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Clinical Case Study EDW Emily Walker

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Clinical Case Study EDW Emily Walker

  1. 1. Patient Case Study Emily Walker Dietetic Intern Benedictine University: MS Nutrition and Wellness
  2. 2. Patient Demographics and Social History Age 34 Gender Male Race African American Relevant personal data Lives at home with his wife and young son Smoking/Alcohol Use Drinks alcohol socially. Reports quitting 2 years ago; 1 pack/day for 5 years. No illicit drug use.
  3. 3. 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
  4. 4. 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.
  5. 5. 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
  6. 6. 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
  7. 7. 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
  8. 8. 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
  9. 9. 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
  10. 10. 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
  11. 11. 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
  12. 12. 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
  13. 13. Heart Mate II
  14. 14. Fang, JC, NEJM, 2009
  15. 15. 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
  16. 16. 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 9.3 Sodium 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)
  17. 17. Nutrition: RD Patient Care Assessment, Diagnoses, Monitoring and Evaluation
  18. 18. 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
  19. 19. Calorie Count Results Date: 1/19 Breakfast: 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 protein Dinner: 365 calories, 29 gm protein Daily 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: 1/20 Breakfast: 345 calories, 18 gm protein Snack:725 calories, 32 gm protein. (this includes 2 Ensure Plus supplements and 1 Beneprotein packet) Lunch:175 calories, 15 gm protein Snack: 240 calories, 7 gm protein Daily total: 1485 calories, 72 grams protein to meet~ 74% pt calorie needs and 44% pt protein needs Date: 1/21 Breakfast: 400 calories, 27 gm protein Lunch: 229 calories, 19 gm protein Dinner: 258 calories, 17 gm protein Ensure/Beneprotein: 1200 calories, 75 gm protein Daily total: 2087 calories, 138 grams protein to meet >100% pt calorie needs and ~85% pt protein needs
  20. 20. 1/26: Anthropometrics 1/26 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)
  21. 21. 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
  22. 22. 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
  23. 23. Nutrition Diagnoses 1. 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
  24. 24. 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
  25. 25. 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
  26. 26. 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
  27. 27. 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
  28. 28. Secondary Nutrition Diagnosis: Monitoring and Evaluation • Patient goals 1. 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!
  29. 29. References 1. Dilated Cardiomyopathy (DCM). 2016. Available at: 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: [Accessed February 16, 2016]. 4. Available at: [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: public/@wcm/@sop/@scon/documents/downloadable/ucm_427332.pdf [Accessed 2016]. 6. HFSA: Few obese patients qualify for heart transplants. 2010. Available at: [Accessed February 17, 2016]. 7. LVAD Nutrition Recommendations Fact Sheet. Edward Hospital Naperville.

Editor's Notes

  • Cardiomyopathy refers to diseases of the heart muscle. These diseases have many causes, signs and symptoms, and treatments.
    In cardiomyopathy, the heart muscle becomes enlarged, thick, or rigid. In rare cases, the muscle tissue in the heart is replaced with scar tissue.
    As cardiomyopathy worsens, the heart becomes weaker. It's less able to pump blood through the body and maintain a normal electrical rhythm. This can lead to heart failure or irregular heartbeats called arrhythmias. In turn, heart failure can cause fluid to build up in the lungs, ankles, feet, legs, or abdomen.

    ICD: implantable cardioverter defibbrillator: electronic device that constantly monitors heart rhythm when it detects a very fast abnormal heart rhythm it delivers energy to the heart muscle

    Pt is well known to EDW due to frequent hospital admissions, and

  • Information from physicians note at admission
  • Milirone: vasodilator short term for advanced heart failure
    Implantable cardioverter defribllator: useful in preventing sudden death from ventricular tachycardia
  • The disease often starts in the left ventricle, the heart's main pumping chamber. The heart muscle begins to dilate (stretch and become thinner). This causes the inside of the chamber to enlarge. The problem often spreads to the right ventricle and then to the atria as the disease gets worse
    Bodybuilders have used gamma-hydroxybutyrate, a potent secretagogue of growth hormone, to promote muscle development.

    Idiopathic, genetic, diabetes, alcohol, drugs,
  • In LV systolic dysfunction, the body activates several neurohormonal pathways to increase circulating blood volume. The sympathetic nervous system increases heart rate and contractility, causes arteriolar vasoconstriction in nonessential vascular beds, and stimulates secretion of renin from the juxtaglomerular apparatus of the kidney. Unfortunately, catecholamines aggravate ischemia, potentiate arrhythmias, promote cardiac remodeling, and are directly toxic to myocytes. Stimulation of the renin-angiotensin system as a result of increased sympathetic stimulation and decreased renal perfusion results in further arteriolar vasoconstriction, sodium and water retention, and release of aldosterone. An increased aldosterone level, in turn, leads to sodium and water retention, endothelial dysfunction, and organ fibrosis.
    In heart failure, baroreceptor and osmotic stimuli lead to vasopressin release from the hypothalamus, causing reabsorption of water in the renal collecting duct. Although these neurohormonal pathways initially are compensatory and beneficial, eventually they are deleterious, and neurohormonal modulation is the basis for modern medical treatment of heart failure.
    In contrast, natriuretic peptides are hormones released by secretory granules in cardiac myocytes in response to myocardial stretching. They have a beneficial influence in heart failure, including systemic and pulmonary vasodilation, possible enhancement of sodium and water excretion, and suppression of other neurohormones.
    With continuous neurohormonal stimulation, the left ventricle undergoes remodeling consisting of LV dilation and hypertrophy, such that stroke volume is increased without an actual increase in EF. This is achieved by myocyte hypertrophy and elongation. LV chamber dilation causes increased wall tension, worsens subendocardial myocardial perfusion, and can provoke ischemia in patients with coronary atherosclerosis. Furthermore, dilation of the LV chamber can cause mitral annular dilatation and functional mitral regurgitation, leading to pulmonary congestion.

    Indicators of poor cardiac prognosis include renal dysfunction, cachexia, valvular regurgitation, ventricular arrhythmias, higher NYHA heart failure class, lower LV ejection fraction (LVEF), high catecholamine and B-type natriuretic peptide (BNP) levels, low serum sodium level, hypocholesterolemia, and marked LV dilation. Patients with combined systolic and diastolic LV dysfunction also have a worse prognosis than patients with either in isolation.3
    Indicators of poor prognosis presents with: Renal dysfunction, high BNP levels,
  • Two year survival if NHYA Class IV [symptomatic at rest] is 13-40%
    LVAD placement necessary this hospital admission.
  • Swan Ganz cathetar placement to monitor hemodynamics and adjust inotropes and diuretics
    Extremely low cardiac output index of 1.1 L /min
    An inotrope is an agent that alters the force or energy of muscular contractions. Negatively inotropic agents weaken the force of muscular contractions. Positively inotropic agents increase the strength of muscular contraction
  • Not a transplant candidate at this time due to weight of 350 pounds.

    No. HeartMate II is not an artificial heart, nor is it a heart replacement. The patient’s native heart is not removed. HeartMate II attaches to the heart and is designed to assist —or take over—the pumping function of the patient’s left ventricle—the main pumping chamber of the heart.

    HeartMate II is designed to last for years. HeartMate II recipients have been living with a single device for over 8 years now, and over 700 recipients have been supported more than 5 years.

    HeartMate II is designed to work for a long time. The Pocket Controller is always checking the system operation. It will let you know if there is a problem, and you will learn what to look for, too. The system also will be checked during your regular medical visits.

    Having extra batteries charged and ready will keep you prepared for a power outage. You will also receive a power module, which can be moved to another location with power or plugged into a car. In an emergency, your Pocket Controller also has at least an additional 15 minutes of backup battery power.

  • Power module: supplies main power provides 30 minutes back up power, electrical interface between system controller and display module
    Batteries: 6-10 hours of support, up to 4 hours to recharge for fully charged battery
    Emergency: 12 hours of support, event of a power outage
  • Dobatamine: Blood pressure support It can treat heart failure and help the heart pump blood
  • INR: monitor effectiveness of warfarin