Natalie Rohr

KNH 411
Prof. Matuszak
3 September 2015
Case Study #5: Myocardial Infarction
1. Mr. Klosterman had a myocardial infarction. Explain what happened to his heart.
Mr. Klosterman had a myocardial infarction, in more common terms he suffered from a
heart attack. A heart attack is a blockage of blood flow to the heart muscle. When a blood
clot blocks blood flow to the heart, the tissue loses oxygen and dies. A heart attack is a
medical emergency and requires the patient to go to the hospital immediately.
Cited:
Heart Attack. (2014, June 11). Retrieved September 2, 2015, from
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0062989/

2. Mr. Klosterman was treated with an angioplasty and stent placement. Explain this
medical procedure and its purpose.
Angioplasty and stent placements are procedures that one does after a myocardial
infarction have occurred. Angioplasty is a non-surgical procedure that is done in order to
open up blocked arteries in the heart. A stent placement is often also done along with an
angioplasty to help keep the artery open and hopefully reduce the likelihood of another
heart attack occurring. A thin plastic tube is inserted into the artery and a catheter is
passed up through the tube and guided up to the arteries surrounding the heart. A stent is a
metal mesh tube that provides support to the coronary artery. The stent is inserted
permanently and over time the artery will grow around the stent. The purpose of this
procedure is to prevent future heart attacks from occurring.
Cited: Angioplasty and stent placement - heart: MedlinePlus Medical Encyclopedia.
(2014, August 12). Retrieved September 2, 2015, from
https://www.nlm.nih.gov/medlineplus/ency/article/007473.htm

3. Mr. Klosterman and his wife are concerned about the future of his heart health. What
role does cardiac rehabilitation play in his return to normal activities and in determining
his future heart health?

Cardiac rehabilitation plays a huge role in Mr. Klostermans future heart health. Cardiac
rehab has been proven an effective way to increase the heart health of individuals who
have undergone heart procedures or have suffered a heart attack. These programs provide
counseling and education services for their patients including increasing physical fitness,
reducing cardiac symptoms, improving health, and reducing the risk of future heart
problems. Attending these programs, such as supervised regular physical activity, can
help the heart get stronger and work better. If Mr. Klosterman goes to cardiac rehab
regularly, he can expect to have a stronger and healthier heart for years to come.
Cited: What Is Cardiac Rehabilitation? (2013, December 24). Retrieved September 2,
2015, from http://www.nhlbi.nih.gov/health/health-topics/topics/rehab

4. What risk factors indicated in his medical record can be addressed through nutrition
therapy?
Mr. Klostermans medical records show high cholesterol as well as high LDL levels. On
the other hand, his HDL levels are rather low. LDL cholesterol is the main source of
cholesterol buildup and blockage in the arteries and HDL helps remove cholesterol from
the arteries. High levels of LDL with low levels of HDL can result in dyslipidemia, which
refers to a lipid profile that increases the risk of atherosclerotic development (Nelms,
310). Mr. Klosterman also appears to be mildly overweight, with a BMI of 26.6. He
consumes a lot of sodium through pretzels, roast beef, canned soup, and cream cheese
when looing at his 24-hour food recall. This high level of sodium intake can also cause
hypertension, which is also a risk factor for the development of certain heart diseases.
Another thing noted in his medical record was the family history of coronary artery
disease (CAD) with his father being diagnosed at the age of 59. The genetic component
plays a role in the development of atherosclerosis as well.
5. What are the current recommendations for nutritional intake during a hospitalization
following a myocardial infarction?
The current recommendations for nutritional intake during hospitalization following postMI period, is the slow progression from liquid to soft foods. Oral intake is decreased in

this time period due to pain, anxiety, fatigue, and shortness of breath. As the patient
stabilizes, he will progress from easily chewed foods to smaller meals. As time goes on,
the main goal of nutrition therapy will be an individualized Therapeutic Lifestyle Change
(TLC) dietary recommendation. (Nelms 325).
6. What is the healthy weight range for an individual of Mr. Klostermans height?
A healthy weight range for an individual of Mr. Klostermans height is 149.4 to 182.6
pounds. This calculation can be shown through the Hamwi Method, which demonstrates
the ideal body weight of an individual:
Male: 106 + [10 (6)] = 166 pounds
166 x 0.1 = 16.6
166 16.6 = 149.4 (subtracting 10% for a small frame)
166 + 16.6 = 182.6 (adding 10% for a large frame)
7. The patient is a Lutheran minister. He does get some exercise daily. He walks his dog
outside for about 15 minutes at a leisurely pace. Calculate his energy and protein
requirements.
In order to calculate his energy need, I used the Mifflin-St. Jeor equation. Mr.
Klostermans resting energy needs are:
Resting 10 (84.09 kg) + 6.25 (177.8 cm) 5 (61) + 5 = 1,652 kcal/day
Total energy needs 1,652 x 1.4 (PAL) = 2,313 kcal/day
I used an activity level of 1.4 for Mr. Klosterman because he demonstrates some activity
but at a very low level by leisurely walking his dog.
For the amount of protein he should have daily, it is recommended he have 1.1 g
protein/kg since he underwent a minor surgery. Therefore he would need
84.09 kg x 1.1 = 92.5 g protein/day (roughly 93 g).
8. Using Mr. Klostermans 24-hour recall, calculate the total number of calories he
consumed as well as the energy distribution of calories for protein, carbohydrate, and fat
using the exchange system.

Using Mr. Klostermans 24-hour recall, it was calculated that he consumes roughly 2518
calories. His protein intake was made up into 135.7 g/day of his caloric intake,
carbohydrates made up 359.3 g/day of his caloric intake and finally fat made up 63.3
g/day of his caloric intake. Shown below are the calculations for the percent of each
macronutrient that Mr. Klosterman consumed that day:
Protein: [(135.7g x 4) / 2518] x 100 = 21%
Carbohydrates: [(359.3g x 4 / 2518] x 100 = 57%
Fat: [(63.3g x 9) / 2518] x 100 = 23%
Shown below is the nutrient report from Mr. Klostermans 24-day recall:
NAME

AMOUN
T

UNIT

Totals

Bagel, with raisins

CALS

FAT(G) CARBS(G)PROT(G)

2518

63.3

359.3

135.7

large

359

2.2

72.3

12.8

0.5

oz

28

2.2

1.2

1.1

Orange juice

fl oz

120

0.3

28.5

1.7

Coffee

mug (8 fl oz)

0.0

0.2

0.3

Vegetable beef soup, canned,

undiluted

can

192

4.6

24.7

13.6

Bread

regular slice

139

1.7

25.6

5.0

Beef, sliced, prepackaged or deli,

luncheon meat

oz

133

3.9

2.9

20.3

Lettuce, raw

large leaf

0.0

0.4

0.1

Cheese spread, cream cheese, light or

lite

AMOUN
T

UNIT

CALS

Tomatoes, raw

thick/large slice
(1/2" thick)

0.1

1.1

0.2

Cucumber pickles, dill

slice

0.0

0.2

0.0

0.2

oz

39

4.2

0.0

0.1

Apple, raw

small (2-3/4" dia)

77

0.3

20.6

0.4

Milk, 2% fat

oz

113

4.5

10.9

7.5

Pork chop, lean only eaten

oz

267

6.7

0.0

49.7

Potato, baked, flesh and skin, without

salt

potato large

278

0.4

63.2

7.5

Margarine

0.2

oz

30

3.4

0.0

0.0

Beans, string, green, cooked

0.5

cup

37

1.7

5.3

1.3

Cabbage salad or coleslaw, with

dressing

0.5

cup

110

7.8

10.1

1.0

Pie, apple, one crust

piece (1/8 of 9"

dia)

363

13.9

58.5

2.7

Milk, 2% fat

oz

113

4.5

10.9

7.5

NAME

Mayonnaise, regular

FAT(G) CARBS(G)PROT(G)

NAME

AMOUN
T

UNIT

CALS

oz

109

Pretzels

FAT(G) CARBS(G)PROT(G)

1.0

22.7

CALORIE BALANCE
9. Examine the chemistry results for Mr. Klosterman. Which labs are consistent with the
MI diagnosis? Why were the levels higher on day 2?
The labs that are consistent with myocardial infarctions diagnosis include his total
cholesterol being too high, his high levels of LDL cholesterol, low levels of HDL
cholesterol, high levels of Troponin I and Troponin T, and low levels of apolipoprotein A.
The high levels of LDL and low levels of HDL show that the heart attack was caused by
cholesterol blocking the artery. The high levels of Troponin I and Troponin T proteins in
the blood show that the heart had been damaged. The proteins are released when the heart
has been damaged and the more damage to the heart there is, the higher the amount of
Troponin will be in the blood. A reduction in Apo A is also associated with increased
cardiac events, which is consistent with the MI diagnosis.
Aspartate Aminotransferase (AST) is an enzyme that is normally found in the blood but
when the heart is damaged, additional AST is released. After severe damage, the levels of
AST rise within 6-10 hours. The cells die due to oxygen deprivation. Normal levels of
AST are 0-35 U/L and Mr. Klosterman had levels on day 2 that were 245 U/L. Creatine
phosphokinase (CPK) levels were also very high on day two with it being 500 U/L with
the normal levels of that enzyme being 10-120 U/L. The high levels of these enzymes
show that Mr. Klosterman had suffered a myocardial infarction and the cells in the heart
were still dying due to oxygen deprivation.
Cited: CPK isoenzymes test: MedlinePlus Medical Encyclopedia. (2013, February 13).
Retrieved September 2, 2015, from
https://www.nlm.nih.gov/medlineplus/ency/article/003504.htm
AST: MedlinePlus Medical Encyclopedia. (2013, January 21). Retrieved September 2,
2015, from https://www.nlm.nih.gov/medlineplus/ency/article/003472.htm

10. What is abnormal about his lipid profile? Indicate the abnormal values.

2.8

Mr. Klosterman had abnormal cholesterol, LDL cholesterol, and HDL cholesterol values
as well as an abnormality in Apo-A.

Lab Results for:

Normal Range

Patients Value

Total Cholesterol

<200 mg/dL

235 mg/dL

LDL

<130 mg/dL

160 mg/dL

HDL

>45 mg/dL

30 mg/dL

Apo-A

>120 mg/dL

72mg/dL

11. Mr. Klosterman was prescribed the following medications on discharge. What are the
food-medication interactions for this list of medications?
Medication
Lopressor 50 mg daily

Possible Food-Nutrient Interactions

Thirst, loss of appetite, nausea, sleep problems,
fatigue and diarrhea. Avoid alcohol,

Lisinopril 10 mg daily

multivitamins and minerals

Avoid high potassium foods. Nausea and

Nitro-Bid 9.0 mg twice daily

vomiting may occur

Take exercise easy while on this medication,

Cited: FDA
(2014). Avo
iding Drug

but no food-medication interactions. Avoid

NTG 0.4 mg sl prn chest pain
ASA 81 mg daily

alcohol
Avoid alcohol
Cramping, nausea, and vomiting. Avoid

caffeine and alcohol

Interactions. Retrieved
from:http://www.fda.gov/forconsumers/consumerupdates/ucm096386.htm
12. You talk with Mr. Klosterman and his wife, a math teacher at a local high school.
They are friendly and seem cooperative. They are both anxious to learn what they can do

to prevent another heart attack. What questions will you as them to assess how to best
help them?
In order to assess how to best help the Klostermans, I will ask the following questions:
a) Do you know how to read a food label?
b) Do you know which foods to avoid with high cholesterol?
c) Is it possible for you to increase your physical activity to 30 minutes a day?
d) Are you willing to change up and create a new diet for yourself?
13. What other issues might you consider to support successful lifestyle changes for Mr.
Klosterman?
Some other issues that I would consider telling Mr. Klosterman to support a successful
lifestyle change would be to first tell him to resist from smoking. When it comes to
smoking, it can be the most important change any individual can make to reduce risk of
hypertension and all forms of cardiovascular disease (Nelms, 306). He also should
engage in more physical activity. Research says that just 30 minutes a day can decrease
blood pressure. Increasing physical activity decreases the relative workload on the heart,
which is a benefit for all forms of cardiovascular disease (Nelms, 306). Lastly, I would
also suggest for him to go grocery shopping with his wife. Since he is watching his diet a
little more closely now, he should know what items to buy and what items should be left
at the store.

14. From the information gathered within the assessment, list possible nutrition problems
using the correct diagnostic terms.
The possible nutrition problems using the diagnostic terms include:
NI 1.3: Excessive energy intake
NI 5.6.1: Inadequate fat intake
NI 5.7.2: Excessive protein intake
NI 5.10.2 Excessive mineral intake; sodium
Cited: (2015). Retrieved September 2, 2015, from https://ncpt.webauthor.com/pubs/idnten/page-037

15. Select two of the identified nutrition problems and complete the PES statement for
each.
a) Overweight as related to excessive energy intake as evidenced by little to no physical
activity, a BMI of 26.6 and a weight of above average for the height of the patient.
b) High cholesterol levels as related to high intake of saturated fats as evidenced by
total cholesterol >200mg/dL.

16. For each of the PES statements you have written, establish an ideal goal and an
appropriate intervention.
Goal: To reduce Mr. Klostermans BMI to a healthy range (18.5-24.9).
Intervention: Educate Mr. Klosterman on how to maintain a healthier diet using the TLC
diet plan. Recommend he stay around a 2000 kcal/day diet while increasing his physical
activity to a 30 min walk with his dog a day.
Goal: To reduce Mr. Klostermans total cholesterol level by reducing LDL levels and
raising HDL levels to <130 mg/dL and >40 mg/dL respectively.
Intervention: Educate Mr. Klosterman on the importance of how to implement his diet.
Explain the TLC diet and how he can use that diet plan to his advantage.
17. Mr. Klosterman and his wife ask about supplements. My roommate here in the
hospital told me I should be taking fish oil pills. What does the research say about
omega-3-fatty acid supplementation for this patient?
Linolenic acid, an omega-3 polyunsaturated fatty acid, is considered an essential fatty
acid. Fish are a particularly rich source of linolenic acid. When comparing these sources
of linolenic acid and cardiovascular disease, research has demonstrated that it reduced
mortality with increased intakes of these specific types of lipids (with other studies
having mixed results). The American Heart Association (AHA) recommends that patients
with cardiovascular disease consume 1 g of these fatty acids daily (Nelms, 319).

18. What would you want to assess in three to four weeks when he and his wife return for
additional counseling?
In three to four weeks, I will want to see Mr. and Mrs. Klosterman back for additional
counseling. I would start off by reviewing any new lab results that had been taken since
their last visit, particularly looking at Mr. Klostermans LDL and cholesterol levels. I
would have him give me a 24-diet recall to see if he was following the diet plan I
recommended for him and getting in the right amount of calories per day. I would then
look to see if he was losing any weight and his BMI (if it had changed). I would then ask
Mrs. Klosterman if she had started making little changes in the food she buys/prepares so
that she can properly assist her husband in his new diet. I would want to see how Mr.
Klostermans physical activity level has changed so I would bring up if he had changed
anything since our last visit. Lastly, I would want to educate Mr. Klosterman on the
harmful effects of his smoking and hopefully help guide him in the right direction in
order to quit.
References:
(2015). Retrieved September 2, 2015, from https://ncpt.webauthor.com/pubs/idnten/page-037

Angioplasty and stent placement - heart: MedlinePlus Medical Encyclopedia. (2014,

August 12). Retrieved September 2, 2015, from
https://www.nlm.nih.gov/medlineplus/ency/article/007473.htm
AST: MedlinePlus Medical Encyclopedia. (2013, January 21). Retrieved September 2,
2015, from https://www.nlm.nih.gov/medlineplus/ency/article/003472.htm

CPK isoenzymes test: MedlinePlus Medical Encyclopedia. (2013, February 13).

Retrieved September 2, 2015, from
https://www.nlm.nih.gov/medlineplus/ency/article/003504.htm

FDA (2014). Avoiding Drug Interactions. Retrieved

from:http://www.fda.gov/forconsumers/consumerupdates/ucm096386.htm

Heart Attack. (2014, June 11). Retrieved September 2, 2015, from

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0062989/
Nelms, M., Sucher, K., & Lacey, K. (2016). Disease of the Cardiovascular System. In
Nutrition Therapy and Pathophysiology (Third ed., pp. 292-334). Boston, MA: Cengage
Learning.
What Is Cardiac Rehabilitation? (2013, December 24). Retrieved September 2, 2015,
from http://www.nhlbi.nih.gov/health/health-topics/topics/rehab