Lauren Pavone
Cardiovascular Case Study Questions
(Myocardial Infarction)
** Case adapted from: Nelms & Anderson (2009).
Medical Nutrition Therapy—A Case Study Approach, Case #8.
Please type your answers in the spaces below. Please show all calculations (these can be
written in by hand.)
1.
Mr. Klosterman had a myocardial infarction. Explain what happened to his heart. (1)
Myocardial Infarction is a result of atherosclerosis in the coronary arteries. Cholesterol
transport by LDL to the coronary arteries builds up and signals an inflammatory
response. This response causes a build up of macrophages in the coronary arteries called
plaque, resulting in narrowing, and hardening of the artery walls. The build up of plaque
ruptured in Mr. Klosterman’s coronary artery attracting platelets to the area and
activating a clotting system to form a thrombus. The thrombus inhibited the flow of
oxygen-rich blood to the heart resulting in death of his myocardial tissue. His heart is
unable to properly contract and circulate oxygen rich blood throughout his body.
2.
What medical procedure was done to the heart area with the infarction, and what was its
purpose? (1)
Mr. Klosterman is treated with an emergency angioplasty of the infarct related artery. An
angioplasty is a procedure used to open narrow or blocked coronary arteries. In his
procedure, the doctor attempted to open the coronary artery in which the blockage
occurred resulting in his myocardial infarction. The purpose of this procedure is to allow
oxygen rich blood to continue to flow to the myocardial tissue.
3.
Examine Mr. Klosterman’s lab values. Which labs are consistent with the MI diagnosis?
Why were the levels higher on day 2? (2)
Lab values that are consistent with MI diagnosis are the enzyme levels significant of
cardiac tissue death. Increased levels of these hormones signify MI diagnosis.
CPK (creatine phosphate), Mr. Klosterman had increased serum levels are 500U/L on
day 2 and 335U/L on day 4. Serum level of Troponin T was increased at 2.4ng/dL on day
1 and 2.8ng/dL on day 2. LDH (Lactate dehydrogenase) had serum levels of 635U/L on
day 2. AST or Apartate aminotransferase had increased serum levels of 245U/L on day 2
and 175 U/L on day 4.
The values are higher on day 2, because the myocardial tissue must be dead in order to
release the enzymes. Since Mr. Klosterman first experienced angina and survived the
attack, the coronary arteries must not have been completely blocked on day 1, but narrow
enough to restrict oxygenated blood to the myocardial tissue. As the thrombus continued
to clot the artery to full blockage, allowing no oxygenated blood to flow, the myocardial
tissue did eventually die and result in the release of enzymes.
4.
List Mr. Klosterman’s modifiable and non-modifiable risk factors for cardiovascular
disease? Which of these can be addressed through medical nutrition therapy? (2)
Non-modifiable risk factors
1. Age , 61 years old
2. Male
Modifiable risk factors
1. Smoking 1pack/day
2. Obese, BMI= 26.5
3. Hyper-lipedemia (increased LDL, TG, TOTAL CHOLESTEROL, decreased HDL)
His obesity can be addressed through medical nutrition therapy with lifestyle change such as diet
and physical Activity. Decrease intake of Saturated Fat, and increase intake of Whole grains,
fruits and veggies.
3. Mr. Klosterman’s blood lipid levels were checked. Which of these were abnormal as
compared to the levels recommended by the National Cholesterol Education Program
Adult Treatment Panel III Guidelines? (2)
ATPIII Guidelines
Desirable
TG <150 mg/dL
LDL<100 mg/dL
HDL>40mg/dL
Total Cholesterol <200
Mr. Klosterman had borderline high LDL Cholesterol (150mg/dL), and Total Cholesterol (210
mg/dL), and Triglycerides (150mg/dL). His HDL Cholesterol is abnormally low (32mg/dL).
4. You talk with Mr. Klosterman and his wife, a math teacher at the local high school.
They are friendly and seem cooperative. They are both anxious to learn what they can
do to prevent another heart attack. What questions will you ask them to assess how to
best help them? (3)
Do you know what types of foods are low in saturated fat, or high in fiber?
Are you familiar with what foods are high in omega 3 fatty acids?
What signs/symptom are associated with MI and or Stroke?
Do you smoke with Mr. Klosterman on occasion?
Do you know what types of food to stay away from when taking certain medications?
5. Calculate Mr. Klosterman’s energy needs using the Mifflin-St. Jeor equation and his
actual body weight. Mr. Klosterman’s exercise consists of walking his dog for about
15 minutes each day at a leisurely pace. (2)
Mifflin-St. Jeor Equation: RMR= (10*kg) + (6.25*cm) – (5*yrs) +5
RMR: [(10*84kg) + (6.25*178) – (5*61) +5] = 1652.5
RMR* stress factor =EER
1652.5 *1.3 =2,148.25 kcal
Obesity -500kcal/day (deficit 1lb/week)
Energy Needs = 1648 kcal/day
Actual Body Weight kg/m^2
185lbs = 84kg
70inches = 178 cm = 1.78m
BMI= 26.5
6. Calculate Mr. Klosterman’s daily protein needs. (1)
Kg = 84kg
Protein needs 0.8g/kg
84*0.8 = 67g protein/day
Peripheral vascular (PPP) peak plantar pressure (feet)??
7. Calculate Mr. Klosterman’s ideal body weight using the Hamwi equation. If Mr.
Klosterman was to have a BMI of 24, what would his weight need to be? How do the
results of these two ways of calculating an ideal weight for Mr. Klosterman differ?
(3)
Ideal Body Weight (Men) 106+ (6*# inches over 5 ft (60 inches))
IBW= 106+(6*10) = 166kcal
BMI=24; kg(/m^2) = 24; kg/(1.78^2)=24
24*(1.78^2)=kg
kg=76kg
1kg=2.2lbs
76*2.2=167lbs
The results of calculating Mr, Klosterman’s ideal body weight are very similar In that they are
just one pound difference from each other.
8. From Mr. Klosterman and his wife, you obtain a record of the foods he ate the day
before his heart attack. It was a typical day. He usually does not eat breakfast but does
eat a mid-morning snack, lunch, dinner, and an evening snack.
Mid-morning snack
1 large cinnamon raisin bagel with 1 T fat-free cream cheese
8 oz orange juice
Coffee
Lunch
1 cup canned vegetable beef soup
Sandwich with 4 oz roast beef
Lettuce, tomato, dill pickles, 2 t mayonnaise
1 small apple
8 oz 2% milk
Dinner
2 lean pork chops (3 oz each)
1 large baked potato, 2 t margarine
1/2 cup green beans
1/2 c coleslaw (cabbage with 1 T salad dressing)
1 sl apple pie
Snack
8 oz 2% milk
1 oz pretzels
Using Diet Analysis Plus, analyze this day of intake for Mr. Klosterman. How many calories did
he consume, and what was the distribution of calories for protein, carbohydrate, and fat. (4)
9. How does Mr. Klosterman’s nutrient intake compare with the recommendations from
the Therapeutic Lifestyle Change dietary pattern? (2)
In order to stay within his weight managemnt, Mr. Klosterman should only be consuming
1,648kcal/day however, according to his supertracker analysis, he is consuming 2630kcal/day.
TLC diet recommends decrease in saturated fat of <7% total kcal. Mr. Klosterman is consuming
9% kcal. His fiber intake is right on check at 25g, which is in the range of the recommended
intake for the TLC dietary pattern. His total fat is in range at 27% total kcal. His CHO intake is
way over, consuming 71% of his total kcal in carbohydrates. The TLC diet recommends that only
50%-60% CHO intake is necessary. Mr. Klosterman is also consuming too much protein with
26% percent total kcal, in comparison to the 15% recommended by the TLC dietary pattern. His
cholesterol is high at 244mg. His Omega 6:Omega 3 ratio is about 12:1, which is acceptable, he
could increase his omega 3 intake a little since it is proven to lower LDL. His sodium intake is
very high at 4363mg, and the TLC diet recommends no more than 2300 mg/day. The TLC dietary
pattern also really recommends plant sterols and stenols, consuming 2g/day, but Mr. Klosterman
does not seem to get this in his diet. He could try to consume more soy as protein rather than
meat, and also his wife could switch from corn oil to canola oil to incorporate more
stenol/sterols in his diet.
10. Using the 24-hour recall above as a guide to Mr. Klosterman’s food preferences,
recommend changes to make his daily intake consistent with the DASH Eating Plan.
Plan a day’s food intake at the calorie level calculated in #7. (2)
DASH Eating Plan
(1600 kcal/day)
6 Grain
3-4 veg
4 fruit
2-3 low fat milk products
3/week nuts/legumes
2 Fats/Oils
0 Sweets/Added Sugar
Midmorning snack
2 pieces whole grain cinnamon raisin toast (2 Grain)
2 Tbsp Peanut Butter (1 nut/seed/legume)
1 8 oz glass Orange juice (2 fruit)
Lunch
8 oz water
1 can low-sodium tomato soup
(Tomato-grilled cheese)
1 whole grain tortilla (1 grain)
11/2 oz fat free cheese (1 fat free milk)
2 slice tomato (1 veg)
1 small apple (1 fruit)
Dinner
1 4 oz lean pork chop (4 lean meat)
½ cup cooked brown rice (1 grain)
1 cup green beans (1 veg)
½ cup raw cucumbers (1 veg)
2Tbsp ranch dressing(1 fat)
1 cup low-fat vanilla frozen yogurt (1 milk)
1 medium apple (warmed in 1 Tbsp brown sugar +cinnamon) (1 fruit) (1 sweet)
Snack
½ coleslaw (cabbage+2 Tbsp dressing)(1 veg +1 fat)
1 oz unsalted pretzels (1 grain)
8 oz water
All his dairy needs to be fat free or low-fat. His can of soup should be low sodium, and he needs
to limit his intake of protein or choose alternative substances as protein sources such as yogurt,
or nuts. I made sure to increase his vegetable intake as well, and change his grains to more heart
healthy whole grains.
11. Mr. Klosterman and his wife ask about specific vitamin supplements. “My roommate
here in the hospital told me I should be taking vitamin E and—I think it was folate.”
Would you recommend Vitamin E and folate supplementation for this patient? If so,
how much? What is your rationale? (please provide citations, at least one should be a
research or review article published in a peer-reviewed journal). (3)
Significant research on the effect of homocysteine as an independent precursor of cardiovascular
disease, has shown that elevated levels of total blood homocysteine, known as
hyperhomocystenemia, is a strong risk factor for atherosclerosis vascular disease in coronary
cerebral and peripheral vessels and for arterial and venal constriction. This increases the risk
of stroke, heat attack, and other cardiovascular diseases. Increased plasma homocysteine can be
acquired from deficiencies in Vitamin B9. Vitamin B9 is also known as folate. Folic acid, the
vitamer form of folate, is proven to reduce homocysteine levels by promoting homocysteine
metabolism and therefore inhibiting the adverse consequences of accumulation of homocysteine
in the blood.
Vitamin E is an antioxidant. The oxidation of LDL is a vital step in the development of
atherosclerosis, since this initiates macrophage attack. Vitamin E as an antioxidant has been
shown to slow the progression of atherosclerosis by inhibiting the oxidation of LDL in arteries.
By slowing the progression of atherosclerosis, Vitamin E can reduce the risk of a cardiovascular
accident such as stroke, heart attack, angina, and peripheral vascular disease.
Although there are studies that have provided evidence that folate and Vitamin E can prevent the
progression of cardiovascular disease, there is not enough evidence to support a
recommendation of supplementation of Vitamin E and folate. Conflicting evidence has been
observed in both vitamins. The best thing for Mr. Klosterman to do is follow the TLC diet pattern
recommendation and be sure to make heart healthy food choices, as well as incorporate physical
activity into his daily routine. His increase in fruits, vegetable, and whole grain should provide
the recommended amounts of folate and vitamin E in his daily diet to promote decrease in risk of
cardiovascular occurrence.
The Heart Outcomes Prevention Evaluation Study Investigators, “Vitamin E Supplementation
and Cardiovascular Events in High Risk Patients.” The New England Journal of
Medicine. Jan 20 2000. 342, pp154-160. Doi:10.1056/NEJM200001203420302.
http://www.nejm.org/doi/full/10.1056/NEJM200001203420302#t=article
Refsum, H., Ueland, P. M., Nygard, O., Vollset, S. E., “Homocysteine and Cardiovascular
Disease,” Annual Review Medicine 1998. 49(1), pp.31-62 doi.0066-4219/98/0201-0031
12. What would you want to assess in three to four weeks when he and his wife return for
additional counseling? (2)
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I would want to assess his lipid profile, LDL, HDL, Total Cholesterol and Triglycerides
I would want to assess for Hypertension
I would want to assess if there has been any weight loss, measuring his weight, and waist
circumference.
I would want to take a 24-hour recall to assess whether any dietary life-style changes
have been made
I would want to assess if there is any enzyme present in the blood that would signify for
myocardial tissue death such as CPK, AST, Troponin T, and LDH
13. Mr. Klosterman was prescribed the following medications on discharge. What are the
functions of each of these medications? What are the food–medication interactions
for this list of medications? (3)
Lopressor 50 mg qd
Lisinopril 10 mg qd
Nitro-Bid 9.0 mg bid
NTG .4 mg sl prn chest pain
ASA 81 mg q daily
Lipitor 10 mg q daily
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Lopressor  a beta blocker, usually prescribed for Hypertension. It works on the
sympathetic nervous system by blocking beta receptors therefore slowing heart rate, and
decreasing the force of contraction of the heart. It can be used as therapy in treating
angina.
Lisinopril an ACE inhibitor. This drug works by inhibitig the bodies ability to produce
angio-tensin II. Without angio-tensin II, the body’s blood vessels relax and dilate
allowing blood to flow more easily, and makes the hearts work more easier.
Nitro-Bid part of the class of drugs called nitrate that are used in the management of
angina. Angina results when the heart is not getting enough oxygenated blood. This
ointment dilates veins and arteries in the body so blood can flow more easily to the heart.
ASA “Aspirin,” this medicine is used to interfere with clotting in the arteries, and is
therefore used as an anti-clotting agent. It prevents blood clots from forming by
preventing blood platelets from sticking together.
Lipitor a statin, HMG-CoA reductase inhibitor, this medicine induces the expression of
LDL receptors in the liver, which in turn increases the catabolism of LDL and lowers
plasma LDL blood cholesterol.
When taking Lipitor, avoid grapefruit and other citrus including pomegranate, since
grapefruit juice can block the absorption Lipitor.
Excessive alcohol consumption can have an impact on all medications due to the way it
can change the livers ability to filter the medication from the body.
When taking Lisinopril and Lopressor be cautious with high-potassium diets, since the
drug may increase serum potassium levels.
When taking Lopressor, be cautious about serum glucose levels.
14. Mr. Klosterman has been referred to a cardiac rehabilitation program. There he will
have the opportunity to interact with the following health professionals:
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Registered Dietitian for nutrition counseling
Physical Therapist for an exercise regiment
Occupational Therapist to assist him in managing activities of daily living
Smoking Cessation Specialist
Nurse or Pharmacist to assist him with his medication regimen
Psychologist to assist him in coming to terms with his health condition
What role does cardiac rehabilitation play in Mr. Klosterman’s return to normal activities and in
determining his future heart health? (2)
The cardiac Rehabilitation program that Mr, Klosterman is enrolled in will allow him to receive
education on how to take his medication, how he should change his dietary style by
incorporating more of some nutrients and less of others, and which foods to increase him intake
and decrease his intake of. He will learn how to read the signs and symptoms he may experience
that will indicate other episode of cardiovascular consequence. He will learn techniques and
tools from the smoking cessation specialist that will help him to quit smoking. Also, Mr.
Klosterman needs to make a life-style change to accommodate his health and he will need
assistance with his mental well-being throughout the process as well as his physical well-being.
Mental stability is also a benefit of the cardiac rehabilitation program.