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Slide 1-

MNT for Heart Failure and Transplant
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Congestive Heart Failure (CHF) A clinical syndrome characterized by progressive deterioration of left ventricular function, inadequate tissue perfusion, fatigue, shortness of breath, and congestion
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Gradual failure of heart 1. Compensated—Lack of O2 to tissues causes increase in heart rate and enlargement of heart 2. Decompensated—Heart no longer adjusts Congestive Heart Failure (CHF) —cont’d
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Causes of Heart Failure Diseases of the heart (valves, muscle, vessels, arteries) and vasculature (hypertension) cause left ventricular systolic dysfunction Once established, myocardial infarction, dietary sodium excess, medication noncompliance, arrhythmias, pulmonary embolism, infection, anemia can precipitate complete CHF
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Prevalence and Incidence Unlike other cardiovascular diseases, CHF is on the increase Number of CHF-related discharges increased 174% from 1979-2003 4.8 million Americans have CHF; overall prevalence 2-6% Krummel DA in Krause, 12th ed., 2008
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Prevalence and Incidence Prevalence increases with age, especially after age 55 Black women have the highest rates, followed by black men, Latino men, white men, white women, and Latino women More Medicare dollars are spent on CHF than on any other diagnosis
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Prevalence and Incidence Incidence has risen in last 20 years because of aging population, increased number of people being saved from premature death secondary to MI, increase in obesity and associated hypertension Incidence of CHF approaches 10 per 1000 people over 65 years Median survival of men and women is 1.7 years and 3.1 years respectively One in five persons with CHF will die within a year of diagnosis
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Risk Factors Hypertension (91% of Framingham cohort had hypertension before CHF) Left ventricular hypertrophy Coronary heart disease (causes 60-65% of cases) Diabetes Mean age of onset is 70 years
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Stages of Heart Failure Krummel in Krause, 12th Ed.
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Classifications of Heart Failure
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Congestive Heart Failure Symptoms Dyspnea Orthopnea Nausea Fullness Pulmonary edema Cardiac edema Cardiac cachexia
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CHF DIAGNOSIS EKG or electrocardiogram measures the rate and regularity of the heartbeat May indicate whether there has been heart damage or changes in anatomy Chest X-ray Shows whether heart is enlarged, fluid in lungs, pulmonary disease
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CHF DIAGNOSIS Echocardiogram Most useful test in diagnosis of heart failure Uses sound waves to create a picture of the heart Evaluates heart function: cardiac output and areas of the heart that are not contracting normally
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Other Cardiac Tests Holter Monitor: ambulatory electrocardiography Worn for 24 hours and provides a continuing recording of heart rhythm during normal activity Cardiac Blood Pool Scan (radionuclide ventriculography or nuclear scan) Uses radioactive imaging agent injected into a vein to outline chambers of the heart and blood vessels Shows how well heart is pumping blood to the rest of the body
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Other Cardiac Tests Cardiac Catheterization Flexible tube passed through vein in the groin or arm to reach the coronary arteries Allows physician to visualize the arteries, check pressure and blood flow in coronary arteries, collect blood samples Coronary angiography: usually done along with cardiac catheterization Dye injected into coronary arteries and/or chambers of the heart Allows angiographer to visualize flow of blood
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Cardiac Tests Exercise Stress Test EKG and blood pressure readings are taken before, during, and after exercise to determine how the heart responds to exercise Patient exercises on a treadmill or stationary bike until reaches a heartrate established by the physician Echocardiogram often included
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BNP and NT-proBNP Blood Test Measure the concentration of BNP (hormone made by the heart) or NT-proBNP (both formed when pro-BNP is cleaved into two fragments) Released as a natural response to heart failure, to hypotension, and to LVH Used to grade the severity of heart failure
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Cachectic Heart A soft, flabby heart characterized by loss of myocardial mass as the result of extreme malnutrition
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Congestive Heart Failure Treatment Goal: decrease work of heart Diet 1. Na restriction (500 to 1000 mg) 2. Monitor serum K—hypokalemia possible with diuretics and digoxin) 3. Fluid restriction 4. Alcohol—none to moderate 5. Caffeine—can cause MI or cardiac arrhythmia
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Medications Used in Heart Failure Diuretics help reduce fluid buildup in lungs and peripheral edema ACE inhibitors lower blood pressure and reduce the strain on the heart. These medications also may reduce the risk of a future heart attack. Beta blockers slow heart rate and lower blood pressure to decrease the workload on the heart. Digoxin makes the heart beat stronger and pump more blood. Vasodilators: reduce blood pressure and stress on the heart
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MNT in HF Fluid restriction Sodium restriction Meet energy/protein needs Prevent cardiac cachexia Small frequent meals
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Fluid Restriction If hyponatremia occurs (serum sodium <130 mEq/L) Limit total fluids to <2000 ml In severe decompensation, limit to 1000-1500 ml Maintain restricted sodium diet even if serum sodium depleted; sodium has moved from blood to tissues
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Fluid Status and Assessment Patients should record daily weights and advise care providers if weight gain exceeds 2-3 lb a day or 5 lb in a week Restricting sodium and fluids (decreasing by 1 to 1.5 cups) may prevent complete HF
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Fluid Calculations Hospitalized patients may be limited to 500-2000 ml daily Foods having a high fluid content may also be limited Foods that are liquid at room temperature such as ice cream, yogurt, gelatin, popsicles count towards fluid allotment
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Living with Fluid Restrictions Freezing fruit or sucking on sugar free hard candy may help Fluid status monitored by measuring urine specific gravity and serum electrolyte values and observing for clinical signs of edema Restrictions often discontinued when patients leave the hospital
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Cardiac Cachexia Involuntary weight loss of >6% of nonedematous body weight over a 6-month period Significant loss of lean body mass: exacerbates HF Cachectic heart: soft and flabby Structural, circulatory, metabolic, inflammatory, and neuroendocrine changes in skeletal muscle Serious complication of HF
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Cardiac Cachexia Patients with cardiac cachexia may lose 10-15% of their body weight (dry weight) Other markers (serum prealbumin and transferrin) may be disproportionately low because of the dilutional effect of excess fluid Use anthropometrics (measurement of calf and thigh circumference, MUAC) and diet history
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Cardiac Cachexia Proinflammatory state in which cytokines (TNF, IL-1 and I-6) are elevated in the blood and myocardial tissue Reduced blood flow to the gut may reduce gut integrity leading to entry of bacteria and endotoxins High TNF associated with reduced BMI, lower skinfolds, reduced visceral proteins Krummel in Krause, 12th ed., 2008
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Energy Needs in HF For obese patients, hypocaloric diets (1000-1200 kcals) will reduce the stress on the heart In undernourished patient, energy needs are increased by 30-50% above basal levels; 35 kcals/kg often used Patients with cardiac cachexia may require 1.6-1.8 times resting energy expenditure for repletion
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Sodium Impaired cardiac function → inadequate blood flow to the kidneys → aldosterone and antidiuretic hormone secretion Aldosterone promotes sodium resorption and ADH promotes water conservation Even patients with mild heart failure can retain sodium and water if consuming a high salt diet (6 g or 250 mEq/day)
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Sodium in Patients with Heart Failure Recommendations vary between 1200 to 2400 mg/day (adequate intake 1200 mg/d) Patients on high dose lasix (>80 mg/day) <2000 mg Severe restrictions are unpalatable and nutritionally inadequate Ethnic differences in sodium intake Use least restrictive diet that achieves clinical goals
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Dietary Sources of Sodium Salt used at the table Salt or sodium compounds added during preparation or processing Inherent sodium in foods Chemically softened water Average American consumes 4 to 6 g sodium/day; 80% from processed foods Minimum to maintain life is 250 mg/day Salt substitutes, herbs, spices and other seasonings Drugs and antacids may contain sodium Kosher foods
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Characteristics of Common Sodium Restrictions
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500 mg Sodium Diet High sodium, moderate sodium foods eliminated. Table salt not allowed. Canned or processed foods containing salt omitted Frozen vegetables (peas, lima beans, mixed vegetables, corn) omitted due to brine High sodium vegetables beets, beet greens, carrots, kale, spinach, celery, white turnips, rutabagas, mustard greens, chard, dandelion greens omitted Low sodium bread instead of regular bread Meat limited to 6 ounces
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High Sodium Foods
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Food Servings for Sodium-Controlled Diets
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Food Servings for Sodium Controlled Diets, cont
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Food Labeling Guide (standard serving) Sodium Free Less than 5 mg Very Low Sodium 35 mg or less Low Sodium 140 mg or less Reduced Sodium At least 25% less sodium than regular food Light Sodium 50% less sodium Unsalted, No salt added during processing Without Added Salt, No Salt Added Lightly Salted 50% less added sodium than normally added (product must state “not a low-sodium food”)
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Nondietary Sources of Sodium Medications: barbiturates, sulfonamides, antibiotics, cough medications, stomach alkalizers, laxatives, mouthwashes Chewable antacid tablet can add 1200 to 7000 mg of sodium daily Aspirin: 50 mg sodium per tablet
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Potassium Potassium wasting diuretics (hydrochlorthiazide, furosemide) increase potassium excretion which may lead to digitalis toxicity Some patients will need potassium supplements Salt substitutes can provide 500-2000 mg of potassium per teaspoon; contraindicated in renal failure and with certain other medications
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Sodium and Salt Gram and Milliequivalent Measures 1 mEq Na = 23 mg NA
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Other Dietary Factors in Heart Failure Alcohol and caffeine Weight maintenance Calcium and vitamin D Magnesium Thiamin supplementation Small frequent feedings Supplements
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Other Nutritional Issues Calcium and Vitamin D: half of patients with severe HF have osteopenia or osteoporosis, especially cachectic patients; use calcium supplements with caution w/ cardiac arrhythmias Magnesium: diuretics may increase mg excretion; measure blood mg levels Thiamin status should be evaluated in HF patients on loop diuretics
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Cardiac Assist Devices Mechanical heart pumps May be helpful in pre-transplant HF patients or in those for whom transplant is not an option
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Heart Transplant Only cure for refractory CHF In 2003, 2000 cardiac transplants in the U.S. Highest number in white men 50-64 years of age
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Pretransplant MNT Goals Body weight 90-110% of ideal body weight Extremes of weight (<80% or >140% IBW predict poor outcome Pretransplant comorbidities (hypertension, hyperlipidemia, diabetes) reduce survival rates Survival 83% at 1 year, 72% at 5 years, 50% at 9 years
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Cardiomyopathy
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Post-Transplant MNT Goals Adequate support to promote healing and fight infection Monitor and correct electrolyte abnormalities Achieve optimal blood glucose control Provide energy for ambulation and physical therapy Energy: 1.3-1.5 times REE; protein 1.5-2 grams/kg body weight; Na 2-4 g/day Hasse in Krause, 12th Ed., p. 896
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Post-Transplant MNT Issues Long Term Immunosuppressants can cause weight gain and hyperlipidemia Risk factors are prednisone dose, baseline cholesterol level, blood glucose levels, and weight gain Graft atherosclerosis is the leading cause of death in long-term survivors TLC diet with 2-4 gram sodium; optimal calcium and vitamin D to prevent steroid-induced osteoporosis
Slide 51-

ADA Nutrition Care Manual Education Resources http://nutritioncaremanual.org/universi13 Heart failure Nutrition Therapy Hypertension Nutrition Therapy DASH Diet guidelines
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Summary CHF—most common reason for long lengths of stay in the elderly Prevention and management is key as prognosis is poor Aggressive nutritional interventions are important.