1. Medical Nutrition Therapy in Cardiovascular Disease
Chapter 35
Medical Nutrition Therapy in Cardiovascular Disease

2. 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 10

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

4. 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.

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

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

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

8. 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

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

10. 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

11. 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

12. Genetic Hyperlipidemias
Familial hypercholesterolemia
Familial combined hyperlipidemia
Familial dyslipidemia
Familial dysbetalipoproteinemia

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

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

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

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

17. 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

18. 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 5

19. 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) 13

20. 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 12

21. LDL Cholesterol Levels Predict Risk of Coronary Heart Disease
Increased by
Fat in diet
Obesity
Diabetes
Hypothyroidism
Decreased by
Estrogen 11

22. 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 Bethesda, MD: National Heart, Lung, and Blood Institute, 1993.)

23. 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 Bethesda, MD: National Heart, Lung, and Blood Institute, 1993.) HDL = high-density lipoprotein.

24. 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 Bethesda, MD; National Institutes of Health. National Heart, Lung, and Blood Institute, 1993.) * Calories from alcohol not included.

25. 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. 6

26. 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 8

27. 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 14

28. 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 15