Heart Failure and Transplant


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  • Heart Failure and Transplant

    1. 1. MNT for Heart Failure and Transplant
    2. 2. Congestive Heart Failure (CHF) <ul><li>A clinical syndrome characterized by progressive deterioration of left ventricular function, inadequate tissue perfusion, fatigue, shortness of breath, and congestion </li></ul>
    3. 3. <ul><li>Gradual failure of heart </li></ul><ul><li>1. Compensated—Lack of O 2 to tissues causes increase in heart rate and enlargement of heart </li></ul><ul><li>2. Decompensated—Heart no longer adjusts </li></ul>Congestive Heart Failure (CHF) —cont’d
    4. 5. Causes of Heart Failure <ul><li>Diseases of the heart (valves, muscle, vessels, arteries) and vasculature (hypertension) cause left ventricular systolic dysfunction </li></ul><ul><li>Once established, myocardial infarction, dietary sodium excess, medication noncompliance, arrhythmias, pulmonary embolism, infection, anemia can precipitate complete CHF </li></ul>
    5. 6. Prevalence and Incidence <ul><li>Unlike other cardiovascular diseases, CHF is on the increase </li></ul><ul><li>Number of CHF-related discharges increased 174% from 1979-2003 </li></ul><ul><li>4.8 million Americans have CHF; overall prevalence 2-6% </li></ul>Krummel DA in Krause, 12 th ed., 2008
    6. 7. Prevalence and Incidence <ul><li>Prevalence increases with age, especially after age 55 </li></ul><ul><li>Black women have the highest rates, followed by black men, Latino men, white men, white women, and Latino women </li></ul><ul><li>More Medicare dollars are spent on CHF than on any other diagnosis </li></ul>
    7. 8. Prevalence and Incidence <ul><li>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 </li></ul><ul><li>Incidence of CHF approaches 10 per 1000 people over 65 years </li></ul><ul><li>Median survival of men and women is 1.7 years and 3.1 years respectively </li></ul><ul><li>One in five persons with CHF will die within a year of diagnosis </li></ul>
    8. 9. Risk Factors <ul><li>Hypertension (91% of Framingham cohort had hypertension before CHF) </li></ul><ul><li>Left ventricular hypertrophy </li></ul><ul><li>Coronary heart disease (causes 60-65% of cases) </li></ul><ul><li>Diabetes </li></ul><ul><li>Mean age of onset is 70 years </li></ul>
    9. 10. Stages of Heart Failure Krummel in Krause, 12 th Ed. Frequently hospitalized; awaiting transplant Advanced structural damage, refractory symptoms D Dyspnea or fatigue due to LV dysfunction; reduced exercise tolerance Structural heart disease with current or prior syx of HF C LVH or fibrosis, left ventricular dilatation; low EF; asymptomatic valve disease, previous MI Structural heart disease associated with HF but no signs/syx B HBP, CAD, diabetes, alcohol abuse, hx rheumatic fever; family hx cardiomyopathy, using cardiotoxins, metabolic syndrome High risk of HF because of presence of risk factors but without syx or structural damage A
    10. 11. Classifications of Heart Failure Inability to carry out physical activity without discomfort; symptoms of cardiac insufficiency or chest pain at rest Class IV Marked limitation of physical activity; patient comfortable at rest Class III Slight limitation of physical activity; patient comfortable at rest Class II No undue symptoms associated with ordinary activity; no limitations Class I
    11. 12. Congestive Heart Failure Symptoms <ul><li>Dyspnea </li></ul><ul><li>Orthopnea </li></ul><ul><li>Nausea </li></ul><ul><li>Fullness </li></ul><ul><li>Pulmonary edema </li></ul><ul><li>Cardiac edema </li></ul><ul><li>Cardiac cachexia </li></ul>
    12. 13. CHF DIAGNOSIS <ul><li>EKG or electrocardiogram </li></ul><ul><ul><li>measures the rate and regularity of the heartbeat </li></ul></ul><ul><ul><li>May indicate whether there has been heart damage or changes in anatomy </li></ul></ul><ul><li>Chest X-ray </li></ul><ul><ul><li>Shows whether heart is enlarged, fluid in lungs, pulmonary disease </li></ul></ul>
    13. 14. CHF DIAGNOSIS <ul><li>Echocardiogram </li></ul><ul><ul><li>Most useful test in diagnosis of heart failure </li></ul></ul><ul><ul><li>Uses sound waves to create a picture of the heart </li></ul></ul><ul><ul><li>Evaluates heart function: cardiac output and areas of the heart that are not contracting normally </li></ul></ul>
    14. 15. Other Cardiac Tests <ul><li>Holter Monitor: ambulatory electrocardiography </li></ul><ul><ul><li>Worn for 24 hours and provides a continuing recording of heart rhythm during normal activity </li></ul></ul><ul><li>Cardiac Blood Pool Scan (radionuclide ventriculography or nuclear scan) </li></ul><ul><ul><li>Uses radioactive imaging agent injected into a vein to outline chambers of the heart and blood vessels </li></ul></ul><ul><ul><li>Shows how well heart is pumping blood to the rest of the body </li></ul></ul>
    15. 16. Other Cardiac Tests <ul><li>Cardiac Catheterization </li></ul><ul><ul><li>Flexible tube passed through vein in the groin or arm to reach the coronary arteries </li></ul></ul><ul><ul><li>Allows physician to visualize the arteries, check pressure and blood flow in coronary arteries, collect blood samples </li></ul></ul><ul><li>Coronary angiography: usually done along with cardiac catheterization </li></ul><ul><ul><li>Dye injected into coronary arteries and/or chambers of the heart </li></ul></ul><ul><ul><li>Allows angiographer to visualize flow of blood </li></ul></ul>
    16. 17. Cardiac Tests <ul><li>Exercise Stress Test </li></ul><ul><ul><li>EKG and blood pressure readings are taken before, during, and after exercise to determine how the heart responds to exercise </li></ul></ul><ul><ul><li>Patient exercises on a treadmill or stationary bike until reaches a heartrate established by the physician </li></ul></ul><ul><ul><li>Echocardiogram often included </li></ul></ul>
    17. 18. BNP and NT-proBNP Blood Test <ul><li>Measure the concentration of BNP (hormone made by the heart) or NT-proBNP (both formed when pro-BNP is cleaved into two fragments) </li></ul><ul><li>Released as a natural response to heart failure, to hypotension, and to LVH </li></ul><ul><li>Used to grade the severity of heart failure </li></ul>
    18. 19. Cachectic Heart <ul><li>A soft, flabby heart characterized by loss of myocardial mass as the result of extreme malnutrition </li></ul>
    19. 20. Congestive Heart Failure Treatment <ul><li>Goal: decrease work of heart </li></ul><ul><li>Diet </li></ul><ul><ul><li>1. Na restriction (500 to 1000 mg) </li></ul></ul><ul><ul><li>2. Monitor serum K—hypokalemia possible with diuretics and digoxin) </li></ul></ul><ul><ul><li>3. Fluid restriction </li></ul></ul><ul><ul><li>4. Alcohol—none to moderate </li></ul></ul><ul><ul><li>5. Caffeine—can cause MI or cardiac arrhythmia </li></ul></ul>
    20. 21. Medications Used in Heart Failure <ul><li>Diuretics help reduce fluid buildup in lungs and peripheral edema </li></ul><ul><li>ACE inhibitors lower blood pressure and reduce the strain on the heart. These medications also may reduce the risk of a future heart attack. </li></ul><ul><li>Beta blockers slow heart rate and lower blood pressure to decrease the workload on the heart. </li></ul><ul><li>Digoxin makes the heart beat stronger and pump more blood. </li></ul><ul><li>Vasodilators: reduce blood pressure and stress on the heart </li></ul>
    21. 22. MNT in HF <ul><li>Fluid restriction </li></ul><ul><li>Sodium restriction </li></ul><ul><li>Meet energy/protein needs </li></ul><ul><li>Prevent cardiac cachexia </li></ul><ul><li>Small frequent meals </li></ul>
    22. 23. Fluid Restriction <ul><li>If hyponatremia occurs (serum sodium <130 mEq/L) </li></ul><ul><li>Limit total fluids to <2000 ml </li></ul><ul><li>In severe decompensation, limit to 1000-1500 ml </li></ul><ul><li>Maintain restricted sodium diet even if serum sodium depleted; sodium has moved from blood to tissues </li></ul>
    23. 24. Fluid Status and Assessment <ul><li>Patients should record daily weights and advise care providers if weight gain exceeds 2-3 lb a day or 5 lb in a week </li></ul><ul><li>Restricting sodium and fluids (decreasing by 1 to 1.5 cups) may prevent complete HF </li></ul>
    24. 25. Fluid Calculations <ul><li>Hospitalized patients may be limited to 500-2000 ml daily </li></ul><ul><li>Foods having a high fluid content may also be limited </li></ul><ul><li>Foods that are liquid at room temperature such as ice cream, yogurt, gelatin, popsicles count towards fluid allotment </li></ul>
    25. 26. Living with Fluid Restrictions <ul><li>Freezing fruit or sucking on sugar free hard candy may help </li></ul><ul><li>Fluid status monitored by measuring urine specific gravity and serum electrolyte values and observing for clinical signs of edema </li></ul><ul><li>Restrictions often discontinued when patients leave the hospital </li></ul>
    26. 27. Cardiac Cachexia <ul><li>Involuntary weight loss of >6% of nonedematous body weight over a 6-month period </li></ul><ul><li>Significant loss of lean body mass: exacerbates HF </li></ul><ul><li>Cachectic heart: soft and flabby </li></ul><ul><li>Structural, circulatory, metabolic, inflammatory, and neuroendocrine changes in skeletal muscle </li></ul><ul><li>Serious complication of HF </li></ul>
    27. 28. Cardiac Cachexia <ul><li>Patients with cardiac cachexia may lose 10-15% of their body weight (dry weight) </li></ul><ul><li>Other markers (serum prealbumin and transferrin) may be disproportionately low because of the dilutional effect of excess fluid </li></ul><ul><li>Use anthropometrics (measurement of calf and thigh circumference, MUAC) and diet history </li></ul>
    28. 29. Cardiac Cachexia <ul><li>Proinflammatory state in which cytokines (TNF, IL-1 and I-6) are elevated in the blood and myocardial tissue </li></ul><ul><li>Reduced blood flow to the gut may reduce gut integrity leading to entry of bacteria and endotoxins </li></ul><ul><li>High TNF associated with reduced BMI, lower skinfolds, reduced visceral proteins </li></ul>Krummel in Krause, 12 th ed., 2008
    29. 30. Energy Needs in HF <ul><li>For obese patients, hypocaloric diets (1000-1200 kcals) will reduce the stress on the heart </li></ul><ul><li>In undernourished patient, energy needs are increased by 30-50% above basal levels; 35 kcals/kg often used </li></ul><ul><li>Patients with cardiac cachexia may require 1.6-1.8 times resting energy expenditure for repletion </li></ul>
    30. 31. Sodium <ul><li>Impaired cardiac function -> inadequate blood flow to the kidneys -> aldosterone and antidiuretic hormone secretion </li></ul><ul><li>Aldosterone promotes sodium resorption and ADH promotes water conservation </li></ul><ul><li>Even patients with mild heart failure can retain sodium and water if consuming a high salt diet (6 g or 250 mEq/day) </li></ul>
    31. 32. Sodium in Patients with Heart Failure <ul><li>Recommendations vary between 1200 to 2400 mg/day (adequate intake 1200 mg/d) </li></ul><ul><li>Patients on high dose lasix (>80 mg/day) <2000 mg </li></ul><ul><li>Severe restrictions are unpalatable and nutritionally inadequate </li></ul><ul><li>Ethnic differences in sodium intake </li></ul><ul><li>Use least restrictive diet that achieves clinical goals </li></ul>
    32. 33. Dietary Sources of Sodium <ul><li>Salt used at the table </li></ul><ul><li>Salt or sodium compounds added during preparation or processing </li></ul><ul><li>Inherent sodium in foods </li></ul><ul><li>Chemically softened water </li></ul><ul><li>Average American consumes 4 to 6 g sodium/day; 80% from processed foods </li></ul><ul><li>Minimum to maintain life is 250 mg/day </li></ul><ul><li>Salt substitutes, herbs, spices and other seasonings </li></ul><ul><li>Drugs and antacids may contain sodium </li></ul><ul><li>Kosher foods </li></ul>
    33. 34. Characteristics of Common Sodium Restrictions 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 1 g (43 mEq) Moderate High sodium foods are eliminated; moderate sodium foods are limited; no more than ¼ t of table salt allowed 2 g (87 mEq) Mild restriction High sodium foods are limited; no more than ½ t of table salt allowed 3 g (131 mEq) No added salt
    34. 35. 500 mg Sodium Diet <ul><li>High sodium, moderate sodium foods eliminated. Table salt not allowed. Canned or processed foods containing salt omitted </li></ul><ul><li>Frozen vegetables (peas, lima beans, mixed vegetables, corn) omitted due to brine </li></ul><ul><li>High sodium vegetables beets, beet greens, carrots, kale, spinach, celery, white turnips, rutabagas, mustard greens, chard, dandelion greens omitted </li></ul><ul><li>Low sodium bread instead of regular bread </li></ul><ul><li>Meat limited to 6 ounces </li></ul>
    35. 36. High Sodium Foods
    36. 37. Food Servings for Sodium-Controlled Diets
    37. 38. Food Servings for Sodium Controlled Diets, cont
    38. 39. Food Labeling Guide (standard serving) <ul><li>Sodium Free Less than 5 mg </li></ul><ul><li>Very Low Sodium 35 mg or less </li></ul><ul><li>Low Sodium 140 mg or less </li></ul><ul><li>Reduced Sodium At least 25% less sodium than regular food </li></ul><ul><li>Light Sodium 50% less sodium </li></ul><ul><li>Unsalted, No salt added during processing Without Added Salt, No Salt Added </li></ul><ul><li>Lightly Salted 50% less added sodium than normally added (product must state “not a low-sodium food”) </li></ul>
    39. 40. Nondietary Sources of Sodium <ul><li>Medications: barbiturates, sulfonamides, antibiotics, cough medications, stomach alkalizers, laxatives, mouthwashes </li></ul><ul><li>Chewable antacid tablet can add 1200 to 7000 mg of sodium daily </li></ul><ul><li>Aspirin: 50 mg sodium per tablet </li></ul>
    40. 41. Potassium <ul><li>Potassium wasting diuretics (hydrochlorthiazide, furosemide) increase potassium excretion which may lead to digitalis toxicity </li></ul><ul><li>Some patients will need potassium supplements </li></ul><ul><li>Salt substitutes can provide 500-2000 mg of potassium per teaspoon; contraindicated in renal failure and with certain other medications </li></ul>
    41. 42. Sodium and Salt Gram and Milliequivalent Measures 1 mEq Na = 23 mg NA
    42. 43. Other Dietary Factors in Heart Failure <ul><li>Alcohol and caffeine </li></ul><ul><li>Weight maintenance </li></ul><ul><li>Calcium and vitamin D </li></ul><ul><li>Magnesium </li></ul><ul><li>Thiamin supplementation </li></ul><ul><li>Small frequent feedings </li></ul><ul><li>Supplements </li></ul>
    43. 44. Other Nutritional Issues <ul><li>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 </li></ul><ul><li>Magnesium: diuretics may increase mg excretion; measure blood mg levels </li></ul><ul><li>Thiamin status should be evaluated in HF patients on loop diuretics </li></ul>
    44. 45. Cardiac Assist Devices <ul><li>Mechanical heart pumps </li></ul><ul><li>May be helpful in pre-transplant HF patients or in those for whom transplant is not an option </li></ul>
    45. 46. Heart Transplant <ul><li>Only cure for refractory CHF </li></ul><ul><li>In 2003, 2000 cardiac transplants in the U.S. </li></ul><ul><li>Highest number in white men 50-64 years of age </li></ul>
    46. 47. Pretransplant MNT Goals <ul><li>Body weight 90-110% of ideal body weight </li></ul><ul><li>Extremes of weight (<80% or >140% IBW predict poor outcome </li></ul><ul><li>Pretransplant comorbidities (hypertension, hyperlipidemia, diabetes) reduce survival rates </li></ul><ul><li>Survival 83% at 1 year, 72% at 5 years, 50% at 9 years </li></ul>
    47. 48. Cardiomyopathy
    48. 49. Post-Transplant MNT Goals <ul><li>Adequate support to promote healing and fight infection </li></ul><ul><li>Monitor and correct electrolyte abnormalities </li></ul><ul><li>Achieve optimal blood glucose control </li></ul><ul><li>Provide energy for ambulation and physical therapy </li></ul><ul><li>Energy: 1.3-1.5 times REE; protein 1.5-2 grams/kg body weight; Na 2-4 g/day </li></ul>Hasse in Krause, 12 th Ed., p. 896
    49. 50. Post-Transplant MNT Issues Long Term <ul><li>Immunosuppressants can cause weight gain and hyperlipidemia </li></ul><ul><li>Risk factors are prednisone dose, baseline cholesterol level, blood glucose levels, and weight gain </li></ul><ul><li>Graft atherosclerosis is the leading cause of death in long-term survivors </li></ul><ul><li>TLC diet with 2-4 gram sodium; optimal calcium and vitamin D to prevent steroid-induced osteoporosis </li></ul>
    50. 51. ADA Nutrition Care Manual Education Resources <ul><li>http://nutritioncaremanual.org/universi13 </li></ul><ul><li>Heart failure Nutrition Therapy </li></ul><ul><li>Hypertension Nutrition Therapy </li></ul><ul><li>DASH Diet guidelines </li></ul>
    51. 52. Summary <ul><li>CHF—most common reason for long lengths of stay in the elderly </li></ul><ul><li>Prevention and management is key as prognosis is poor </li></ul><ul><li>Aggressive nutritional interventions are important. </li></ul>