1. Clinical Case Study: Acute Onset Heart Failure
Amy Lofley
Case study #2

2. Objectives Case Study Overview of Acute Heart Failure
Medical Hx
Nutrition Assessment
Nutrition Intervention
Prognosis
Conclusion
Overview of Acute Heart Failure
Physiology
Pathophysiology
Treatment
Multidisciplinary team

3. Acute Heart Failure
Clinical Update

4. Normal Physiology
The heart pumps blood throughout the body to deliver oxygen and nutrients and bring back carbon dioxide and waste.
A normal heart is able to pump this blood effectively throughout the body.

5. Pathophysiology (1)
In heart failure the heart isn’t able to pump adequate blood supply to the rest of the body.
This is indicated by a low ejection fraction and a high B-natriuretic peptide (BNP).
It does not mean that an individual has had a heart attack or that the heart is no longer working.
The beginning stages of HF are usually asymptomatic and can progress if not treated.

6. Pathophysiology

7. Pathophysiology

8. Stages of Heart Failure (2)

9. Classification of Heart Failure (1)
Class I – No undue symptoms associated with ordinary activity and no limitation of physical activity
Class II – Slight limitation of physical activity; patient comfortable at rest
Class III – Marked limitation of physical activity; patient comfortable at rest
Class IV – inability to carry out physical activity without discomfort; symptoms of cardiac insufficiency or chest pain at rest

10. Risk Factors Hypertension DM Coronary Heart Disease
Left ventricular hypertrophy
Age
Dyslipidemia \Obesity
Atherosclerosis

11. Practice Recommendations
Primary treatment
Treated with IV lasix
Primary intervention
MNT
Fluid restriction
1500 mg Na restriction

12. Evidence-Based Practice (3)
Referral to a RD for MNT when an individual has HF. An initial visit lasting 45 minutes and up to three planned follow up visits lasting 30 minutes to improve diet and quality of life.
Protein needs for patients are based on their nutrition status. Patients that are clinically stable but protein depleted should have at least 1.37 g/kg and patients with a normal nutrition status should have 1.12 g/kg actual body to preserve body composition and limit hypercatabolism.

13. Evidence-Based Practice (3)
Energy needs are best determined with indirect calorimetry but if not possible usual predictive equations should be used adjusting with increased needs for a catabolic state.
Fluid should be limited to between 1.4 and 1.9 L per day, depending on symptoms of edema, fatigue, and shortness of breath.
Sodium intake should be limited to less than 2000 mg per day from AND and 1500 mg from the AHA.
Patients with HF should consume the DRI for folate, B6, and B12.
A multi-vitamin/mineral should be recommended that contains B12, B6 and folate.

14. Evidence-Based Practice (3)
Thiamine status should be monitored closely because of diuretic use. Encouraging the patient to consume the DRI of thiamine is important until further research is conducted.
Magnesium should be consumed at the DRI because of the increased risk for HF patients to have an irregular heart beat.

15. Multidisciplinary team
Physician
Hospitalist
Cardiologist
Registered Dietitian
Nurses
PCT RN
HF RN

16. Case Study

17. Mr. F Medical Diagnosis Acute episode of heart failure
Age: YOM, Caucasian
Presents to hospital with shortness of breath, weakness, and chest pain
Medical Diagnosis
Acute episode of heart failure
UTI

18. Past Medical/Surgical/social History
Past Medical History
Stage 4 CKD
HTN
UTI
Hypothyroidism
CHF
Severe mitral regurgitation
Non-ST elevation myocardial infarction with possible (A1)
Paroxysmal atrial fibrilation
Past Surgical History
No significant hx
Social History
Lives with wife at home

19. Clinical Data Physical Exam Nutrition Assessment
Appears to be at a normal weight
Resting comfortably in the bed
Stage 2 decubitus ulcer on bottom
Heels red
Decreased appetite
Nutrition Assessment
Height: 64 inches
Weight: 68.9 kg
No wt changes pta
BMI: 26.07

20. Labs/Medications Lab Lab Value Normal Value Medications: lasix Albumin
2.6
3.5-5
Creatinine
1.7
mg/dL
FSBS
94-106
Medications: lasix

21. Dietary data
According to patient, he follows a no added salt diet at home.

22. Nutrition Assessment Calorie Needs Fluid Needs Protein Needs
25-29 kcals/kg/d
kcals needed
Fluid Needs
2000 mL Fluid Restriction
Protein Needs
1-1.2 g/kg/d
69-80 g needed

23. Nutrition diagnosis
Increased nutrient needs (protein/kcals) RT increased demands for wound healing AEB skin breakdown, delayed wound healing, decreased intake x 2 days.
Food and nutrition related knowledge deficit RT lack of prior diet education AEB lacks understanding of prescribed diet

24. Nutrition Intervention
PO intake at least 50% in 5 days.
50% intake of supplement next 5 days.
Add berry magic cup BID and pb grahams BID
Maintain wt within 1 kg of 68.9 kg over next 5 days.
Prevent further skin breakdown and help heal decubitus ulcers next 5 days.
Pt will identify high fat/chol/sodium foods within the next 5 days.
HF nutrition education to caregiver. Good comprehension and expect good compliance

25. Nutrition Monitoring and Evaluation
Monitor and evaluate:
GI tolerance
Labs
PO intake
Skin integrity and wound healing
Weight
Monitor 2 times weekly

26. Follow Up Assessment Diet order: 1500 mg Na, 2000 FR
New PES: Inadequate oral intake RT decreased appetite AEB <50% PO intake.
PO intake 50-75%, < 240 ml fluid per meal
Assessment
Wt kg
No change in skin noted
Tolerating food with no complaints
Labs
Alb 2.6, Cr 1.9, FSBS
Hospice is being consulted
Goal: Intake to meet > 50% of needs next 3-4 days ( met and continue)
Monitor GI, labs, PO adequacy, skin and wt

27. Expected Outcomes Prognosis is good
A full recovery from Acute episode of HF should occur within the next week
Wound healing will take time.

28. References
Mahan LK, Escott-Stump S. Medical nutrition therapy for heart failure and transplant. Krause. 2008:
Jessup M, Abraham WT, Case DE, et al focused update: ACCF/AHA guidelins for the diagnosis and management of heart failure in adults. Journal of the American College of Cardiology. 2009; 53(15):
Academy of Nutrition and Dietetics. Evidence Analysis Library. Available at: