1. Medical Nutrition
Therapy in
Cardiovascular
Disease
Chapter 35

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Coronary Heart Disease (CHD) or
Coronary Artery Disease (CAD)
Disease involving the network of blood vessels
surrounding and serving the heart
Manifested in clinical end points of myocardial
infarction (MI) and sudden death

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Cardiovascular Disease (CVD)
CVD has been the leading cause of death in the
United States for every year since 1900, except
1908.
CVD kills almost as many people yearly as the
next seven causes of death combined.

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Prevalence and Incidence
The United States ranks 14th and 16th, among
industrialized nations for the prevalence of
CVD in women and men, respectively.
More than 61 million Americans have at least
one form of CVD (i.e., hypertension, CHD,
stroke, rheumatic heart disease, or congestive
heart failure).
The incidence of CHD is high; an American
experiences a coronary event almost every 29
seconds.

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Natural Progression of Atherosclerosis
(From Harkreader H. Fundamentals. Philadelphia: W.B. Saunders, 2000)

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Plaque That Has Been Surgically Removed
from Coronary Artery
Courtesy Ronald D. Gregory and John Riley, MD.

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Prevention
Blood lipids and lipoproteins
Total cholesterol
Total triglycerides
Lipoproteins and metabolism
—Chylomicrons, VLDL, IDL, LDL, HDL

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Functions of the Plasma Lipoproteins
Chylomicron—Transport of dietary
triglyceride
VLDL—Transport of endogenous
triglyceride
IDL—LDL precursor
LDL—Major cholesterol transport
lipoprotein
HDL—Reverse cholesterol transport

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Lipoprotein Assessment
Includes measurement of total cholesterol, LDL
cholesterol, HDL cholesterol, and triglyceride
level after fasting

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Cardiovascular Risk Factors
Category I—cigarette smoking, LDL
cholesterol, high-fat diet, hypertension
Category II—diabetes mellitus, physical
inactivity, HDL cholesterol, TG, obesity
Category III—psychosocial factors,
lipoprotein a, homocysteine
Category IV—age, male gender, low
socioeconomic status, family history

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Quantity of Soluble Fiber Needed Daily to
Produce Lipid-Lowering Effect
Pectin: 6 to 40 g
Gums: 8 to 36 g
Dried beans or legumes: 100 to 150 g
Dry oat bran: 25 to 100 g
Oatmeal: 57 to 140 g
Psyllium: 10 to 30 g

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Genetic Hyperlipidemias
Familial hypercholesterolemia
Familial combined hyperlipidemia
Familial dyslipidemia
Familial dysbetalipoproteinemia

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Nutrient Composition of the
Therapeutic Lifestyle Change Diet
Saturated fat
Polyunsaturated fat
Monounsaturated fat
Total fat
Carbohydrate
Fiber
Protein
Cholesterol
Total calories
(energy)

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Category I Risk Factors for
Coronary Heart Disease
Cigarette smoking
Elevated LDL and total cholesterol
Hypertension
Left ventricular hypertrophy (LVH)
Thrombogenic factors

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Category II Risk Factors for
Coronary Heart Disease
Diabetes mellitus types 1 and 2
Physical inactivity
Low HDL cholesterol
Obesity
Menopausal factors

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Major Disease Processes Contributing to
Coronary Heart Disease
Atherosclerosis—chronic (long-term
development)
Thrombosis—acute (late and brief event)

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Pathophysiologic Steps in Development of
Coronary Heart Disease/Myocardial Infarction
Phase 1 Fatty streaks (atherogenesis)
Phase 2 Atheroma (or plaque)
formation
Phase 3 Complicated lesions with
rupture (nonocclusive
thrombosis)
Phase 4 Complicated lesions with
rupture and occlusive
thrombosis
Phase 5 Fibrosis (occlusive) lesions

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Hyperlipidemias
Elevated blood triglycerides and/or cholesterol
Lipoproteins found in blood
Chylomicrons = postprandial dietary fat
Very-low-density lipoproteins (VLDL) = lipid
being transported from liver to peripheral tissue
Low-density lipoproteins (LDL) = transport of
cholesterol
High-density lipoproteins (HDL) = reverse
transport of cholesterol, tissues to liver
Type of hyperlipidemia depends upon portion
of particles present

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LDL and HDL Cholesterol
Laboratory Values Predict Risk of CHD
LDL-C >130 mg/dl
HDL-C <35 mg/dl
Total cholesterol (TC) >200 mg/dl
Total triglycerides (TG) >150 mg/dl
Formula: LDL-C = TC – HDL-C–(TG/5)

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HDL Cholesterol Levels Predict
Risk of Coronary Heart Disease
Increased by: Exercise
Weight loss
Moderation of alcohol
Decreased by: Obesity
No exercise
Cigarettes
Androgenic steroids
B blockers
High TGs
Genetic factors

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LDL Cholesterol Levels Predict
Risk of Coronary Heart Disease
Increased by
Fat in diet
Obesity
Diabetes
Hypothyroidism
Decreased by
Estrogen

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Primary Prevention with Lipoprotein Analysis
(From National Cholesterol Education Program: Second Report of the Expert Panel on Detection, Evaluation, and Treatment of
High Blood Cholesterol in Adults (Adult Treatment Panel II). National Institutes of Health, NIH Publication No. 93-3095. Bethesda,
MD: National Heart, Lung, and Blood Institute, 1993.)

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Primary Prevention in Adults without Evidence of CHD:
Initial Classification Based on Total Cholesterol and
HDL Cholesterol
(From National Cholesterol Education Program: Second Report of the Expert Panel on Detection, Evaluation, and Treatment of
High Blood Cholesterol in Adults (Adult Treatment Panel II). National Institutes of Health, NIH Publication No. 93-3095. Bethesda,
MD: National Heart, Lung, and Blood Institute, 1993.) HDL = high-density lipoprotein.

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Diet Therapy for High Blood Cholesterol
(Data from National Cholesterol Education Program [NCEP]. Second Report of the Expert Panel on Detection, Evaluation, and
Treatment of High Blood Cholesterol in Adults [Adult Treatment Panel II]. NIH Publication N. 93-3095. Bethesda, MD; National
Institutes of Health. National Heart, Lung, and Blood Institute, 1993.) * Calories from alcohol not included.

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General Goals for Treatment
of Hyperlipidemias
Achieve IBW.
Decrease simple sugars and alcohol.
Decrease total fat, especially cholesterol and
SFA.
Increase complex carbohydrate and fiber.

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Lipid-Lowering Drugs
Added if Diets Are Not Successful
After a 6-month trial on each diet,
drugs are added to the treatment.
Types:
Nicotinic acid and lovastatin
Gemfibrozil, probucol, clofibrate—
for high TGs
Cholestyramine and colestipol (bile
acid sequestrants)—to lower high
cholesterol; may increase TGs

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Myocardial Infarction (MI)
Coronary Infarction, Coronary Thrombosis,
or Heart Attack
Some part of coronary circulation blocked
Ischemia leads to muscle destruction
Diagnosis: ECG; blood levels of enzymes
such as LDH and CPK

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Myocardial Infarction—MI
Postinfarction nutrition
1. 1st 24 hrs: no caffeine, liquid diet
(nausea and choking are common)
2. Small frequent meals; soft or liquid diet
3. Na+
restriction if BP and fluid status indicate
4. Consistent diet information
5. Drugs that cause nausea—digitalis, morphine