP is cleaved into two fragments)  Released as a natural response to heart failure. to hypotension.

Cachectic Heart  A soft. flabby heart characterized by loss of myocardial mass as the result of extreme malnutrition .

Alcohol—none to moderate 5. Na restriction (500 to 1000 mg) 2. Monitor serum K—hypokalemia possible with diuretics and digoxin) 3. Fluid restriction 4.Congestive Heart Failure  Goal: decrease work of heart Treatment  Diet 1. Caffeine—can cause MI or cardiac arrhythmia .

 Beta blockers slow heart rate and lower blood pressure to decrease the workload on the heart.Medications Used in Heart Failure  Diuretics help reduce fluid buildup in lungs and peripheral edema  ACE inhibitors lower blood pressure and reduce the strain on the heart.  Digoxin makes the heart beat stronger and pump more blood. These medications also may reduce the risk of a future heart attack.  Vasodilators: reduce blood pressure and stress on the heart .

MNT in HF  Fluid restriction  Sodium restriction  Meet energy/protein needs  Prevent cardiac cachexia  Small frequent meals .

limit to 1000-1500 ml  Maintain restricted sodium diet even if serum sodium depleted. sodium has moved from blood to tissues .Fluid Restriction  If hyponatremia occurs (serum sodium <130 mEq/L)  Limit total fluids to <2000 ml  In severe decompensation.

Fluid Status and Assessment  Patients should record daily weights and advise care providers if weight gain exceeds 2-3 lb a day or 5 lb in a week  Restricting sodium and fluids (decreasing by 1 to 1.5 cups) may prevent complete HF .

popsicles count towards fluid allotment .Fluid Calculations  Hospitalized patients may be limited to 500-2000 ml daily  Foods having a high fluid content may also be limited  Foods that are liquid at room temperature such as ice cream. gelatin. yogurt.

Living with Fluid Restrictions  Freezing fruit or sucking on sugar free hard candy may help  Fluid status monitored by measuring urine specific gravity and serum electrolyte values and observing for clinical signs of edema  Restrictions often discontinued when patients leave the hospital .

metabolic. circulatory. inflammatory. and neuroendocrine changes in skeletal muscle  Serious complication of HF .Cardiac Cachexia  Involuntary weight loss of >6% of nonedematous body weight over a 6- month period  Significant loss of lean body mass: exacerbates HF  Cachectic heart: soft and flabby  Structural.

MUAC) and diet history .Cardiac Cachexia  Patients with cardiac cachexia may lose 10-15% of their body weight (dry weight)  Other markers (serum prealbumin and transferrin) may be disproportionately low because of the dilutional effect of excess fluid  Use anthropometrics (measurement of calf and thigh circumference.

2008 .. IL-1 and I-6) are elevated in the blood and myocardial tissue  Reduced blood flow to the gut may reduce gut integrity leading to entry of bacteria and endotoxins  High TNF associated with reduced BMI. reduced visceral proteins Krummel in Krause.Cardiac Cachexia  Proinflammatory state in which cytokines (TNF. lower skinfolds. 12th ed.

6-1.Energy Needs in HF  For obese patients. 35 kcals/kg often used  Patients with cardiac cachexia may require 1. hypocaloric diets (1000-1200 kcals) will reduce the stress on the heart  In undernourished patient.8 times resting energy expenditure for repletion . energy needs are increased by 30-50% above basal levels.

Sodium  Impaired cardiac function → inadequate blood flow to the kidneys → aldosterone and antidiuretic hormone secretion  Aldosterone promotes sodium resorption and ADH promotes water conservation  Even patients with mild heart failure can retain sodium and water if consuming a high salt diet (6 g or 250 mEq/day) .

Sodium in Patients with Heart Failure  Recommendations vary between 1200 to 2400 mg/day (adequate intake 1200 mg/d)  Patients on high dose lasix (>80 mg/day) <2000 mg  Severe restrictions are unpalatable and nutritionally inadequate  Ethnic differences in sodium intake  Use least restrictive diet that achieves clinical goals .

spices and other seasonings  Drugs and antacids may contain sodium . herbs. 80% from processed foods  Minimum to maintain life is 250 mg/day  Salt substitutes.Dietary Sources of Sodium  Salt used at the table  Salt or sodium compounds added during preparation or processing  Inherent sodium in foods  Chemically softened water  Average American consumes 4 to 6 g sodium/day.

table salt not allowed. Difficult to maintain at home . no more than ¼ t of table salt allowed 1 g (43 mEq) High and moderate sodium foods Moderate eliminated. mixed veg and corn omitted d/t brine in processing.Characteristics of Common Sodium Restrictions 3 g (131 mEq) High sodium foods are limited. no more No added salt than ½ t of table salt allowed 2 g (87 mEq) High sodium foods are eliminated. lima beans. canned/processed foods containing salt omitted. regular bread and baked goods limited. Mild restriction moderate sodium foods are limited. frozen peas.

corn) omitted due to brine  High sodium vegetables beets. chard. beet greens. mustard greens. Table salt not allowed. dandelion greens omitted  Low sodium bread instead of regular bread  Meat limited to 6 ounces . celery. mixed vegetables. lima beans. spinach. rutabagas.500 mg Sodium Diet  High sodium. carrots. kale. moderate sodium foods eliminated. white turnips. Canned or processed foods containing salt omitted  Frozen vegetables (peas.

Food Labeling Guide (standard serving) Sodium Free Less than 5 mg Very Low Sodium 35 mg or less Low Sodium 140 mg or less Reduced Sodium At least 25% less sodium than regular food Light Sodium 50% less sodium Unsalted. No Salt Added Lightly Salted 50% less added sodium than normally added (product must state “not a low-sodium food”) . No salt added during processing Without Added Salt.

mouthwashes  Chewable antacid tablet can add 1200 to 7000 mg of sodium daily  Aspirin: 50 mg sodium per tablet . sulfonamides. stomach alkalizers.Nondietary Sources of Sodium  Medications: barbiturates. laxatives. antibiotics. cough medications.

Potassium  Potassium wasting diuretics (hydrochlorthiazide. contraindicated in renal failure and with certain other medications . furosemide) increase potassium excretion which may lead to digitalis toxicity  Some patients will need potassium supplements  Salt substitutes can provide 500-2000 mg of potassium per teaspoon.

Sodium and Salt Gram and Milliequivalent Measures 1 mEq Na = 23 mg NA .

Other Dietary Factors in Heart Failure  Alcohol and caffeine  Weight maintenance  Calcium and vitamin D  Magnesium  Thiamin supplementation  Small frequent feedings  Supplements .

especially cachectic patients.Other Nutritional Issues  Calcium and Vitamin D: half of patients with severe HF have osteopenia or osteoporosis. measure blood mg levels  Thiamin status should be evaluated in HF patients on loop diuretics . use calcium supplements with caution w/ cardiac arrhythmias  Magnesium: diuretics may increase mg excretion.

Cardiac Assist Devices  Mechanical heart pumps  May be helpful in pre-transplant HF patients or in those for whom transplant is not an option .