By: Natalie MacTavish & Cassie Alvarado

By: Natalie MacTavish & Cassie Alvarado

Background Information

Myocardial Infarction:“the damaging or death of an area of the heart muscle

(myocardium) resulting from a blocked blood supply to that area:medical term for a heart attack”

– American Heart Association

Cause: An obstruction in a vessel of the heart thatcauses a blockage of blood supply

Symptoms: Pressure, fullness or sharp pain in center of chest Pain can extend to arm, back, shoulder & jaw SOB Sweating Fainting Nausea & Vomiting

Background Information cont.

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(ARIC Surveillance: 1987-2004). Source: NHLBI.

* by Age, Race and Sex.* MI diagnosed by expert committee based on review of hospital records.

Incidence of Myocardial Infarction

Comparison of Low-Fat Versus Mediterranean-StyleDietary Intervention After First Myocardial Infarction

American Journal of Cardiology

Objective: to compare low-fat and Mediterranean style diet after firstheart attack in a randomized, controlled clinical trial

- n=51 in intervention group, 50 in control group.

- Both diets were low in saturated fat (<7kcal) and cholesterol (<200mg)

- Mediterranean diet distinguished by greater omega-3 FA intake

-Both groups compared to “usual care group” made up of participantswho matched control groups

-Participants received counseling sessions, both group and individual

Comparison of Low-Fat Versus Mediterranean-StyleDietary Intervention After First Myocardial Infarction

American Journal of Cardiology

-Results: no difference in MI risk between two groups,however:

-Usual care group participants had worse lab results in bothcholesterol and saturated fat in comparison with dietaryintervention group, and higher risk for second MI

-Conclusion: Whether the diet is low-fat or Mediterraneanstyle, both are effective in treating MI patients and indecreasing chances of a sedond MI

Effect of garlic and fish-oil supplementation on serum lipidand lipoprotein concentrations in hypercholesterolemic men

- American Journal of Clinical Nutrition

Study Design:

• 12-week, randomized, placebo-controlled trial with 4different supplement treatments

• (garlic pills double-blind & fish-oil single-blind)

Methods:

• 100 men screened for requirements – 50 selected

• Blood samples collected and analyzed for cholesterol,LDL, HDL, and triacylglycerol throughout the 12 weeks

Results:

• Placebo: No significant effect

• Garlic + Fish-oil:

• Significant total cholesterol (-12.2%), LDL (-9.5%) &triacylglycerol concentrations (-34.3%)

• Significant cholesterol:HDL (-16.2%) & LDL:HDL (-19%)

• Significant HDL & EPA:Arachidonic Acid

• Garlic Alone:

• Significant total cholesterol (-11.5%), LDL (-14.2%),cholesterol:HDL (-12.5%) & LDL:HDL (-15.3%)

• Fish-oil Alone:

• Significant HDL, LDL (+8.5%), & EPA:Arachidonic Acid

• Significant triacylglycerol concentrations (-37.3%)

Treatment LDL TG Chol. LDL:HDL Chol:HDL

Placebo - - - - -

Garlic -14.2% - -11.5% -15.3% -12.5%

Fish-Oil + 8.5% - 37.3% - - -

Both -9.5% -34.3% - 12.2% -19.0% -16.2%

- = not significant

At the end of the 12 weeks, no significantdifference between HDL levels and 3 treatments

Results:

Conclusion:

• The efficacy of this combined CAM therapy is superiorto a single CAM therapy

• The supplementation of both garlic and fish-oilproved to be most beneficial

• This combination also prevented any rise in LDLthat was a result from the fish-oil supplement

• Beneficial therapy based on the effects of serumlipid levels and lipoprotein concentrations

Patient Information

Age: 61Sex: MaleHt.: 5’10”Wt.: 185Complaint: Severe, unrelenting precordial chest pain

for past 1.5 hoursMedical Hx: No meds or previous hospitalizationsNutrition Hx: Good Appetite & well-balanced dietMedical Diagnosis: Myocardial Infarction

Nutrition Care ProcessAssessment:Medical History:

– Emphysema/lung problems & Angina/chest pain

Biochemical Parameters:– Normal: Albumin, sodium, BUN, TG– High: Glu, LDL, Chol, VLDL, LDL:HDL, CPK (day 2)– Low: HDL

Physical Exam:– Mildly Overwt. BMI: 26.5 %IBW: 111 w/ pale skin– BP 118/78, HR 92 bpm, RR 20 bpm,

Potential Diet-Drug Interactions: NoneFood intake: GoodPreferences: NoneAllergies: Sulfa drugs

Assessment cont.Family influences:

– Wife cooks meals

Motivation/readiness:– Pt. saw community dietitian last yr and is currently changing diet– Perceived readiness & motivation: high

Lifestyle and health risk appraisal:– Smokes 1 pack/day x 40 years– Father had MI at 59

Personal and preferred learning style:– High level of education– Nutrition education preferred with spouse

Nutrition Care Process

Diagnosis:

Behavioral/environmental: [NB-1.1]

Food and nutrition related knowledge deficit related tonew diagnosis as evidenced by patient report of beinganxious to learn about reducing risk for future MI.

Nutrition Care Process

Intervention:

Initial/brief nutrition education E-1- Nutrition Education with patient and spouse

- Heart healthy diet- Meal planning/cooking- Physical Activity (cardiac rehab)

- Education on guidelines for lipid levels- How to maintain low LDL and high HDL levels

Intervention: Diet Recommendation

Diet Order: Cardiac Diet

TLC Diet Guidelines:

• Less than 7% of the day's total calories from saturated fat.

• 25-35 percent of the day’s total calories from fat.

• Less than 200 milligrams of dietary cholesterol a day.

• Limit sodium intake to 2400 milligrams a day.

• Just enough calories to achieve or maintain a healthyweight and reduce your blood cholesterol level.

(http://www.nhlbi.nih.gov/cgi-bin/chd/step2intro.cgi)

Intervention: Patient GoalsOutcome goal:-To minimize risk for future occurrence of MI (improvedblood lipid levels, weight, physical activity level ifapplicable)

Action-oriented goals short term:-To gradually increase fiber intake-Increase intake of plant stanols (replace margarine)-Replace PUFA’s (corn oil/margarine) with MUFA’s(olive oil)

Action-oriented goal long term:- Maintain good blood lipid ratios & smoking cessation

Nutrition Care Process

Monitor/Evaluate:Track progress by a follow-up appt with cardiac rehab

dietitian in 2 weeks Reassess lab values for: cholesterol, HDL, LDL, TG,

LDL:HDL, Glu, Na+ Check for behavior change in dietary intake and PA

References• Adler, A, J. (1997).Effect of garlic and fish-oil supplementation on serum lipid and lipoproteinconcentrations in hypercholesterolemic men. The American Journal of Clinical Nutrition. 65, 445-450.

• Tuttle, K, R. (2008).Comparison of Low-Fat Versus Mediterranean-Style Dietary InterventionAfter First Myocardial Infarction. American Journal of Cardiology . 101, 1523-1530.

• (2008 March, 20). American heart association. Retrieved September 25, 2008, from Life after aheart attack Web site: http://americanheart.org/presenter.jhtml?identifier=238

• (2008). National Heart, Lung and Blood Institute. Retrieved September 25, 2008, from How youcan lower your cholesterol level: Introduction to the Therapeutic Lifestyle Changes Diet Web site:http://www.nhlbi.nih.gov/cgi-bin/chd/step2intro.cgi