Cardiac Case Study

Kristine Myers
Dietetic Intern

Introduction:
Patients initials- SA
Primary problem- CAD
Height- 170 cm (67 in)
Weight- 87 kg (191 lbs)
Age- 53
Sex- Male
Reason patient was chosen for study- CAD and CABG procedure
Date of study- 01/05/16 - 01/14/16
Focus of this study- s/p CABG patient, heart healthy cardiac diet
Social History:
Occupation- unemployed
Marital status- Single
Health insurance- Medicare
Children and ages- N/A
Religion- Seventh Day Adventist
Normal anatomy and physiology of body function:
The primary use of the heart is to pump blood throughout the body to
supply oxygen and nutrients to the bodys tissues. Veins connected to the heart
are the channels blood uses to reach the tissues . Like the other parts of the
body, the heart tissue also requires oxygen and nutrients to function . When blood
is passing through the hearts chambers it is not supplying oxygen and nutrients .
The heart receives its oxygen and nutrients from the left and right coronary
arteries. 1,2
Plaque can harden in the coronary arteries over time . As plaque build up
in the arteries occurs, oxygenated blood has a harder time getting to the heart
tissue. As this happens the heart has to work harder to pump . The lack of oxygen
weakens the heart and blood is not pumped to the rest of the bodys tissues
efficiently. This commonly causes chest pain or angina. If left untreated a heart
attack can occur. 1

Past Medical History:

Coronary artery disease (CAD)

Hyperlipidemia (HL)
Aspergers syndrome

Previous Admissions

SA was admitted on October 11th 2015 and underwent cardiac

catheterization as well as having a stent placed in his mid LAD due to a
non-ST segment elevation myocardial infraction (NSTEMI) . The patient
was sent home and doctors were hopeful the stent placement would be
adequate treatment.

Patient SA was admitted for chest pain on November 13 th 14th 2015 for
an observation stay.

Present Medical Status and Treatment:

Theoretical discussion of disease condition
CAD is the most common type of heart disease and is the leading cause
of death among men and women in the United States . CAD occurs when plaque
build up accumulates on the inner walls of the arteries . Blood uses these arteries
to get to the heart. The build up of plaque is known as atherosclerosis . The
greater the build up the less blood passes through, resulting in the heart not
receiving the blood or oxygen it needs to continue working . This will cause chest
pain and likely a heart attack if a blood clot forms completely cutting off
circulation to the heart. The longer CAD remains the weaker the heart becomes,
which leads to heart failure.2,3
There are many different diagnostic tools or tests to identify CAD and a
persons risk of heart attack. Some of these include a lipid profile, cardiac MRI,
echocardiography, and coronary angiography. Depending on the test(s) chosen
by the doctor and the results of the tests, the treatment route will be determined
accordingly. Regardless of the treatment plan, exercise and healthy nutrition are
always key factors in the health of the heart.3
Usual treatment of the condition
There are two common procedures used to treat Coronary Artery Disease
(CAD). Both make a clearer path for blood to travel through on its way to the
heart. One uses a balloon to open up a semi-blocked blood vessel and the other
reroutes the blood by connecting a new blood vessel around the blocked one .4,5

Percutaneous Coronary Intervention is a procedure also referred to as

coronary angioplasty. It is a non-surgical method used to open the arteries for
blood to pass through. A catheter is inserted into either the upper thigh or upper
arm through the artery. Inserting a catheter opens the narrowing pathway for
blood to better reach the heart.4
Coronary Artery Bypass Grafting (CABG) is a surgical procedure used
when arteries become blocked. The plaque build up, which prevents blood from
getting to the heart, causes a need to bypass the narrowing vein . When this
happens, surgery is required to help avoid a heart attack from occurring . The
CABG procedure is a form of surgery where a blood vessel from a different area
of the body is used to bypass the blocked artery. This blood vessel may be a vein
taken from the leg or another artery in the chest . One end of the blood vessel is
attached above the blocked artery and the other is attached below the blocked
artery. Bypassing the blocked vessel creates a new path for oxygenated blood to
reach the heart. 2,4,5
Originally this procedure was always done as an open-heart surgery,
breaking the sternum in half, spreading it apart and temporarily stopping the
heart. Tubes were hooked up to the heart and a machine was used to pump the
body with blood. Though this traditional form of CABG surgery is still used, there
have been new discoveries of less invasive CABG surgeries . New developments
like the off-pump CABG procedure do not require the heart to be stopped .
Robotic procedures have become an increasingly popular way to perform CABG
surgeries as well.4,5
Other developments in the way CABG surgeries are performed include the
way in which the graft is taken. Traditionally a long incision is cut down the inner
thigh or calf. Now endoscopic vein harvesting and endoscopic radial artery
harvesting are used as a less invasive way to locate a blood vessel for the use of
grafting. These two improvements have provided patients with less leg pain after
surgery and shorter hospital stays.4
Patients symptoms upon admission leading to present diagnosis and
explain etiology

Chest pain: related to plaque build up in the arteries, preventing proper

blood flow to the heart. The lack of sufficient blood flow likely causes chest
pain.

Shortness of breath (SOB): related to the organs of the body, specifically

lungs, not receiving adequate oxygenated blood . When the blood has
difficulty passing through the arteries the rest of the organs in the body are
affected.

Lab findings and interpretation

Date
1/5/16

Lab
A1c

Value
6.0

Range
4-6%

1/6/16

Sodium
Potassium
Glucose
BUN
Creatinine
GFR/Cl
Magnesium
Cholesterol
HDL
LDL
Triglycerides

140
4.1
221 (H)
10
0.62 (L)
>110/129
2.5
103
41
33
147

132-143
3.5-5.0
70-100
6-20
0.7-1.2
>110
1.7-2.6
<180
40-60
70-189
<200

1/13/16

Sodium
Potassium
Glucose
BUN
Creatinine
GFR/Cl

138
4.9
93
13
0.60 (L)
>110/134

132-143
3.5-5.0
70-100
6-20
0.7-1.2
>110

SAs laboratory values above upon admission were mostly in range . SA

had high glucose levels and low creatinine, but other than that, looked
satisfactory. The patients sodium value was in range at 140 . Before discharge,
patient SA continued to have relatively in-rage lab values . His glucose was down
to 93 and sodium dropped slightly to 138. His creatinine was still marginally low
at 0.60. Surprisingly, the patients lipid values were all in range, aside from LDL
cholesterol, which was lower than the normal range . His total cholesterol and
triglycerides observed were at adequate levels .
Medications

Aspirin 81 mg/day
o Prescribed for chest pain
o No known interactions with food
Atorvastatin 80 mg/day

o Prescribed for maintenance of adequate cholesterol and triglyceride

levels
o Grapefruit is not advised while taking Atorvastatin
Pepcid 20 mg BID
o Prescribed for heartburn
o No known interactions with food
Heparin 250 mL while at the hospital
o Prescribed as a blood thinner for the prevention of blood clots
o No known interactions with food
Metoprolol 50 mg BID
o Prescribed for high blood pressure and chest pain
o No known interactions with food
Xanax 0.25 mg TID
o Prescribed for anxiety
o Grapefruit is not advised while taking Xanax
Clopidogrel 75 mg/day taken at home
o Prescribed as a blood thinner to prevent heart attacks
o No known interactions with food
Treatment

Treatment options include:

Surgeries
Procedures
Healthy nutrition
Exercise

The treatment used for patient SA was CABG x 4 . Following this openheart procedure, nutrition is vital. Adequate nutrition with adherence to a heart
healthy cardiac diet will provide the best nourishment during recovery .
As new procedures and techniques come out for treatment of CAD, the
CABG surgery remains prominent. The balloon angioplasty and stents, which
were both discovered after CABG, have lost their appeal as their unpredictability
has been uncovered. According to a study published in 2015, bypass surgery is
one treatment that despite the pain and discomfort it causes patients, has not lost
credibility or attraction. It is a very common treatment option with pleasing
results.6

Medical Nutrition Therapy:

Nutrition history
Patient reports eating three meals a day with snacks in between . He
prepares his own meals in his kitchen. SA stated he uses mostly canned fruits
and vegetables, but is going to start buying frozen or fresh when able . He is a
vegetarian who eats dairy products, but not fish . He gets most of his protein from
nuts and soy. SA is allergic to eggs, but stated he eats yogurt occasionally. He
likes peanut butter and soy butter sandwiches . He told me during a visit that he
likes vegetarian burgers. Patient SA likes to buy black bean or tofu burgers when
he can afford them. SA acknowledged he eats many prepackaged snacks such
as potato chips and Twinkies. He knows these are not healthy snack choices and
wants to try eliminating them from his diet when he leaves the hospital . Another
change he is looking to make to his diet is switching from whole and 2% milk to
skim milk. Prior to admission SA stated he was not aware he should be buying
skim milk.
Analysis of previous 24 hour recall
Time:
9:00 am

Food:
Oatmeal
Banana
Orange juice

Portion:
cup
1 medium
8 oz

11:00 am

Hostess snack

1 pkg

1:00 pm

Wheat bread
Peanut butter
Canned mandarin oranges
Canned green beans
Apple juice

2 slices
2 tablespoons
1/2 cup
1/3 cup
8 oz

3:00 pm

Potato chips

1 oz

6:00 pm

Wheat bread
Soy butter
Pudding
Canned peaches
Orange juice

2 slices
2 tablespoons
cup
1/3 cup
8 oz

According to SAs 24-hour dietary recall, he is consuming adequate

amounts of grains and fruit, but is lacking in vegetables and dairy. His protein
intake is also below the recommended amount . Protein intake is important for
wound healing. A man of his statue should be consuming 80-100 grams of
protein to facilitate healing. As a vegetarian, it is important the patient is eating

adequate non-meat protein sources and though his protein intake from the recall
does not appear sufficient, he named many protein sources that he enjoys . His
calorie intake status post surgery should be between 2,010-2,345 kcals. The
dietary recall provided falls just short of this range . SA greatly exceeded the
recommended amount of added sugar per day. He was advised during his
hospital stay about cutting back items such as his pre-packaged hostess snacks .
He may also benefit from cutting back his juice intake, because of the high sugar
content in fruit juice.
SA was greatly lacking in Calcium intake. This is not surprising as his
recall shows a deficit in dairy consumption. A glass of skim milk at breakfast and
low-fat yogurt for a snack could improve his dairy consumption, therefore his
Calcium intake. The recall also made apparent his lack of water-soluble vitamins
and vitamin B12. An increase in vegetables consumed will benefit his vitamin
status. Though the patients diet is not perfect, he seemed motivated to make
any necessary changes.
Current prescribed diet
The patient was prescribed a 2-gram sodium, heart healthy cardiac diet at
the hospital. The heart healthy cardiac diet includes low fat and low cholesterol .
SA was put on this diet following his open-heart surgery. Adequate oral intake
abiding by this diet is essential following surgery to facilitate healing of the chest
incision.
Rationale for diet or changes
Sodium and fat are the key nutritional players involved in causing a heart
attack. The more sodium consumed by an individual the harder their heart has to
work. Sodium and water attract and settle near the heart . The more sodium and
water the more pressure there is near the heart . This makes the heart work
harder to pump blood. By limiting the sodium to 2 grams (2,000 mg), there is less
pressure surrounding the heart muscle. Fat is the other important player.
Unhealthy fats, such as saturated fat and trans fat, cause the build up of plaque
in the arteries. The more saturated and trans fat eaten by an individual the more
plaque builds up. A build up of plaque causes the arteries to harden and prevents
the blood from passing through.
When patient SA is discharged, he should continue monitoring his sodium
and fat intake. Following a 2,000 mg sodium diet and watching his fat intake will
be beneficial for his recovery. SAs current prescribed diet will hopefully prevent
him from visiting the hospital in the future for further severe heart issues .
Patients physiological response to diet

The diet SA is on currently should help improve his chest pain and heart
problems. It should prevent the feeling of shortness of breath . In theory a patient
prescribed the same diet as SA will have improvement in laboratory values .
Although in this patients case he already had satisfactory values . Before
discharge SA was feeling much better and was not experiencing SOB .
Evaluation of present nutritional status
Prior to discharge the patient was stable and appeared adequately
nourished. His laboratory values were in range and he was eating well . The
patient was following a 2-gram sodium diet as well as one low in fat and
cholesterol. With an excellent lipid profile and avoidance of high fat/high sodium
items, SA should experience a more healthy life . He stated he is an avid walker,
as he does not own a car, so he gets plenty of exercise daily.
Prognosis:
Following the CABG surgery, SA should do very well . The surgery has
been shown to improve or completely eliminate symptoms of angina or chest
pain. SA was very open to listening to nutrition education . Though the
conversation had to be redirected often during the teaching, SA seemed
receptive. The patient was able to repeat back nutrition knowledge he had
previously been taught. If SA applies the nutritional information he learned in the
hospital to his daily life, he should do very well .
Summary and conclusion:
With SAs retention of knowledge, motivation to change his diet and
frequent daily walking, I believe he will do a wonderful job maintaining great
health. He was admitted to the hospital for chest pain and SOB . After receiving
CABG x4 he experienced a great deal of pain . Once recovered and upon
discharge he stated he was feeling much better .
I provided SA with diet education and stressed the importance of healthy
nutrition accompanied by exercise. SA is an avid walker and stated he will
continue to exercise daily. Though he regularly consumes pre-packaged desserts
and canned vegetables, he is going to work on cutting those back . In place of
those, he agreed to substitute the canned goods for fresh or frozen vegetables .
He also agreed to replace his whole and 2% milk with skim milk . He understands
that the high fat milk is unnecessary for him to consume and that he can get all
the beneficial vitamins and minerals from non-fat milk .
This patient was a very interesting case for me . I was interested in
learning more about the CABG procedure, because it was not something I was
very familiar with. This patient had an added challenge with his Aspergers

Syndrome. He seemed very receptive and intelligent during the education I

provided him, but often became side tracked. I frequently had to redirect our
conversation to stay on topic and get through all the material . I found that short
frequent conversations worked better than one long education session . I visited
SAs room on a few occasions to talk about nutritional needs .
I learned so much about the heart and heart healthy nutrition during this
case study. I also became very familiar with the CABG procedure and how it is
performed. The patient challenged me to provide the most up to date and
relevant information. He challenged me to provide explanation behind why
certain recommendations are in place. Im very grateful for the learning
experience SA was able to provide me.

Bibliography
1. Coronary Artery Bypass Grafting Surgery. Johns Hopkins Medicine Website.
http://www.hopkinsmedicine.org/healthlibrary/test_procedures/cardiovascular/cor
onary_artery_bypass_graft_surgery_cabg_92,P07967 . Accessed January 9,
2016.
2. Nutrition Therapy & Pathophysiology, 2nd edition; Authors, Marcia Nelms,
Kathryn Pucher, Karen Lacey (2011)

3. Coronary Artery Disease. National Institute of Health website.

https://www.nlm.nih.gov/medlineplus/coronaryarterydisease.html. Accessed
January 11, 2016.
4. Angioplasty. National Institute of Health website.
http://www.nhlbi.nih.gov/health/health-topics/topics/angioplasty. Accessed
January 10, 2016
5. Nutrition Care Manual. Academy of Nutrition and Dietetics website.
https://www-nutritioncaremanual-org-proxy1-cl-msuedu.proxy2.cl.msu.edu/topic.cfm?ncm_category_
id=1&lv1=5543&lv2=145193&ncm_toc_id=145193&ncm_heading=Nutrition
%20Care. Accessed January 10, 2016.
6. Sigwart U. Treatment of coronary artery disease from the inside: Light at

the end of the tunnel? Global Cardiology Science & Practice.

2015;2015(4):53.