Heart FailurePrimary Disease Process

• Heart failure is characterized by a complex grouping of symptoms related to the hearts reduced ability to sufficiently pump blood and oxygen to the bodies tissues.

• These symptoms vary in manifestation and severity.

Damage to the Heart• Any structural or functional deficit that reduces the ability of

the ventricles of the heart to expel blood can result in heart failure.

• Though most heart failure is associated with reduced left ventricle function, often due to a cardiac event, this is not the only dysfunction that can lead to a diagnosis of heart failure.

• Any damage to or lack of function of the pericardium, myocardium, endocardium, heart valves or great vessels can also lead to decreased ability of the heart to supply blood and oxygen to the tissue of the body.

Etiology• For Americans over the age of 40, there is a 20% risk of developing

heart failure over a lifetime.

• Risk of heart failure is higher in populations with one or more of the following risk factors: • Coronary artery disease• Previous myocardial infarction• History of hypertension• Abnormal heart valves• Congenital heart disease• Severe lung disease• Diabetes • Obesity• Sleep apnea• Various forms of cardiomyopathy or myocarditis

Why Such a Focus On Heart Failure? Higher incidence of

chronic diseases and risk factors.

Improved treatment for chronic

conditions. Higher survival rates of

myocardial infarctions

Patients living longer into their diseases

states.

More patients are being diagnosed with

heart failure.

Increased hospitalizations, use of resources, more ailments to treat.

Sign or Symptom People with Heart Failure May Experience...

Why It Happens

Shortness of breath (also called dyspnea)

...breathlessness during activity (most commonly), at rest, or while sleeping, which may come on suddenly and wake you up. You often have difficulty breathing while lying flat and may need to prop up the upper body and head on two pillows. You often complain of waking up tired or feeling anxious and restless.

Blood "backs up" in the pulmonary veins (the vessels that return blood from the lungs to the heart) because the heart can't keep up with the supply. This causes fluid to leak into the lungs.

Persistent coughing or wheezing

...coughing that produces white or pink blood-tinged mucus.

Fluid builds up in the lungs (see above).

Buildup of excess fluid in body tissues (edema)

...swelling in the feet, ankles, legs or abdomen or weight gain. You may find that your shoes feel tight.

As blood flow out of the heart slows, blood returning to the heart through the veins backs up, causing fluid to build up in the tissues. The kidneys are less able to dispose of sodium and water, also causing fluid retention in the tissues.

Tiredness, fatigue ...a tired feeling all the time and difficulty with everyday activities, such as shopping, climbing stairs, carrying groceries or walking.

The heart can't pump enough blood to meet the needs of body tissues. The body diverts blood away from less vital organs, particularly muscles in the limbs, and sends it to the heart and brain.

Lack of appetite, nausea ...a feeling of being full or sick to your stomach. The digestive system receives less blood, causing problems with digestion.

Confusion, impaired thinking ...memory loss and feelings of disorientation. A caregiver or relative may notice this first.

Changing levels of certain substances in the blood, such as sodium, can cause confusion.

Increased heart rate ...heart palpitations, which feel like your heart is racing or throbbing.

To "make up for" the loss in pumping capacity, the heart beats faster.

Diagnosing Heart Failure• %LVEF is the measure of the amount of blood that is pumped from the

left ventricle during each contraction of the heart.• Normal: 55%-70%• Compromised: 40%-55%• Advanced cardiomyopathy or Heart failure: <40%

• . B-type natriuretic peptide, commonly known as BNP is a reliable indicator of the function of the heart. • Made by the liver and rises in correspondence with the amount of pressure

inside the heart.• Normal functioning heart BNP levels range between 0 pg/mL to 99 pg/mL. • >100pg/mL indicates some possible damage to the heart• Severe heart failure is recognized when BNP raises to greater that 900 pg/ml

• C-reactive protein is most usually elevated in cases of heart failure as well, but can be unreliable in fluid overloaded state.

Treatment

• Multifactorial approach, very individual results.• Pharmaceutical treatment• Anticoagulants, ACE inhibitors, beta blockers, calcium channel

blockers, cholesterol lowering medication, diuretics and vasodilators.

• Smoking cessation• Diet modifications• Dry weight loss• Increased Exercise• Surgical Intervention• Heart Transplant, LVAD

Prognosis• According to the Academy of Nutrition and Dietetics, in 2011,

“Fatality rates for HF after hospitalization were 10.4% after 30 days, 22% after one year, and 42.3% for 5 years”.2

• Other studies support closer to a 50% mortality rate in 5 years.

• Though recently patients are living longer with the condition of heart failure, treatment and lifestyle management can only go so far in many cases to slow the progression of the condition.

Current ResearchSodium

• Sodium restriction recommendations vary from 1.5g/day(American Heart Association) to 2-3 g/day(Heart Failure Society of America for NYHA I & II) depending on which advising body you refer too.

• Other studies have shown that ranges of 2.7-3g/day are considered therapeutic.

• DRI’s are <2,300 for healthy individuals, <1,500 for at risk individuals

• We counsel on 2 g based on the AND recommendation. • Allows “cushion” for patient

Current ResearchSupplementation

• Co-Q10 supplementation of 100mg twice daily over 2 years led to reduced adverse events, most notably in death from heart failure, heart failure hospitalizations and cerebral strokes.7 • Statin medications often taken by heart failure patients deplete

CoQ10 in the body.

• Though supplementation of specific Amino Acids has been an area of focus, there is limited evidence supporting that any specific amino acid supplementation improves heart failure outcomes. 8

Current ResearchOver and Under Nutrition

• Obese patients suffering from heart failure are often encouraged to attempt gradual, healthy dry weight loss to improve their clinical outcomes.

• In a study published in the Journal of Nutrition a BMI in the overweight category, 25-30 kg/m2, led to more favorable outcomes than a BMI in the “normal” range of less than 25.9 • Overweight may not be beneficial, just less adverse than

undernutrition in heart failure treatment.

• Patients assessed as malnourished or at risk for malnutrition have poorer outcomes than those who are not at risk.10

Current ResearchEfficacy of MNT

• In a study based on motivational interviewing, a practice used by many registered dietitians, clinical outcomes were shown to improve with more consistent patient/clinician contact.11

• In a study performed at a small VA hospital, 23-31% of heart

failure hospital admissions logged could have been prevented if the patient had reported their symptoms earlier.12

• This is especially important to note because of the readmission goals we have for our HF patients.

Medical Nutrition Therapy

•The RD difference!• The Academy states that, “A planned initial visit lasting at least 45

minutes and at least one to three planned follow-up visits (at least 30 minutes each) can lead to improved dietary pattern and quality of life and decreases in edema and fatigue. Along with optimal pharmacological management, MNT may also reduce hospitalizations”.13

Medical Nutrition TherapyAND Guidelines

• Protein: Normally nourished – 1.12g/kg body weight, Nutrient depleted – 1.37 g/kg body weight. (fair)

• Energy: Indirect calorimetry or predictive equations accounting for hyper catabolic state.

• Fluid: 1.4-1.9 liters per day. (fair)• Vary with patient sensitivity and body size.

• Sodium: <2g per day

• Vitamins: Folate, B12, B6

Medical Nutrition TherapySelf Monitoring

• Self-monitoring is an important factor of successfully managing heart failure.• Daily weights• Fluid and Sodium intake• Electrolyte levels

• Loop and potassium sparing diuretics

CASE STUDY APPLICATION

General Information• J.E.• Male• 56 y/o• Caucasian• US Navy Veteran• Post military, J.E. was a truck driver but was no longer working at the

point of contact due to his symptoms. • PTA J.E. was a 1PPD smoker• Moderate/Heavy ETOH consumption• Reports ranging from 2 drinks to 18 drinks per night.

• J.E. was chosen for this case study because of his presentation of classic HF symptoms, his demonstrated need for medical nutrition therapy and prospect of having a transplant or LVAD placed within the next 6 months to 1 year.

Present Admission• J.E. was admitted to C.W. Bill Young VA hospital on August 14,

2015 to the MICU for CHF exacerbation.• Attending Physician: Dr. Mansoor• C/O

• Severe Orthopnea• PND• Lower Extremity Edema

• %LVEF of 15%• Comorbidities

• Hyperlipidemia• DM type 2(recently diagnosed)• CAD

*It is important to note that the medical nutrition therapy for J.E. will encompass actions needed to prepare him for the possibility of a heart transplant or placement of a LVAD.*

Pertinent Labs: August 14, 2015 – August 27, 2015

8/14 8/15 8/16 8/17 8/18 8/20 8/21 8/22 8/24 8/27 REF

BNP 1711 H 2566 H 1329 H - 1114 H - - - 1376 H 1054 H 5-80

CREAT 1.59 H 1.44 H 1.81 H 1.63 H 1.53 H 1.14 1.24 1.4 H 1.3 H 1.21 H .64 - 1.27

mg/dL

BUN 18 24 H 36 H 41 H 32 H 20 20 22 H 22 H 14 H 8 – 20 mg/dL

eGFR 45 L 51 L 39 L 44 L 47 L >=60 >=60 52 L 57 L >=60 L >=60 mL/min

K+ 3.5 L 3.5 L 3.6 4.4 4.0 4.4 4.1 4.2 4.1 3.6 3.6 - 5.1

mEq/L

MG 2.0 - 2.1 1.7 L - 2.1 - - 2.0 2.1 1.8-2.4 mg/dL

ALB 3.2 L 3.0 L - 2.7 L 2.7 L - 2.6 L 2.7 - 3.5-4.8 g/dL

POC GLU 259 125-177 135-176 134-190 214 125-178 115-207 175-275 117-173 108-164 74-118

Medication Purpose/action Nutritional ImplicationsAtorvastatin(Lipitor) Statin - cholesterol lowering medication Refrain from grapefruit juice.

Bumetanide IV Loop diuretic – Inhibits sodium reabsorption, causing increased urination to rid the body of excess sodium and fluid. Often used in patients who furosemide has been found ineffective.

Can deplete the body of Magnesium and Potassium along with Sodium.

Cyclobenzaprine Muscle relaxer/pain reducer. Blocks nerve impulses that send pain signals to the brain.

None to note.

Nitroglycerine A nitrate that is used to relax blood vessels. Used to treat chest pain caused by hypertension and during surgery to lower blood pressure.

Avoid alcohol, or drink in moderation.

Dobutamine Increases the efficiency of the heart by stimulating the heart muscle. Used in a short term capacity to treat decompensated heart failure.

None to note.

Docusate Sodium Stool Softener Avoid supplementation with mineral oil.

Insulin Aspart Human Sliding Scale Insulin Can cause hypoglycemia.

Insulin Detemir Long acting insulin Can cause hypoglycemia.

D50W 50% Dextrose in water injection used to maintain blood glucose levels

Increases blood sugar levels

Temazepam Benzodiazepine that is used to treat insomnia Caffeine is counteractive. Avoid caffeine prior to administration.

Spironolactone Potassium sparing diuretic used to rid the body of excess sodium and fluid while retaining potassium.

Can cause buildup of potassium in the body. Avoid use of KCL salt substitutes.

J.E. MEDICAL NUTRITION THERAPY

Assessment• Intake• Moderate decrease in total energy intake since MI 2 mo. PTA• Mechanical advanced foods preferred(no top teeth)• 2 meals per day, prepared at home by his wife• Recent effort to reduce sodium, pre-fluid overload heavy

consumption of convenience foods• Preferences

• Pork, beef, chicken, LS deli meats, milk, cottage cheese, eggs• Little consumption of fresh fruits or vegetables

• Fluid• 32-48 oz. of coffee per day, 16-20 oz. water per day

• Diet Recall

Assessment• Anthropometrics• 67 inches tall• 206.6 lbs• BMI: 32.4 (Obesity I)

• Note that veteran was in a fluid overloaded state at this time• Calculated IBW: 163 lbs• Stated UBW: 215-220 lbs• Estimated dry weight: 200 lbs

• Comparative Standards• Energy: 2,245 kcal/day (Mifflin)• Protein: 100-125 g/day (based on AND 1.37g/kg)

Assessment• Nutrition Focused Physical Exam• Veteran stated noticeable loss of bilateral muscle mass and ongoing LE

edema• 2+ to 4+ pitting edema since admission per nursing notes

• Mid-Upper arm circumference – 30 cm• Between the 10th and 50th percentile for his age

• Visual Observations and Palpatation• Mild muscle wasting in the clavicle, bicep and shoulder• Mild subcutaneous fat loss in triceps

• No evidence of skin breakdown. • Activities of daily living in tact.

Diagnosis• Decreased nutrient needs (sodium and fluid) related to HF as

evidenced by conditions associated with diagnosis including fluid overload.

• Increased nutrient needs (protein) related to increased demand for nutrient as evidenced by loss of muscle mass and estimated intake of food/supplements containing needed nutrient less than estimated requirements.

Intervention• Indicated to add 2g sodium diet order.• Oral protein supplements ordered to meet estimated

requirements.• Boost Plus 3x per day, replacing milk(to ensure fluid restriction

compliance)• 360 kcal & 14 g PRO each = 1080 kcal & 42g PRO per day

• Counseling topics• Importance of smoking cessation and abstinence from alcohol.• Discussion on relation of undernutrition and mortality in regards

to possible transplant.• Diet modifications for post discharge were discussed to increase

protein intake, while still staying in the confines of a sodium and fluid restricted diet.

Intervention

• Goals•Maintain intake of greater than or equal

to 75% of total nutrition being provided during inpatient stay.

• Veteran making a concerted effort to monitor his PO fluid intake and remain within restriction limits.

Monitors

• Food/nutrition-related history outcomes:• Food/nutrient intake: types and amounts of food/fluids consumed• Knowledge/beliefs/attitudes: comprehension of nutrition-related concepts;

emotions/feelings towards nutrition-related concepts• Behaviors: adherence to nutrition recommendations• Physical activity and functional capacity• Nutritional QOL

• Anthropometric Measurements:• -Weight/weight change (edematous and non-edematous)

• Biochemical data:• Trends in visceral protein stores and lymphocyte count

• Medical tests/procedures:• Further cardiac work up

• Nutrition-Focused Physical Findings:• Notable changes in physical assessment• GI distress• Affect/body language

Inpatient Follow-Up• September 2, 2015 – MICU • Veteran had diuresed ~28 lbs

• Current weight 187.6• Veteran stated that appetite had grown and was remaining strong

• Consuming all protein provided in meals and supplements.• Did not enjoy many of the vegetables he was being served• Preferences noted and inputted into computrition to maximize PO intake

Meds and LabsMedication Purpose/action Nutritional Implications

Atorvastatin Cholesterol lowering medication Refrain from grapefruit.

Enoxaparin Anticoagulant Avoid alcohol due to increased bleeding risk.

Lisinopril ACE inhibitor, used to treat HTN. Hyperkalemia is possible.

Metoprolol Beta Blocker, used to keep heart rate steady. Can cause lethargy.

None to note.

Nicotine Patches prescribed for aid with smoking cessation(Veteran states to not need)

Patients involved in smoking cessation often become victim to weight gain.

Potassium Chloride

Used in cases of loop diuretics to ensure adequate levels of potassium in the body.

Potassium levels should be monitored and oral KCL intake consistent.

• Albumin increase to 3.2 from 2.7 on August 24, 2015• BNP dropped to 925 from a previous measure of over 1000

Outpatient Follow-Up• September 15, 2015 – Outpatient CHF Clinic• Daily weights not recorded

• Net 5 lb weight loss since discharge • Nutrition Focused Physical Exam

• Handgrip: 11.6 PSI• Reference for 56 y/o male is 12.6 PSI

• Mid-Upper Arm Circumference: 25 cm, 5 cm less than pre-diuresed measure• Below the 5th percentile for men over the age of 20

• Percent Arm Muscle Area: 30.07• Below the 5th percentile for males age 55-64

• By comparing the Veteran’s BMI of 28.1 in his current dry state, to his Percent Arm Muscle area it can be concluded that J.E. is sarcopenic and has been affect by muscle loss.

Outpatient Follow Up• Intake• Making a concerted effort to reduce sodium• Demonstrated ability to read food labels and had retained

information from previous counseling sessions. • Strong effort to consume adequate protein• Veteran stated that he continued to refrain from use of tobacco

and alcohol post discharge.• Intervention• Basics of a carbohydrate consistent diet(new DM Type 2).• Low sodium eating for HF• High protein and Adequate calorie diet to ward of further wasting

*Educational materials provided*

MENUS

MENUS

Goals

1. Consume recommended amounts of sodium(2 g/day) and fluid(1.4-1.9 liters/day) to avoid fluid overload.

2. Increase protein to recommended levels (100-125 g/day) to defer further muscle wasting.

3. Eat a carbohydrate consistent diet 5 out of 7 days per week.

4. Continue to refrain from use of tobacco and alcohol.

Summary• QOL can improve from nutritional and medical intervention,

but LVEF% will not improve.• By following diet recommendations, J.E. can prepare himself

for a possible heart transplant or LVAD in the next 6 months to 1 year.

• Dietary and medication compliance can reduce risk for fluid overload and hospital readmission.

• Compliance with self-monitoring is important to note issues and seek help quickly.

Bibliography1. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: executive summary: a

report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation. 2013;128(16):1810-52.

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3. About Heart Failure. HEARTORG. Available at: http://www.heart.org/heartorg-/conditions/heartfailure/heart-failure_ucm_002019_subhomepage.jsp. Accessed 2015.

4. Boilson, BA, Raichlin, E, Park, SJ, Kushwaha, SS. Device Therapy and Cardiac Transplantation for End-Stage Heart Failure. Current Problems in Cardiology. 2010:8–64.

5. Wendling, P. Low Sodium Diet Keeps Arteries Flexible in Hypertensive Patients. Family Practice News. 2005:20–20. 6. Reilly, CM, Anderson, KM, Baas, L, et al. American Association of Heart Failure Nurses Best Practices paper: Literature

synthesis and guideline review for dietary sodium restriction. Heart & Lung: The Journal of Acute and Critical Care. 2015:289–298.

7. Mortensen, SA. Overview on coenzyme Q 10 as adjunctive therapy in chronic heart failure. Rationale, design and end-points of “Q-symbio” - A multinational trial. BioFactors. 2014:79–89.

8. Carubelli, V, Castrini, AI, Lazzarini, V, Gheorghiade, M, Metra, M, Lombardi, C. Amino acids and derivatives, a new treatment of chronic heart failure? Heart Failure Reviews Heart Fail Rev. 2014:39–51.

9. Casas-Vara, A, Santolaria, F, Fernández-Bereciartúa, A, González-Reimers, E, García-Ochoa, A, Martínez-Riera, A. The obesity paradox in elderly patients with heart failure: Analysis of nutritional status. Nutrition. 2012:616–622.

10. Aggarwal, A, Kumar, A, Gregory, MP, et al. Nutrition Assessment in Advanced Heart Failure Patients Evaluated for Ventricular Assist Devices or Cardiac Transplantation. Nutrition in Clinical Practice. 2012:112–119.

11. Creber, RM, Patey, M, Lee, CS, Kuan, A, Jurgens, C, Riegel, B. Motivational interviewing to improve self-care for patients with chronic heart failure: MITI-HF randomized controlled trial. Patient Education and Counseling. 2015.

12. Stevenson, C, Pori, D, Payne, K, Black, M, Taylor, V. Hearing the Veteranʼs Voice in Congestive Heart Failure Readmissions. Professional case management. 2015:186–187.

13. HEART FAILURE (HF) GUIDELINE (2008). Evidence Analysis Library. Available at: http://www.andeal.org/topic.cfm?menu=5289&cat=2800. Accessed 2015.

Questions?