Transcript Heart Failure and Transplant

MNT for Heart Failure
and Transplant
Congestive Heart Failure
(CHF)

A clinical syndrome characterized by
progressive deterioration of left
ventricular function, inadequate tissue
perfusion, fatigue, shortness of breath,
and congestion
Congestive Heart Failure (CHF)
—cont’d
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
Causes of Heart Failure
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Diseases of the heart (valves, muscle,
vessels, arteries) and vasculature
(hypertension) cause left ventricular systolic
dysfunction
Once established, myocardial infarction,
dietary sodium excess, medication
noncompliance, arrhythmias, pulmonary
embolism, infection, anemia can precipitate
complete CHF
Prevalence and Incidence
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Unlike other cardiovascular diseases,
CHF is on the increase
Number of CHF-related discharges
increased 174% from 1979-2003
4.8 million Americans have CHF;
overall prevalence 2-6%
Krummel DA in Krause, 12th ed., 2008
Prevalence and Incidence
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Prevalence increases with age,
especially after age 55
Black women have the highest rates,
followed by black men, Latino men,
white men, white women, and Latino
women
More Medicare dollars are spent on
CHF than on any other diagnosis
Prevalence and Incidence
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Incidence has risen in last 20 years because
of aging population, increased number of
people being saved from premature death
secondary to MI, increase in obesity and
associated hypertension
Incidence of CHF approaches 10 per 1000
people over 65 years
Median survival of men and women is 1.7
years and 3.1 years respectively
One in five persons with CHF will die within
a year of diagnosis
Risk Factors
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Hypertension (91% of Framingham
cohort had hypertension before CHF)
Left ventricular hypertrophy
Coronary heart disease (causes 6065% of cases)
Diabetes
Mean age of onset is 70 years
Stages of Heart Failure
A
High risk of HF because
of presence of risk
factors but without syx
or structural damage
B
Structural heart disease LVH or fibrosis, left ventricular
associated with HF but dilatation; low EF; asymptomatic
no signs/syx
valve disease, previous MI
C
Structural heart disease Dyspnea or fatigue due to LV
with current or prior syx dysfunction; reduced exercise
of HF
tolerance
D
Advanced structural
damage, refractory
symptoms
Krummel in Krause, 12th Ed.
HBP, CAD, diabetes, alcohol abuse,
hx rheumatic fever; family hx
cardiomyopathy, using cardiotoxins,
metabolic syndrome
Frequently hospitalized; awaiting
transplant
Classifications of Heart
Failure
Class I
No undue symptoms associated with
ordinary activity; no limitations
Class II
Slight limitation of physical activity;
patient comfortable at rest
Class III Marked limitation of physical activity;
patient comfortable at rest
Class IV Inability to carry out physical activity
without discomfort; symptoms of
cardiac insufficiency or chest pain at
rest
Congestive Heart Failure
Symptoms
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Dyspnea
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Orthopnea
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Nausea
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Fullness
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Pulmonary edema
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Cardiac edema
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Cardiac cachexia
CHF DIAGNOSIS
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EKG or electrocardiogram
– measures the rate and regularity of the
heartbeat
– May indicate whether there has been
heart damage or changes in anatomy
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Chest X-ray
– Shows whether heart is enlarged, fluid in
lungs, pulmonary disease
CHF DIAGNOSIS
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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
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Holter Monitor: ambulatory
electrocardiography
– Worn for 24 hours and provides a continuing
recording of heart rhythm during normal activity
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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
Other Cardiac Tests
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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,
collect blood samples
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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
Cardiac Tests
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Exercise Stress Test
– EKG and blood pressure readings are
taken before, during, 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
BNP and NT-proBNP
Blood Test
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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, and to LVH
Used to grade the severity of heart failure
Cachectic Heart
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A soft, flabby heart characterized by
loss of myocardial mass as the result
of extreme malnutrition
Congestive Heart Failure
Treatment
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Goal: decrease work of heart
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Diet
1. Na restriction (500 to 1000 mg)
2. Monitor serum K—hypokalemia possible
with diuretics and digoxin)
3. Fluid restriction
4. Alcohol—none to moderate
5. Caffeine—can cause MI or cardiac
arrhythmia
Medications Used in Heart
Failure
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Diuretics help reduce fluid buildup in lungs and
peripheral edema
ACE inhibitors lower blood pressure and reduce the
strain on the heart. These medications also may
reduce the risk of a future heart attack.
Beta blockers slow heart rate and lower blood
pressure to decrease the workload on the heart.
Digoxin makes the heart beat stronger and pump
more blood.
Vasodilators: reduce blood pressure and stress on
the heart
MNT in HF
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Fluid restriction
Sodium restriction
Meet energy/protein needs
Prevent cardiac cachexia
Small frequent meals
Fluid Restriction
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If hyponatremia occurs (serum sodium
<130 mEq/L)
Limit total fluids to <2000 ml
In severe decompensation, limit to
1000-1500 ml
Maintain restricted sodium diet even if
serum sodium depleted; sodium has
moved from blood to tissues
Fluid Status and
Assessment
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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
Fluid Calculations
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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,
yogurt, gelatin, popsicles count
towards fluid allotment
Living with Fluid
Restrictions
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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
Cardiac Cachexia
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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, circulatory, metabolic, inflammatory,
and neuroendocrine changes in skeletal muscle
Serious complication of HF
Cardiac Cachexia
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Patients with cardiac cachexia may lose 1015% 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, MUAC) and diet
history
Cardiac Cachexia
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Proinflammatory state in which cytokines
(TNF, 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,
lower skinfolds, reduced visceral proteins
Krummel in Krause, 12th ed., 2008
Energy Needs in HF
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For obese patients, hypocaloric diets (10001200 kcals) will reduce the stress on the
heart
In undernourished patient, energy needs
are increased by 30-50% above basal
levels; 35 kcals/kg often used
Patients with cardiac cachexia may require
1.6-1.8 times resting energy expenditure for
repletion
Sodium
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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
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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
Dietary Sources of Sodium
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Salt used at the table
Salt or sodium compounds added during preparation
or processing
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Inherent sodium in foods
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Chemically softened water
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Average American consumes 4 to 6 g sodium/day;
80% from processed foods
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Minimum to maintain life is 250 mg/day
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Salt substitutes, herbs, spices and other seasonings
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Drugs and antacids may contain sodium
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Kosher foods
Characteristics of Common
Sodium Restrictions
3 g (131 mEq)
No added salt
High sodium foods are limited; no more than
½ t of table salt allowed
2 g (87 mEq)
Mild restriction
High sodium foods are eliminated; moderate
sodium foods are limited; no more than ¼ t
of table salt allowed
1 g (43 mEq)
Moderate
High and moderate sodium foods eliminated;
table salt not allowed; canned/processed
foods containing salt omitted; frozen peas,
lima beans, mixed veg and corn omitted d/t
brine in processing; regular bread and baked
goods limited. Difficult to maintain at home
500 mg Sodium Diet
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High sodium, moderate sodium foods eliminated.
Table salt not allowed. Canned or processed foods
containing salt omitted
Frozen vegetables (peas, lima beans, mixed
vegetables, corn) omitted due to brine
High sodium vegetables beets, beet greens, carrots,
kale, spinach, celery, white turnips, rutabagas,
mustard greens, chard, dandelion greens omitted
Low sodium bread instead of regular bread
Meat limited to 6 ounces
High Sodium Foods
Food Servings for
Sodium-Controlled Diets
Food Servings for Sodium
Controlled Diets, cont
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 during processing
Without Added Salt,
No Salt Added
Lightly Salted
50% less added sodium than
normally added (product must
state “not a low-sodium food”)
Nondietary Sources of
Sodium
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Medications: barbiturates,
sulfonamides, antibiotics, cough
medications, stomach alkalizers,
laxatives, mouthwashes
Chewable antacid tablet can add 1200
to 7000 mg of sodium daily
Aspirin: 50 mg sodium per tablet
Potassium
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Potassium wasting diuretics
(hydrochlorthiazide, 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; contraindicated in
renal failure and with certain other
medications
Sodium and Salt Gram and
Milliequivalent Measures
1 mEq Na = 23 mg NA
Other Dietary Factors in
Heart Failure
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Alcohol and caffeine
Weight maintenance
Calcium and vitamin D
Magnesium
Thiamin supplementation
Small frequent feedings
Supplements
Other Nutritional Issues
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Calcium and Vitamin D: half of patients with
severe HF have osteopenia or osteoporosis,
especially cachectic patients; use calcium
supplements with caution w/ cardiac
arrhythmias
Magnesium: diuretics may increase mg
excretion; measure blood mg levels
Thiamin status should be evaluated in HF
patients on loop diuretics
Cardiac Assist Devices
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Mechanical heart pumps
May be helpful in pre-transplant HF
patients or in those for whom
transplant is not an option
Heart Transplant
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Only cure for refractory CHF
In 2003, 2000 cardiac
transplants in the U.S.
Highest number in white men
50-64 years of age
Pretransplant MNT Goals
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Body weight 90-110% of ideal body
weight
Extremes of weight (<80% or >140%
IBW predict poor outcome
Pretransplant comorbidities
(hypertension, hyperlipidemia, diabetes)
reduce survival rates
Survival 83% at 1 year, 72% at 5 years,
50% at 9 years
Cardiomyopathy
Post-Transplant MNT
Goals
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Adequate support to promote healing and
fight infection
Monitor and correct electrolyte
abnormalities
Achieve optimal blood glucose control
Provide energy for ambulation and physical
therapy
Energy: 1.3-1.5 times REE; protein 1.5-2
grams/kg body weight; Na 2-4 g/day
Hasse in Krause, 12th Ed., p. 896
Post-Transplant MNT
Issues Long Term
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Immunosuppressants can cause weight gain
and hyperlipidemia
Risk factors are prednisone dose, baseline
cholesterol level, blood glucose levels, and
weight gain
Graft atherosclerosis is the leading cause of
death in long-term survivors
TLC diet with 2-4 gram sodium; optimal
calcium and vitamin D to prevent steroidinduced osteoporosis
ADA Nutrition Care Manual
Education Resources
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http://nutritioncaremanual.org/universi13
Heart failure Nutrition Therapy
Hypertension Nutrition Therapy
DASH Diet guidelines
Summary
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CHF—most common reason for long
lengths of stay in the elderly
Prevention and management is key as
prognosis is poor
Aggressive nutritional interventions are
important.