Patient Case StudyEmily Walker

Dietetic Intern Benedictine University: MS Nutrition and Wellness

Patient Demographics and Social History

Age 34Gender MaleRace African AmericanRelevant personal data Lives at home with his wife

and young sonSmoking/Alcohol Use Drinks alcohol socially.

Reports quitting 2 years ago; 1 pack/day for 5 years. No illicit drug use.

Food and Nutrition Related History

• Enjoys cooking, grilling at home• Reports preference for meats, some rich foods • Reports frequent intake of fast food in past years • No dietary restrictions. Includes all food groups in his

diet. • Usual body weight per patient recall 330-400 pounds

over recent years

Past Medical History • CHF: Diagnosed at age 27

• Dilated Cardiomyopathy• EF 30%

• 2013: Implantable Cardioverter Defibrillator due to non-sustained ventricular tachycardia

• Morbid Obesity BMI >40• Type II diabetes mellitus

• CKD, Stage II• Pulmonary HTN, Essential HTN• Hyperlipidemia • Sleep Apnea• GERD• CVA• Extrinsic Asthma

Patient known well to Edward, has been followed by physicians at HF Clinic. Patient had been approved for LVAD at the end of January.

Admission: Edward Hospital Naperville, IL

• 12/31/2015 • ER: Syncope and collapse• Increased SOB with activity

and difficulty lying flat • Noticed increased swelling• Recent weight gain of 25#• BMI: 45.26

Admission: Medical Diagnoses and Plan

• Decompensated cardiomyopathy; acute on chronic biventricular systolic heart failure, EF 10-15% • Milirone• Scheduled for LVAD end of January, 2016.

May need sooner• Syncope

• Ventricular Tachycardia • Non-sustained ventricular tachycardia

• SubQ ICD: Interrogated from Boston Scientific

• CKD Stage III • GFR stable• Aggressive Diuretics

• Dyslipidemia• Statin

• DM2, well controlled • SSI

Pathophysiology: Cardiomyopathy• Dilated Cardiomyopathy

• Most common• Male gender• Left ventricle often affected first • Risk factors/causes: Idiopathic, genetic,

diabetes, alcohol use, certain drugs• Drug use: Growth hormone excess has

been associated with left ventricular hypertrophy while anabolic steroids have been associated both with myocardial hypertrophy, focal myocardial fibrosis, and premature myocardial infarction2

3

Pathophysiology: CHF5

• Congestive Heart Failure: Inability of the heart to provide sufficient blood flow to meet metabolic demands of tissues at rest and during exercise. • Ejection fraction (EF) decreases as HF worsens

• As blood flow slows blood returning to the heart through the veins backs up causing congestion in the body's tissues.

• Edema; SOB (fluid collection in pleural regions)• HF affects kidneys ability to dispose of water and sodium• Etiology for this Patient:

• Acute LV systolic dysfunction due to dilated cardiomyopathy

Cardiologist Conclusion• Left Ventricle: Cavity size markedly increased. Wall thickness

normal. Systolic function markedly reduced. EF 10-15% • Mitral Valve: Dilated, moderate regurgitation • Left Atrium: Volume markedly increased• Right Ventricle: The cavity size upper limits of normal.

Systolic function low normal. • Tricuspid valve: Structurally normal, moderate regurgitation • Severe pulmonary HTN • CONCLUSION: NYHA CLASS IV Acute on Chronic Systolic

HF. • Two year survival rate for NYHA Stage IV heart failure is 13-40%5

4

Medical Options for Stage IV HF5

• Medical/Nutrition Management: Diuretics, ACE inhibitors, Beta-blockers, digitalis, dietary salt restriction, fluid restriction

• Mechanical Circulatory Support: LVAD • Heart transplantation: patient is not eligible due to weight of

350# • Continuous IV inotrope infusions for palliation • Hospice care

Patient Medical Progression

• 1/04: Patient feels “horrible.” Abdominal cramping/pain, nausea, vomiting, SOB, edema worsens, hyponatremia, metabolic acidosis. • Medical team determines LVAD surgery will occur 1/13

• 1/06: Right heart catheterization procedure performed • 1/08: LVAD placement moved up to 1/11 • 1/11: Destination Heart Mate II Left Ventricular Assist

Device Placement

Medical/Surgical Intervention: LVAD5

• Ventricular Assist Device: Mechanical pump that assists the weakened ventricle by pumping heart throughout the blood and body

• Left Ventricular Assist Device: LV changes from pumping chamber to filling chamber. LVAD receives blood from the LV and pumps it into the aorta

Heart Mate II

Fang, JC, NEJM, 2009

Patient Medical Care Post LVAD• 1/12: S/p LVAD intubated and sedated

in CCU

• 1/13: Extubated, awake, alert. No N/V/D. No cough or SOB.

• Followed by cardiology: • Dilated CM s/p LVAD • Acute Systolic CHF EF 10-15% with

moderate RV dysfunction • Cardiogenic Shock • Required aggressive diuresis with

dobatamine drips and diuretic drips

• Followed by nephrology: AKI/CKD • Kidney function eventually stabilized

• Followed by endocrinology: DM • HgbA1c= 5.9%

• Developed: Acute gout flare, blood loss anemia, leukocytosis

• Eventually stable enough to be discharged to rehab facility on oral diuretics

Lab Value Admission Post LVAD Discharge Glucose 65-99 mg/dL 211 (H) 120 (H) 134 (H) HGBA1C 4-5.6% 5.9 % “ “ BUN 6-20 mg/dL 81 (H) 98 (H) 74 (H)Creatinine 0.76-1.27

mg/dL 2.71 (H) 2.54 (H) 1.99 (H)

GFR >=60 31 (L) 37 (L) 49 (L)Albumin 3.5-4.8 g/dL 3.5 2.8 (L) 2.9 (L)CALCIUM 8.7-10.2 mg/dL 9.6 9.1 9.3Sodium 134-144

mmol/L 134 (L) 135 (L) 131 (L)

Potassium 3.5-5.2 mmol/L 4.4 4.3 3.5 (L) Chloride 97-108 mmol/L 95 (L) 99 (L) 98 (L) Beta Natriuretic Peptide

2-99 pg/mL 2917 (H) - -Lactate Dehydrogenase

84-249 U/L 317 (H) 450 (H) 358 (H) AST(SGOT) 0-40 IU/L 43(H) 86(H) 32 INR 0.86-1.15 1.55 (H) 1.30 (H) 2.70(H)Hemoglobin 12.6-17.7 g/dL 9.4 (L) 8.8 (L) 12.2 (L) Hematocrit 37.5-51.0 % 28.1 (L) 24.2 (L) 34.5 (L)

Nutrition: RD Patient Care

Assessment, Diagnoses, Monitoring and Evaluation

Dates

Appetite Nutrition Risk

Intervention Education Diet & Supplements

1/04 Poor. <50% intake Moderate

• Meals and snacks: Monitor PO intake. Encourage adequate intake of current diet

• Supplements: RD added Ensure Plus TID with goal of increasing calorie and protein consumption due to a poor PO intake from foods

• Importance of adequate protein consumption: high protein foods

• Management of poor appetite

• Cardiac, 1800 mL fluid restriction

• Ensure Plus TID

1/14 Poor. Does not want to eat solid high protein foods, such as meat. <50% intake

Moderate

• Meals and Snacks: Monitor PO intake of solid food. Encourage adequate intake of solid foods.

• Supplements: RD changed supplements to 6 Nepro per day. This will be for his kcal, protein and fluid for the day. This will provide 2700 kcal, 156 gm protein and 1560 ml fluid (including 1 cup of ice.) This meets 100% kcal needs and 96% protein needs.

No new education • Cardiac, 1800 kcal diabetic, 1500 mL FR, day

• 6 Nepro per day

1/15 Change from Nepro Ensure Plus per patient flavor preference. Patient is still not eating solid food.

Moderate

• Ensure plus 6 cans per day with 2 packets of beneprotein mix in per can. This will provide 2430 kcal and 150 gm protein and 1440 ml fluid. Meeting 100% kcal need and 93% protein needs.

No new education • Cardiac, 1800 kcal diabetic, 1500 mL FR, day

• 6 Ensure + 12 beneprotein

1/18 Pt is eating more solid foods. 50-75% including supplements.

Moderate

• Meals and Snacks: Encourage PO intake of solid foods. 3 day calorie count started

• Supplements: Reduce to Ensure Plus TID

• Reinforce importance of increased protein consumption

• Cardiac, 1800 kcal diabetic, 1800 mL FR,

• Ensure Plus TID

1/22 Pt is eating solid foods, drinking supplement, struggling with quick satiety

Moderate

• Meals and Snacks: Encourage PO intake of solid foods. 3 day calorie count started

• Supplements: Ensure Plus TID

• Education on small frequent meals/nutrient dense foods

• Cardiac, 1800 kcal diabetic, 1800 mL FR

• Ensure Plus TID

Past RD Patient Assessments and Interventions

Calorie Count Results Date: 1/19Breakfast: 280 calories, 6 gm protein Snack:750 calories, 38 gm protein. (this includes 2 Ensure Plus supplements and 2 Beneprotein packets)Lunch:181 calories, 12 gm proteinDinner: 365 calories, 29 gm proteinDaily total: 826 calories, 22 grams protein to meet 41% pt calorie needs and 29% pt protein needs (with oral supplements--1576 kcal, 60 gm protein )

Date: 1/20Breakfast: 345 calories, 18 gm proteinSnack:725 calories, 32 gm protein. (this includes 2 Ensure Plus supplements and 1 Beneprotein packet)Lunch:175 calories, 15 gm proteinSnack: 240 calories, 7 gm proteinDaily total: 1485 calories, 72 grams protein to meet~ 74% pt calorie needs and 44% pt protein needs

Date: 1/21Breakfast: 400 calories, 27 gm proteinLunch: 229 calories, 19 gm proteinDinner: 258 calories, 17 gm proteinEnsure/Beneprotein: 1200 calories, 75 gm proteinDaily total: 2087 calories, 138 grams protein to meet >100% pt calorie needs and ~85% pt protein needs

1/26: Anthropometrics1/26

Height 185.4 cm (6' 0.99")

Weight 150 kg (330 lb )

BMI 43.64

IBW 80.9 kg (178 lb)

% IBW 185%

WEIGHT HISTORY: • 1/26/16: 150 kg (330 lb.) • 1/22/16: 155.6 kg (343 lb) • 01/07/16 : 154.5 kg (340 lb

9.8 oz)• 12/29/15 : 152.499 kg (336 lb

3.2 oz)• 12/15/15 : 150.1 kg (330 lb

14.6 oz)• 11/22/15 : 154.677 kg (341

lb)

1/26: Nutrition Assessment • Appetite: Fair-Good. Appetite is improved. Patient is

able to eat a majority of breakfast and lunch. Patient feels full towards dinner time, and is only able to eat a small amount. Patient is drinking Ensure Plus TID

• Patient is fixated on getting a certain number of grams of protein per day (>120g)

• Patient has high motivation to adhere to prescribed diet to become healthier. Interest in cooking healthy meals.

• Nutrition Risk: Moderate

Nutritional Implications of a LVAD7

• Poor nutrition status is an independent indicator of mortality in advanced heart failure patients

• Malnutrition is a preoperative risk factor associated with a high risk of death • Obesity is not a contraindication of using an LVAD; it is for a transplant • Post-op Recommendations:

• Liberalize diet• Oral supplements• Frequent meals• Multivitamin, iron supplements• Poor appetite due to poor perfusion, congestion, hepatomegaly and inactivity common: possible

appetite stimulants

Nutrition Diagnoses1. Inadequate oral intake related to decreased ability to consume

adequate energy secondary to LVAD placement as evidenced by quick satiety and need for oral supplements three times a day to satisfy needs• Immediate problem to address. Inpatient intervention focuses on this diagnosis.

2. Overweight/obesity related to long term high caloric diet as evidenced by BMI of 43 • Long term issue. Patient must lose weight to be eligible to be on the heart transplant

list

Nutrition Prescription

NUTRITION PRESCRIPTION:• Calories: 2020-2430 calories/day (25-30 calories per kg pt IBW)• Protein: 121-162 grams protein/day (1.5-2 grams protein per kg

pt IBW - to monitor given pt renal function)• Increased protein needs to promote tissue healing status post LVAD

• Fluid: ~1800 ml/day per MD order• CHF related fluid retention • CKD Stage III

Intervention • Meals and Snacks: Encourage adequate intake of diet through

small frequent meals. Encourage taking advantage of appetite and eating when hungry, instead of forcing food when full. Encouraged nutrient dense healthy choices.

• Supplements: Continue Ensure Plus, decrease to BID. Recommend weaning off Ensure as intake by mouth increases.

• Education:• Reinforce HF education: 1500 mg sodium, 1500 mL fluid

• Label reading, restaurant foods, convenience foods, processed foods. • Handouts provided

• Education on nutrient dense foods, foods high in protein • Information on general, healthful nutrition

Monitoring and Evaluation

Goals • 1. PO intake to meet at least 75% patient nutrition

prescription• Patient to consume 75% of dinner

• 2. At least 75% intake of oral supplements• 3. No signs of skin breakdown• 4. Maintain lean body mass

Secondary Nutrition Diagnosis: Long Term

• Intervention• Once short term problem evolved Focus on developing a

sustainable healthy diet that promotes a gradual weight loss • Meals and snacks: Elimination of fast foods, limiting restaurant

foods, alteration in cooking methods, emphasis on increasing vegetable and fruit consumption, focusing on lean protein sources, whole grains, limiting processed foods

• Physical activity: If physician improved incorporate regular physical activity- start off slowly

Secondary Nutrition Diagnosis: Monitoring and Evaluation

• Patient goals1. Consistent BMI < 35 to be eligible for heart transplant.

1. Most heart transplant centers will not take patients with BMIs > 35. Obesity increases the risk of heart failure and leads to worse outcomes after heart transplantation6

2. Goal weight <= 265# 2. To engage in light to moderate physical activity 2-3 days

per week. 3. Reduce consumption of fast food to <1 time per week

• Patient has high motivation to make changes to improve his health!

References

1. Dilated Cardiomyopathy (DCM). 2016. Available at: http://www.heart.org/HEARTORG/Conditions/More/Cardiomyopathy/Dilated-Cardiomyopathy_UCM_444187_Article.jsp#.VsKdBJMrKt8 [Accessed February 16, 2016].

2. Mark PB. Cardiomyopathy induced by performance enhancing drugs in a competitive bodybuilder. Heart. 2005;91(7):888–888.

3. GeneDx. Dilated Cardiomyopathy genetic testing - genetic testing company | the DNA diagnostic experts. Available at: http://www.genedx.com/test-catalog/cardiology/dilated-cardiomyopathy/ [Accessed February 16, 2016].

4. Available at: http://www.sciencekids.co.nz/pictures/humanbody/heartdiagram.html [Accessed February 16, 2016].5. Grady K. Clinical Management for Patients with Destination Therapy Left Ventricular Assist Devices. Bluhm

Cardiovascular Institute; Northwestern University; 2011. Available at: https://my.americanheart.org/idc/groups/ahamah-public/@wcm/@sop/@scon/documents/downloadable/ucm_427332.pdf [Accessed 2016].

6. HFSA: Few obese patients qualify for heart transplants. 2010. Available at: http://www.medpagetoday.com/MeetingCoverage/HFSA/22192 [Accessed February 17, 2016].

7. LVAD Nutrition Recommendations Fact Sheet. Edward Hospital Naperville.