This document discusses nutrition considerations for patients undergoing cardiac surgery or being treated for heart failure. It outlines testing and treatment options for heart failure, including surgical procedures. It describes the risks of malnutrition for cardiac patients and recommends early enteral nutrition to prevent complications. Enteral nutrition is preferred over parenteral nutrition when possible. Estimates for caloric and protein needs are provided. Fluid and electrolyte management is also discussed.

1. Cardiothoracic Surgery
Irelda Ceballos Walls
Mtra. Martha Lara
Mayo, 2017

2. Heart Failure
Heart failure develops when the heart, via an abnormality of
cardiac function (detectable or not), fails to pump blood at
a rate commensurate with the requirements of the metabolizing
tissues or is able to do so only with an elevated diastolic
filling pressure.

3. Testing
- Complete blood count (CBC)
- Urinalysis
- Electrolyte levels
- Renal and liver functions studies
- Lipid profiles
- Electrocardiography
- Chest radiography

4. Surgical Treatment
Electrophysiologic intervention
Revascularization procedures
Valve replacement/repair
Ventricular restoration
Extracorporeal membrane oxygenation
Ventricular assist devices
Heart transplantation

6. Epidemiology
In the United States, there currently are approximately 5
million individuals with chronic heart failure (CHF).
The lifetime-attributable risk for CHF for both men and women
is approximately 1 in 5.
Reverse epidemiology or obesity paradox indicate that certain
markers that predict a low likelihood of CV events (low BMI,
low blood pressure, low cholesterol), become paradoxically
strong risk factors for increased morbidity and mortality in
patients with CHF.

7. Risk Factor
- Hypercholesterolemia
- Hypertension
- Obesity
- Sedentarism
- Genetics
The incidence of malnutrition in cardiac surgical patients
has been estimated to be 10% to 25% and is associated with a
increased incidences of postoperative infectious
Evans, A., Hosseinian, L., Mahabir, T., Kurtis, S., & Mechanick, J. (2016). Nutrition and the Cardiac Surgery Intensive Care Unit

8. Common causes of heart failure
- Previous myocardial infraction
- High blood pressure
- Atrial fibrillation
- Valvular heart disease
- Excess alcohol use
- Infection
- Cardiomyopathy

10. Complications
Although some patients may present for cardiac surgery
already malnourished, many more present in a healthy state
and become at high risk for complications and malnourishment
from a systemic inflammatory response to cardiac surgery
secondary to accelerated loss of total body protein and
redistribution of essential micronutrients.
This process can occur slowly from poor intake or rapidly
from severe metabolic response to surgery.
Evans, A., Hosseinian, L., Mahabir, T., Kurtis, S., & Mechanick, J. (2016). Nutrition and the Cardiac Surgery Intensive Care Unit

11. Malnutrition
Malnutrition is an often overlooked comorbid condition in patients
scheduled for cardiac surgery.
Patients with cardiac disease are exposed to two types of
malnutrition:
1. Cardiac Cachexia
2. Malnutrition → related to the consequences of cardiac surgery
The diagnosis of malnutrition or cardiac cachexia should be based
upon the amount of dry weight lost, upper arm anthropometry and
serum hepatic protein concentrations (PCR, albúmin, prealbumin)
De Waele, E., Nguyen, D., De Bondt, K., La Meir, M., Diltoer, M., & Honoré, P. et al. (2017). The CoCoS trial: Caloric Control in
Cardiac Surgery patients promotes survival, an interventional trial with retrospective control. Clinical Nutrition.

12. Cardiac Cachexia
Associated with chronic heart failure, global loss of fat, muscle and bone tissue,
characterized by an unintentional and non-edematous >7.5% weight loss of premorbid
normal weight over >6 months.
Is recognized as a multifactorial neuroendocrine disorder with poor prognosis.
Preoperative nutritional support significantly reduced postoperative respiratory
failure and operative mortality in this subgroup of surgical patients.
Patients considered to be at high risk of malnutrition and scheduled to undergo
cardiac surgery have higher in-hospital mortality, increased length of intensive
care and hospital stay, need longer antibiotic and vasopressor treatment and more
frequently have positive blood cultures
De Waele, E., Nguyen, D., De Bondt, K., La Meir, M., Diltoer, M., & Honoré, P. et al. (2017). The CoCoS trial: Caloric Control in
Cardiac Surgery patients promotes survival, an interventional trial with retrospective control. Clinical Nutrition.

13. Cardiac Cachexia
Early diagnosis of cardiac cachexia (protein-calorie
malnutrition, anorexia and gastrointestinal dysfunction) and
early intervention are critical given that the 18-month
survival is approximately 50% when cardiac cachexia is
detected.
Assessment of other clinical outcomes, such as expected
length of time on mechanical ventilation or ICU LOS on
admission, can serve as a proxy for the expected duration and
severity of stress metabolism.
De Waele, E., Nguyen, D., De Bondt, K., La Meir, M., Diltoer, M., & Honoré, P. et al. (2017). The CoCoS trial: Caloric Control in
Cardiac Surgery patients promotes survival, an interventional trial with retrospective control. Clinical Nutrition.

15. Prognosis
When cardiac cachexia in patients with chronic heart failure, 18-month survival is
only approximately 50%, primary because no specific therapy for patients who are
cachectic with chronic heart failure exists.
One objective measure of malnutrition is the serum albumin concentration, and
preoperative serum albumin levels had been found to be strong independent predictors
of morbidity and mortality in a recent large study of patients undergoing noncardiac
surgery.
Three categories of mechanisms are thought to be responsible for the development of
cardiac cachexia:
- Malabsorption and metabolic function
- Dietary deficiency
- Loss Of nutrients via the urinary or digestive tract
Sanchez, J., Sanchez, L., & Dudrick, S. (2011). Nutritional Considerations in Adult Cardiothoracic Surgical Patients. Surgical Clinics Of North

16. Preoperative nutrition
Patients with severe malnutrition may derive some benefit
from delaying surgery to be fed, but are at an increased risk
for infectious complications if treated with total parenteral
nutrition. Patients will benefit more from enteral feeding
whenever it is possible.
For patients who are adequately nourished or who have mild-
to-moderate malnutrition, surgery need not be delayed for
preoperative parenteral or enteral supplementation.

17. Postoperative Nutrition
For many postoperative patients, early enteral nutrition (<24 hours) is
possible and is associated with beneficial effects. Enteral nutrition (oral or
tube feeds) rather than parenteral nutrition should be instituted whenever
possible. For patients with a delayed return of intestinal function,
postoperative parenteral nutrition is indicated only if return of bowel
function is not anticipated for more than 10 days. Earlier intervention may be
appropriate in patients who are severely malnourished at baseline, or who have
a complicated postoperative course.
Some studies recommend 1.5 to 2.0 g/kg for protein and the restriction of
sodium (2g/d).
Fluid of 1000-1500 mL/d using high density continuous IV nutrient infusion.

18. PCN

19. Anthropometry
- Height
- Weight
- BMI
- Waist-hip ratio
- Weight Changes
- Hand-grip strenght
- Indirect Calorimetry

20. Biochemistry
- CRP
- Serum CoQ10
- BNP
- Uric Acid
- OXimetry
- Triglycerides
- Cholesterol
- Glucose
- Albumin
Patients with high output HF should
also be assessed for thiamin
deficiency.
Patients with wet beriberi can have
an enlarged heart, nonspecific
electrolyte alterations, profound
vasodilation and peripheral neuritis.
This deficiency can be found in
patients with alcohol abuse and HF
patients taking furosemide and
digoxin because these decrease
thiamin uptake by cardiac cells.
Gottschlich, M. (2007). The A.S.P.E.N. nutrition support core curriculum (1st ed.). Silver Spring (MD): American Society for Parenteral and Enteral Nutrition.

21. Clinical
- Shortness of breath
- Dry, hacking cough or wheezing
- Skin: cyanotic or pale
- Abnormal breath
- Pitting edema
- Fatigue
- Dyspnea
Gottschlich, M. (2007). The A.S.P.E.N. nutrition support core curriculum (1st ed.). Silver Spring (MD): American Society for Parenteral and Enteral Nutrition.

22. Nutritional Evaluation
- Malnutrition Universal Screening Tool
- Nutritional Risk Screening 2002
- Mini Nutritional Assessment
- Short Nutrition Assessment Questionnaire
None of these tools effectively considers the severity of
heart failure or signs of cardiac cachexia, which limits
their use in these subgroups of cardiac surgical patients.
Evans, A., Hosseinian, L., Mahabir, T., Kurtis, S., & Mechanick, J. (2016). Nutrition and the Cardiac Surgery Intensive Care Unit

23. Malnutrition Universal Screening Tool

24. Nutritional Diagnosis
Problem Etiology Signs and symptoms
NI-1.1 Hypermetabolism Catabolic illness, infection, sepsis Fever, increases heart reate,
increased respiratory rate
NI-1.4 Inadequate Energy Intake Pathologic or physiologic causes which
result in increased energy requirements or
decreased ability to consume stuffiness
energy, e.g., increased nutrient
needs due to prolonged catabolic illness
Weight loss, inssufficient
energy intake
NI 5.2 Malnutrition Physiologic causes, e.g. altered nutrient
needs due to prolonged catabolic illness,
malabsorption
Weight loss of > 10% in 6
months, Albumin < 3.4 mg/dL
(disease/trauma related
malnutrition), chronic or
acute disease
NC-2.2 Altered Nutrition-
related laboratory values
Kidney, liver, cardiac, endocrine,
neurologic and/or pulmonary dysfunction
Changes in biochemical data,
Edema, shortness of breath
(cardiac disorders), cachexia

25. Drug-Nutrient Interactions
Drug Interaction
Diuretic Monitor for electrolyte abnormalities, fluid depletion,
hypotension and azotemia.
Correct potassium deficits with short-term use of
potassium supplements, consider magnesium supplementation
if potassium deficit is severe.
Aldosterone Antagonists Hyperkalemia, especially if initial creatinine was less
than 2-2.5 mg/dL.
NSAID and
cyclooxigenase--2
inhibitors
Avoid using in HF patients.
Discontinue use of potassium supplements
Diarrhea or other causes of dehydrations should be
addressed emergently.
Digitalis Assess for GI disturbances such as anorexia, nausea,
vomiting.
Beta Blockers Fluid retention
Gottschlich, M. (2007). The A.S.P.E.N. nutrition support core curriculum (1st ed.). Silver Spring (MD): American Society for Parenteral and Enteral Nutrition.

26. Objectives
- Lessen demands on the heart and restore hemodynamic stability
- Prevent cardiogenic shock, thromboembolism and renal failure
- Maintain BP 140/90 mm Hg in all patients or 130/80mm Hg in those with
diabetes or chronic kidney disease
- Eliminate or reduce edema
- Avoid distention and elevation of diaphragm, which reduces vital capacity.
Avoid overfeeding in cachexic patients to prevent refeeding syndrome.
- Attain desirable BMI and WHR to decrease oxygen requirements and tissue
nutrient demands. Replenish lean body mass (LBM) when needed.
- Prevent or correct cardiac cachexia, anorexia, nausea, vomiting and sepsis
Gottschlich, M. (2007). The A.S.P.E.N. nutrition support core curriculum (1st ed.). Silver Spring (MD): American Society for Parenteral and Enteral Nutrition.

27. Requirements
Basal energy requirements should be increased by 30% to 50% in
severe HF because of increased cardiac and pulmonary expenditure.
Indirect calorimetry is the best option to assess the energy
requirements, but 20-25 kcal/IBW/d is a good amount.(Arenas, 2012)
Many HF patients will also present with diabetes and hypertension,
and their nutritional regimen needs to be regulated accordingly.
Proteins: 1 - 1.5 g/kg/d (Arenas, 2012)
CHO´s: 1-3 mg/kg/min
Lipids: 10-15% of total requirement.
De Waele, E., Nguyen, D., De Bondt, K., La Meir, M., Diltoer, M., & Honoré, P. et al. (2017). The CoCoS trial: Caloric Control in
Cardiac Surgery patients promotes survival, an interventional trial with retrospective control. Clinical Nutrition.

28. Energy Requirements
Estimate caloric needs as follows, if IC is not available
- Calculate basal energy expenditure from Harris-Benedict
- Add to basal value an additional 15-25% for minimal physical
activity of patients with CHF
- Add another 10% to 20% for hypermetabolism of severe HF, add less if
mild or moderate
- Adjust intake upward if urinary and fecal losses are increased
- Major surgery or sepsis increases energy requirements by about 20%
to 50%
- Values are approximations. Excessive energy intake may cause severe
hyperglicemia or worsen CHF
Gottschlich, M. (2007). The A.S.P.E.N. nutrition support core curriculum (1st ed.). Silver Spring (MD): American Society for Parenteral and Enteral Nutrition.

29. Enteral Nutrition
EN is the most often used method of nutritional support in patients unable to
tolerate oral intake because of reduced gastrointestinal function.
ESPEN recommend initiation within 24-48 hours of hospitalization. Continuous
feeds are preferred because it decreases myocardial oxygen consumption.
The benefits attributed to continued use of the alimentary tract, include
preservation of intestinal mucosa, mesenteric blood flow and gut-associated
lymphoid tissue.
There is an increased preoperative immunity, decreased rate of postoperative
infection, decreased mortality and decreased LOS.
Evans, A., Hosseinian, L., Mahabir, T., Kurtis, S., & Mechanick, J. (2016). Nutrition and the Cardiac Surgery Intensive Care Unit

30. Enteral Nutrition
Enteral nutrition in cardiac surgical patients repleted
cardiomyocytes with nutrients, improved left ventricular end-
diastolic volume preoperatively,19 improved preoperative host
defense, reduced the number of postoperative infections, and
preserved renal function.
Sanchez, J., Sanchez, L., & Dudrick, S. (2011). Nutritional Considerations in Adult Cardiothoracic Surgical Patients. Surgical Clinics Of North

31. Enteral Nutrition
EN is recommended in cardiac cachexia to stop or reverse
weight loss on the basis of physiological plausability
(ESPEN, 2006).
There is no indication for enteral nutrition in the
prophylaxis of cardiac cachexia (ESPEN, 2006).
Additionally, recognized barriers to achieving ideal caloric
targets with EN, are known to contribute to an increased
energy deficit and worse outcomes.
Evans, A., Hosseinian, L., Mahabir, T., Kurtis, S., & Mechanick, J. (2016). Nutrition and the Cardiac Surgery Intensive Care Unit

32. Parenteral Nutrition
Although there is no evidence available from well-designed studies, PN is recommended to stop or
reverse weight loss in patients with evidence of malabsorption, on the basis that it improves
outcome in other similar conditions and there is a plausible physiological argument for it
(ESPEN, 2006).
Currently there is no indication for PN in the prophylaxis of cardiac cachexia. Further studies
are needed to assess the impact of the parenteral administration of specific substrates on
cardiac function (ESPEN, 2006).
There are no specific contraindications to PN in CHF patients. However, considering that cardiac
function is decreased and water retention is frequently found in CHF patients, it is recommended
that PN should be avoided, other than in patients with evidence of malabsorption in whom enteral
nutrition has been shown, or is strongly expected, to be ineffective.
In cardiac surgery patients, parenteral amino acid supplementation increased esophageal core
temperature; shortened duration of postoperative mechanical ventilation, intensive care unit
stay, and hospitalization.
Evans, A., Hosseinian, L., Mahabir, T., Kurtis, S., & Mechanick, J. (2016). Nutrition and the Cardiac Surgery Intensive Care Unit

33. Parenteral Nutrition
Sanchez, J., Sanchez, L., & Dudrick, S. (2011). Nutritional Considerations in Adult Cardiothoracic Surgical Patients. Surgical Clinics Of North

34. Fluid and Electrolyte Management
1.Estimate water requirements: uncomplicated heart failure
water intake 0.5 mL/kcal or 1000 to 1500 mL/d
2.Sodium at or near normal level of 140 mEq/dL
3.K-maintain between 4 and 5 mEq/dL
4.Monitor and supplements as appropriate: zinc, magnesium,
calcium
5.Monitor azotemia
Gottschlich, M. (2007). The A.S.P.E.N. nutrition support core curriculum (1st ed.). Silver Spring (MD): American Society for Parenteral and Enteral Nutrition.

35. Kalantar-Zadeh, K., Anker, S., Horwich, T., & Fonarow, G. (2008). Nutritional and Anti-Inflammatory Interventions in Chronic Heart

36. Evans, A., Hosseinian, L., Mahabir, T., Kurtis, S., & Mechanick, J. (2016). Nutrition and the Cardiac Surgery Intensive Care Unit

37. Supplements
Nutritional interventions including AA supplementation with
anti-inflammatory and antioxidant properties may be more
effective in patients with CHF than the mere provision of
protein and energy.
- Omega 3: 3-6 g/d
- Thiamin: 100 - 200 mg/d for one week (ASPEN)
- Vitamin E
- Vitamin C
Kalantar-Zadeh, K., Anker, S., Horwich, T., & Fonarow, G. (2008). Nutritional and Anti-Inflammatory Interventions in Chronic Heart

38. Supplements
- Arginine is the precursor of nitric oxide (NO), a dominant active
compound that influences blood flow and endothelial function, is involved
in myocardial relaxation and distensibility, and might improve left
ventricular function.
- Exogenous glucose provided in enteral or parenteral nutrition can avoid
conversion of the administered amino acids into glucose via
gluconeogenesis and can prevent or minimize protein catabolism
- Vitamins and minerals in parenteral and enteral nutrient formulations are
essential ingredients of the nutritional regimen of the cardiac surgery
patient because several of them have antioxidant properties and all of
them can prevent micronutrient deficiencies from occurring
Sanchez, J., Sanchez, L., & Dudrick, S. (2011). Nutritional Considerations in Adult Cardiothoracic Surgical Patients. Surgical Clinics Of North

39. Orexigenic Agents to stimulate appetite
- Anabolic steroids
- Other corticosteroids
- Megestrol acetate
- Medroxyprogesterone
- Pentoxifylline
- Dyprohetadine
- Dronabinol
Kalantar-Zadeh, K., Anker, S., Horwich, T., & Fonarow, G. (2008). Nutritional and Anti-Inflammatory Interventions in Chronic Heart

40. Recommendations
- Small frequent meals to help anorexia and dyspnea
- Sodium-restricted diet (2g/d) → DASH diet
- Consume folate through food and combine with B6, B12 and folate
supplementations.
- If TPN → ensure adequate intake of all micronutrients.
- Provide antioxidants
- If patient is obese, a calorie-controlled diet can be
recommended.

41. Monitoring
- Identify the stage of readiness for certain lifestyle
changes and supervise changes.
- Weight changes
- Nutrient deficiencies
- Catabolic state
- Drug - Nutrient interactions

42. Exercise
Exercise has been shown to reduce the activation of
neurohumoral system and attenuate the process of ventricular
remodeling and may be considered as an additional treatment
modality.
Heart failure patients who participated in an exercise
regimen experienced fewer symptoms, had an increased exercise
capacity, and improved quality of life.
Gottschlich, M. (2007). The A.S.P.E.N. nutrition support core curriculum (1st ed.). Silver Spring (MD): American Society for Parenteral and Enteral Nutrition.

43. Metabolic therapy is a promising new avenue for the treatment of
heart failure, and suitable targets for therapy are substrate
utilization, oxidative phosphorylation, and the availability of
high-energy phosphates. A multipronged effort is needed to fully
investigate this concept. Experimental studies will, for example,
further clarify the mechanisms leading to energetic derangement and
will suggest new molecular targets for therapeutic intervention. New
metabolic modulator compounds need to be developed by academia and
industry. Proof-of-principle clinical studies may use the myocardial
phosphocreatine/ATP ratio of the heart to monitor metabolic therapy,
and this method may provide a surrogate marker of long-term
prognostic effects.

44. References
Alaeddini, J., & Talavera, F. (2017). Angina Pectoris: Practice Essentials, Background, Pathophysiology. Emedicine.medscape.com. Retrieved
25 May 2017, from http://emedicine.medscape.com/article/150215-overview
Hunt SA. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult. A Reportof the American
College of Cardiology/American Heart Association Task Force on Practice Guidelines.
Evans, A., Hosseinian, L., Mahabir, T., Kurtis, S., & Mechanick, J. (2016). Nutrition and the Cardiac Surgery Intensive Care Unit Patient—
An Update. Journal Of Cardiothoracic And Vascular Anesthesia. http://dx.doi.org/10.1053/j.jvca.2015.10.005
Kalantar-Zadeh, K., Anker, S., Horwich, T., & Fonarow, G. (2008). Nutritional and Anti-Inflammatory Interventions in Chronic Heart
Failure. The American Journal Of Cardiology, 101(11), S89-S103. http://dx.doi.org/10.1016/j.amjcard.2008.03.007
De Waele, E., Nguyen, D., De Bondt, K., La Meir, M., Diltoer, M., & Honoré, P. et al. (2017). The CoCoS trial: Caloric Control in Cardiac
Surgery patients promotes survival, an interventional trial with retrospective control. Clinical Nutrition.
http://dx.doi.org/10.1016/j.clnu.2017.03.007
Gottschlich, M. (2007). The A.S.P.E.N. nutrition support core curriculum (1st ed.). Silver Spring (MD): American Society for Parenteral
and Enteral Nutrition.
Sanchez, J., Sanchez, L., & Dudrick, S. (2011). Nutritional Considerations in Adult Cardiothoracic Surgical Patients. Surgical Clinics Of
North America, 91(4), 857-875. http://dx.doi.org/10.1016/j.suc.2011.06.001