Nutrition Department

Medical Faculty Diponegoro University

Atherosclerosis

 Involves progressive narrowing of the arterial

tree.
 Fat deposits accumulation occur
 Most often affected : heart, brain, leg arteries
 Underlying cause of Coronary Heart Disease
Pathophysiologic Steps in Development of
Coronary Heart Disease/Myocardial Infarction

Phase 1 Fatty streaks (atherogenesis)

Phase 2 Atheroma (or plaque) formation
Phase 3 Complicated lesions with rupture
(nonocclusive thrombosis)
Phase 4 Complicated lesions with rupture and
occlusive thrombosis
Phase 5 Fibrosis (occlusive) lesions
Natural Progression of
Atherosclerosis

(From Harkreader H. Fundamentals. Philadelphia: W.B. Saunders, 2000)

© 2004, 2002 Elsevier Inc. All rights reserved.

Plaque That Has Been Surgically Removed
from Coronary Artery

Courtesy Ronald D. Gregory and John Riley, MD.

Coronary Heart Disease (CHD) or
Coronary Artery Disease (CAD)

 Disease involving the network of blood vessels

surrounding and serving the heart
 Manifested in clinical end points of myocardial
infarction (MI) and sudden death
Cardiovascular Disease (CVD)
• CVD has been the leading cause of death in
the United States for every year since 1900,
except 1908.
• CVD kills almost as many people yearly as the
next seven causes of death combined.
Category I Risk Factors
for Coronary Heart Disease

 Cigarette smoking
 Elevated LDL and total cholesterol
 Hypertension
 Left ventricular hypertrophy (LVH)
 Thrombogenic factors
Category II Risk Factors
for Coronary Heart Disease
 Diabetes mellitus types 1 and 2
 Physical inactivity
 Low HDL cholesterol
 Obesity
 Menopausal factors
Hyperlipidemias
 Elevated blood triglycerides and/or cholesterol
 Lipoproteins found in blood
 Chylomicrons = postprandial dietary fat
 Very-low-density lipoproteins (VLDL) = lipid being transported from liver
to peripheral tissue
 Low-density lipoproteins (LDL) = transport of cholesterol
 High-density lipoproteins (HDL) = reverse transport of cholesterol,
tissues to liver

 Type of hyperlipidemia depends upon portion of particles present

LDL and HDL Cholesterol
Laboratory Values Predict Risk of CHD

 LDL-C >130 mg/dl

 HDL-C <35 mg/dl
 Total cholesterol (TC) >200 mg/dl
 Total triglycerides (TG) >150 mg/dl
 Formula: LDL-C = TC – HDL-C–(TG/5)
DYSLIPIDEMIA
(A consequence of abnormal lipoprotein
metabolism)

 Elevated Total Cholesterol (TC)

 Elevated Low-density lipoproteins (LDL)
 Elevated triglycerides (TG)
 Decreased High-density lipoproteins (HDL)
 PRIMARY DYSLIPIDEMIA
ETIOLOGY
 SINGLE OR MULTIPLE GENE MUTATION –
RESULTING IN DISTURBANCE OF LDL, HDL
AND TRIGYLCERIDE, PRODUCTION OR
CLEARANCE.
Should be suspected in patients with
 premature heart disease
 family hx of atherosclerotic dx.
 Or serum cholesterol level >240mg/dl.
 Physical signs of hyperlipidemia.
SECONDARY DYSLIPIDEMIA
(Most adult cases of dyslipidemia are secondary in nature in
western civilizations)

 Sedentary lifestyle
 Excessive consumption of cholesterol –
saturated fats and trans-fatty acids.
Secondary Dyslipidemia
(Medical Conditions Associated with
dyslipidemia)
 Diabetes
 Hypothyroidism
 Cholestatic liver disease.
 Nephrotic syndrome
 cigarette smoking
HDL Cholesterol Levels Predict
Risk of Coronary Heart Disease
 Increased by: Exercise
Weight loss
Moderation of
alcohol
 Decreased by: Obesity
No exercise
Cigarettes
Androgenic steroids
B blockers
High TGs
Genetic factors
LDL Cholesterol Levels Predict
Risk of Coronary Heart Disease

 Increased by
 Fat in diet
 Obesity
 Diabetes
 Hypothyroidism
 Decreased by
 Estrogen
Primary Prevention with Lipoprotein
Analysis

(From National Cholesterol Education Program: Second Report of the Expert Panel on Detection, Evaluation,
and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II). National Institutes of Health,
NIH Publication No. 93-3095. Bethesda, MD: National Heart, Lung, and Blood Institute, 1993.)
Primary Prevention in Adults without Evidence of
CHD: Initial Classification Based on Total
Cholesterol and HDL Cholesterol

(From National Cholesterol Education Program: Second Report of the Expert Panel on Detection,
Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II). National
Institutes of Health, NIH Publication No. 93-3095. Bethesda, MD: National Heart, Lung, and Blood
Institute, 1993.) HDL = high-density lipoprotein.
Diet Therapy for High Blood Cholesterol

(Data from National Cholesterol Education Program [NCEP]. Second Report of the Expert Panel on Detection, Evaluation, and
Treatment of High Blood Cholesterol in Adults [Adult Treatment Panel II]. NIH Publication N. 93-3095. Bethesda, MD; National
Institutes of Health. National Heart, Lung, and Blood Institute, 1993.) * Calories from alcohol not included.
 Angina Pectoris
 Involves retrosternal chest pain or discomfort
from decreased blood flow to the myocardium,
from decreased oxygen supply
 Mostly correlated with hypertension or coronary
heart disease
 Other sign and symptomps : shortness of breath,
sweating, nausea, vertigo
Medical Nutrition Therapy

 Relieve chest pain, improve circulation to the

heart
 Increase activity only as tolerated
 Maintain adequate rest periods
 Maintain weight or lose weight if obese
 Avoid constipation without straining
Dietary and Nutritional
Recommendations
1. Small, frequent feedings
2. Increased fiber as tolerated
3. Restricted saturated fats, cholesterol, sodium
and caffeine
4. Promote calorie control if overweight
5. Increased antioxidant intake
6. Folic acid, Vit B6 and B12 ( if homocystein levels
are high)
Myocardial Infarction (MI)
Coronary Infarction, Coronary Thrombosis,
or Heart Attack

 Some part of coronary circulation blocked

 Ischemia leads to muscle destruction
Risk factor for MI:

 Cigarette smoking  Lack of physical

 Chronic alcoholism Exercise
 Excessive intake of  Severe emotional
saturated fats
stress
 Coffee
 Familial
 Excessive
carbohydrate intake predisposition
 Lack of dietary fibers
Myocardial Infarction—MI

Postinfarction nutrition
1. 1st 24 hrs: no caffeine, liquid diet
(nausea and choking are common)
2. Small frequent meals; soft or liquid diet
3. Na+ restriction if BP and fluid status indicate
Congestive Heart Failure (CHF)

 A clinical syndrome characterized by

progressive deterioration of left ventricular
function, inadequate tissue perfusion, fatigue,
shortness of breath, and congestion
Gradual failure of heart
1. Compensated—Lack of O2 to tissues causes
increase in heart rate and enlargement of heart
2. Decompensated—Heart no longer adjusts
Congestive Heart Failure
 Symptoms:
- Dyspnea: labored of difficult breathing
- Orthopnea: difficult breathing in the
recumbent
position
- Nausea
- Pulmonary edema
- Cardiac edema
- Cardiac cachexia: loss of muscle strength of
the heart
Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000.
Medical Nutrition Therapy

 Lower elevated serum lipids

 Initiate and maintain weight loss if patient is
obese
 Improve HDL cholesterol levels
 Correct high level of homocysteine
Dietary and Nutritional
Recommendation (1)
 Calorie-controlled diet (complex CHO rather
than simple sugar)
 Weight loss may be masked by fluid retention
 Total fat should be controlled at 30 % of otal
Kcal
 Restricted SFA (to 10% of total FA), Increase
MUFA and PUFA
 Limit cholesterol to 250 mg / day
Dietary and Nutritional
Recommendation (2)
 Fewer animal proteins, more legumes and
vegetables
 Adequate high soluble fiber intake
 Antioxidant
 Folic acid, vitamin B6 and B12
 Sodium restriction; individualize from moderate(4 g:
Na) to severe(250 mg: extreme diet rarely used)
 Education
High-Sodium Foods
Sodium-Containing Additives