Case StudyCongestive Heart Failure

By: Ellinor Lagerberg

Gain knowledge about CHF (congestive heart failure) and its etiology.

To understand how nutrition education is applied in acute care for patients with CHF.

To learn how comorbidities such as DM (diabetes) and obesity impacts treatment options for CHF.

Reason for study

Heart failure is a chronic progressive disorder that affects over 5 million people in the United States and is expected to increase due to the extended population life expectancy.

Heart failure

The normal heart is about the size of a fist. Muscular pump that continuously sends

oxygenated blood throughout the circulatory system.

The heart contains four chambers that beat in a coordinated way for the heart to function properly.

Heart function

With heart failure this function is diminished and the heart can no longer keep up with demands to pump blood to the body.

Heart failure can affect all four chambers but most often the left ventricular is affected.

Heart failure progression

There are two types of heart failure systolic and diastolic.

In systolic heart failure the ventricles becomes stretched and dilated and are no longer able to efficiently pump blood out of the heart.

In diastolic heart failure the ventricles become stiff and do not fill up efficiently with blood in between beats.

Heart failure

In heart failure, the heart muscle is unable to pump enough blood through the heart to meet the body's needs for blood and oxygen. Heart failure usually results in an enlarged heart.

As HF progresses, the heart’s pumping becomes less efficient causing blood to collect in other areas of the body.

This may cause fluid to accumulate in the lungs, liver, gastrointestinal tract and extremities.

Referred to as congestive heart failure.

Congestive heart failure

Symptoms

L.M. 60 YOWM Wt: 148.70 kg (41lb wt gain over past 4

months) Ht: 200.66 cm BMI: 36.9 Admitting diagnosis: SOB secondary to

decompensated CHF

Pt information

Disability Military Lives in SNF Insured through Medicaid Married w/o children No alcohol/tobacco or drug use

Social Hx

CHF DM2 Hypothyroidism GERD Obstructive sleep apnea COPD Syncope Obesity Nephrolithiasis Nonischemic cardiomyopathy Atrial fibrillation

Past medical history

Obesity is known to lead to several metabolic disorders and thyroid dysfunctions that increases mortality risks in adults.

Diabetes – research shows patients diagnosed with type 2 DM have a 2 fold for risk for HF hospitalization. High blood glucose levels can over time lead to increased deposits of fatty material on the insides of the blood vessel walls. These deposits may affect blood flow, increasing the chance of clogging and hardening of blood vessels.

Hypothyroidism – reduced T3 hormone affects the hearts ability to relax its smooth muscle.

Patient comorbidities

1998 – Left toe amputation, MRSA infection 2005- Endocarditis, MRSA 2008 – Biventricular pacemaker, right foot

transmetatarsal amputation 2010- Left second toe amputation 2012- Corrective amputation surgery 2013- Left hand infection, digit amputation,

UTI, MRSA, E. Coli.

Past hospitalization

CHF - progressed to stage D class IVStage D -  Treatment-heart failure requiring specialized intervention.Class IV - Patients with cardiac disease resulting in an inability to carry on any physical

activity without discomfort. Symptoms of heart failure or chest pain may be present even at rest. If any physical activity is undertaken, discomfort increases.

Evaluated by heart transplant team but was not considered a candidate for any advanced treatments including heart transplant or LVAD secondary to multiple comorbidities.

Current medical status

4 stages

In stage D patients suffer from structural heart disease with heart failure symptoms that require specialized intervention if suitable as a candidate: transplantation left ventricular assist device (LVAD) left ventricular surgical remodeling (LVSR) stem cell therapy in clinical trials compassionate end-of-life care

Treatment for stage D

Palliative Care Integrative Model

As CHF progresses, the ratio of palliative care to life-prolonging care gradually increases.  Eventually, life-prolonging care is discontinued and a transition to hospice care is made.

Palliative care focuses on relieving & preventing suffering of patients and is now recommended by the American College of Cardiology and American Heart Association to improve outcomes in patients with end stage CHF.

Their view is that aggressive procedures performed in the last months of life are not appropriate since quality of life is reduced.

Compassionate end-of-life care

Admitted December 10th, 2013 for dyspnea, fatigue and fluid retention.

At time of admission he was hemodynamically stable.

L.M. was visited on 4 separate occasions.

Most recent hospitalization

L.M. sleeping at time of visit.First visit- pressure sore consult

Lab values Normal Range First Visit

Na 135-145 mEq WNLK 3.5-5 mEq WNLCl 100-106 mEq 93Co2 23-29 mEq/L WNLBUN 7-21 mg/dL 48Creatinine 0.5-1.4 2.54Glucose 70-100 170GFR >60 26Phosphorus 3.0-4.5 mg/dL WNL

Elevated BUN-CHF contributes to poor renal perfusion

Elevated creatinine – CHF contributes to poor blood flow causing

Diminishing GFR-CHF contributes to reduction in renal function

Coumadin/Warfarin and moderate 60-75g carbohydrate diet providing 1400-1600 calories per day.

Recommendations left for the physician to change diet to fluid restriction, cardiac and to liberalize carbohydrate diet to allow for 90-105g carbohydrates per meal allowing for approximately 2200-2600 calories per day.

Diet order

Reported Height in Cm 200.66 cmReported Admit Weight in kg 148.7 kgIBW 100 kg% IBW 149%Adjusted Weight 112.2BMI 36.9Estimated Kcal Needed per Day 3370-3930 kcal/day ( 30-35 kcal/kg adj.

wt 2’ wounds)Estimated Fluid Needed per Day 1 ml per kcal or per physicianEstimated Protein Needed per Day 135-168 g/kg ( 1.2-1.5g/kg adj. wt 2’

wounds)

Estimated needs

L.M. awake and alert, but disinterested in diet education focused on cardiac, low-sodium intake and fluid restrictions. He kept falling asleep when asked specific food related questions.

Second visit

Lab values Normal Range Second Visit

Na 135-145 mEq WNL

K 3.5-5 mEq WNL

Cl 100-106 mEq 95

Co2 23-29 mEq/L 30

BUN 7-21 mg/dL 51

Creatinine 0.5-1.4 2.59

Glucose 70-100 95

GFR >60 25

Phosphourus 3.0-4.5 mg/dL WNL

Elevated

Lower

Elevated

L.M. reports having struggled with his weight for his whole life and referred to himself as a “fat kid.” He also mentioned his mother always telling him to watch the amount of cookies he ate.

L.M. admitted that the only time he followed a specific diet was during his time in the military and that was because he didn’t have the options of choosing meals and only ate what was served.

Nutrition

On a usual day in the nursing home L.M. typically eats two individual boxes of fruit loops along with two cups of low fat milk. Lunch is usually a turkey sandwich with potato chips and 12oz can of diet coke. His snack is typically cookies and for dinner L.M. orders takeout food. His favorite is Chinese food.

Diet pattern

L.M. typical diet history. The 24-hour recall shows his diet being low in fiber, calcium, iron, Vitamin A and Vitamin C. L.M doesn’t consume recommended amount of fruits and vegetables.

Diet is high in fat. Estimated intake approximately

2000calories/day, 80g total fat, 1700g sodium.

24 hr recall

Servings Calories Total fat Cholesterol Fiber Sodium Calcium Iron Vitamin A Vitamin C

Breakfast

Fruit loops (27g/serving)

2 200 2g 0g 6g 250mg 0% 20% 8% 20%

Milk 1%(1 cup/serving)

2 200 6g 20mg 0g 240mg 30% 0% 10% 4%

Lunch

Potato chips 1 160 10g 0mg 1.4g 170mg 0% 2% 0% 10%

Turkey sandwich

1 280 8g 50mg 1.3g 990 mg 15% 13% 29% 2%

Mayonnaise (1pkg)

1 68 7g 4mg 0g 64mg 0% 0% 0% 0%

Diet Coke 1 - - - 0g 40mg 0% 0% 0% 0%

Chocolate chip cookie

1 120 10g 0 119mg 1% 8% 0% 0%

Dinner

White rice(1 cup/serving)

1 242 - - - 0% 15% 0% 0%

Chinese foodBeef & broccoli

2 676 36g 160mg 810mg 0% 0% 0% 0%

Total 1946 79g 184mg 8.7g 1693mg 31% 45% 18% 34%

L.M.’s nutrition related diagnosis was food and nutrition knowledge deficit related to disinterest in learning/applying information, as evidenced by verbalizing unwillingness and disinterest in learning information.

Patient would benefit from diet education and the goal was for him to be able to name 3 concepts of a heart healthy diet.

Nutrition Diagnosis

L.M. stated he had reviewed the material since last visit but he still unable to name 3 heart healthy concepts.

Third visit

Lab values Normal Range Third visit

Na 135-145 mEq WNL

K 3.5-5 mEq WNL

Cl 100-106 mEq 92

Co2 23-29 mEq/L WNL

BUN 7-21 mg/dL 67

Creatinine 0.5-1.4 3.38

Glucose 70-100 117

GFR >60 19

Phosphorus 3.0-4.5 mg/dL 5.6

Elevated

Elevated, indication of renal failure

Reduced

Although current recommendations for hospitalized patients with end stage heart failure includes sodium restriction, new research has emerged implying that sodium restriction can cause damage through increased neurohormonal activation and hypovolemia. Currently, there are insufficient data to endorse any specific level of sodium intake with certainty.

Nutrition

Lab values Normal Range Fourth visitNa 135-145 mEq WNL

K 3.5-5 mEq WNL

Cl 100-106 mEq 94

Co2 23-29 mEq/L WNL

BUN 7-21 mg/dL 91

Creatinine 0.5-1.4 3.75

Glucose 70-100 106

GFR >60 17

Phosphorus 3.0-4.5 mg/dL WNL

Fourth visitAt the fourth follow up, L.M.’s condition had severely worsened. He showed signs of lethargy, drowsiness and was diagnosed with acute hypercapnic respiratory insufficiency. Not appropriate for diet education.

Elevated

Significantly lower

The following day a consult for tube feeding received.

L.M. was transferred to the ICU where he was intubated.

Scheduled to receive hemodialysis. Lab values BUN 91, creatinine 3.75 and GFR

17. L.M.’s wife was present and per

documentation, she had requested a change from “do not resuscitate” to “full code.”

Decreasing function

Allopurinol (Zyloprim) Alprazolam (Xanex) Belladonna-opium Bumex (Bumetanide) Bupropion (Wellbutrin) Calcium acetate Docusate Fenofibrate Finasteride (Proscar) Lantus Humalog

Iron sucrose Synthroid Metoprolol Aldactone Coumadin IV Medication-

started on 12/20 Fentanyl Versed

Medications

L.M. was recently extubated and his tube feeding was removed. However, he has not been cooperating with his diet advancement and is refusing meals. He is rejecting some of his essential medications and is not willing to provide verbal responses.

L.M.’s prognosis is poor due to his comorbidities and noncompliance to follow recommended medical and nutritional treatment.

Prognosis

Longhi, S., Radettis, G. (2013). Thyroid Function and Obesity. Journal of Clinical Research in Pediatric Endocrinology 5(Suppl 1), 40–44.

Adler, E., Goldfinger, J., Jill Kalman, K., Park, M., Meier, D. (2009). Contemporary Reviews in Cardiovascular Medicine: Palliative Care in the Treatment of Advanced Heart Failure. Circulation, 120, 2597-2606.

Mahan, K. L., Escott-Stump, S., (2008). Medical Nutrition Therapy for Heart Failure. In Krause's Food and Nutrition therapy. (12th ed., p 888). Canada: Saunders Elsevier

Gupta., D., Georgiopoulou. V., Kalogeropoulos. A., Dunbar. S., Reilley. C., Sands. J., Fonarow. G., Jessup. M., Gheorghiade. M., Yancy. C., Butler. J. (2012) Dietary Sodium Intake in Heart Failure. Circulation, 126, 479-485.

 Zouein, F., Zgheib, C., Kenneth W., Liechty, K., Booz, G. (2013). Post-infarct biomaterials, left ventricular remodeling, and heart failure: Is good good enough? Congestive Heart Failure 18(5), 284-290.

  PubMed Health. (n.d.). Heart Failure Overview. Retrieved December 24, 2013 from

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001211/

References