Myocardial Infarction

Myocardial Infarction
Lauren Baker and Samantha Daily
Madonna University

Myocardial Infarction

Patient profile and health history

Patient is a sixty-one year old male who weighs one hundred eighty five pounds and is
five foot eleven inches. The patient was admitted into the hospital due to a sudden onset of
severe precordial pain radiating in his jaw and left arm that has lasted ninety minutes. The patient
lives with his wife and is a Lutheran minister. He is of German descent. According to the patient
he drinks one glass of alcohol per day and has smoked one pack of cigarettes everyday for the
past forty years. He states he does not take any prescribed medication nor does he partake in
recreational drugs. There was no mention of any aerobic or strength training exercises within the
daily routine.
The family medical history includes cancer, which his maternal grandmother had, and
coronary artery disease, which could have led to a myocardial infarction in his father at age fiftynine. The patients medical history includes emphysema and/or lung problems and angina and/or
chest pain. The patient was previously hospitalized ten years ago for a cholecystectomy and had
an appendectomy thirty years ago. The only allergies that cause a problem are sulfa drugs which
lead to hives.
The patient stated that his appetite is good, but has been wanting to make dietary changes
to his lifestyle. Within the last year, he saw a community dietitian to start making changes. His
wife purchases and prepares all the meals in the home, but has been trying to make healthier
choices when it comes to cooking. According to the patient, his usual diet includes a midmorning
snack of a bagel with fat free cream cheese, orange juice, and coffee. His lunch consists of a
sandwich with mayonnaise, canned soup, a fruit, and a milk. For dinner the patient consumes six
ounces of meat, a potato and vegetable, coleslaw for a salad, and a dessert. The evening snack is
a milk with pretzels.

Myocardial Infarction

When the patient arrived in the Emergency Room due to his precordial pain, he received
an emergency coronary angiography with an angioplasty. He requires bed rest, heart rhythm
monitoring, cardiograms, and cardiac enzymes.
Overview of the Disease
A myocardial infarction is simply a heart attack. The heart is deprived of blood supply
from an obstruction or the flow of blood is slowed (1). An obstruction in the coronary arteries
can be due to plaque build up, which causes the arteries to become rigid and narrow. Plaque is
built up due to increase levels of cholesterol such as low density lipoproteins and a lack of
aerobic exercise. Increased levels of a persons low density lipoproteins can be contributed to
high intakes of saturated fat, trans fatty acids, and cholesterol (1). Aside from the dietary intake,
trauma leading to inflammation, infection, and cell damage can also cause plaque build up (1). A
person could be at risk for myocardial infarction if they have high blood pressure and
cholesterol, and if they are a smoker (2).
The symptoms of a myocardial infarction are common with other diseases, but should be
taken seriously. Some of the symptoms that could indicate a myocardial infarction include
pressure on the chest or pain, pain radiating in one or both shoulders, the jaw, and/or back,
shortness of breath, nausea, lightheadedness, and clammy skin (2). Not all symptoms have to be
present to be having a heart attack. Most women do not have radiating pain, but rather have a
feeling of an elephant sitting on their chest. If an individual is feeling immense pain, they should
seek medical attention right away.
The possible medical treatments available for myocardial infarction are medication,
lifestyle change, and/or medical procedures such as an angioplasty or a bypass (1). An
angioplasty is a surgery that repairs or unblocks an blood vessel or artery that has been

Myocardial Infarction

obstructed. A bypass is a surgery where surgeons create a new way for blood to flow more
efficiently to the heart when an artery is blocked. Lifestyle changes that can be beneficial in the
aftermath of a myocardial infarction are exercising and diet modifications. Another lifestyle
change that is going to make a difference is to quit smoking (2). Dietary treatments include
meeting with a registered dietitian nutritionist to discuss how to go about changing ones diet
through reducing sodium intake, increasing fluids such as water, and how to increase aerobic
exercise (3). More dietary changes include reducing the amount of saturated and trans fats that
are consumed as well as minimizing the amount of cholesterol that is ingested through animal
products. Eating more fruits and vegetables, as well as whole grains, legumes, protein, and fiber
can have a major impact on the health of the heart. Adding quality, healthy foods to the diet can
improve healing times and strengthen the heart.
If a coronary artery is not unblocked it can cause a myocardial infarction which can lead
to death if medical attention is not received in a timely manner. Once a myocardial infarction has
occurred and medical treatment has been established, the prognosis is fairly good. The chances
of having another heart attack increase after the first one, but if with lifestyle modifications,
medications and medical procedures, that can be avoided.
To prevent a myocardial infarction, there are many things that can be done. Adding daily
activity to ones lifestyle, changing to a healthier diet, and maintaining a healthy weight can all
positively effect the heart (1). A medication that has the possibility of preventing a myocardial
infarction is low dosages of aspiring daily (4). Also, for those who smoke should stop smoking to
prevent myocardial infarctions.
Nutrition Assessment
Anthropometrics

Myocardial Infarction

The patient is an overweight male, weighing one hundred and eighty-five pounds,
standing at a height of five feet and ten inches, or seventy inches. The patients calculated body
mass index (BMI) is 26.6. This value signifies the patient is overweight, which is associated with
greater risk for diseases associated with heart disease such as hypertension and diabetes mellitus.
There is no reported edema or weight change in the patients history.
The patients ideal body weight, calculated using the Hamwi equation, is one hundred
and sixty-six pounds. Currently, the patient is 111.45% his ideal body weight.
Biochemical Labs
Biochemical lab findings for the patient indicate a high cholesterol status. The patients
average total cholesterol over a four-day period was 210 milligrams per deciliter, slightly above
the normal range of 140 to 199 milligrams per deciliter. The patient also showed an elevated
LDL cholesterol with an average value of 150 milligrams per deciliter, a value that falls above
the recommended normal limit of 130 milligrams per deciliter. Additionally, the patient had a
low average HDL value of 31.7 milligrams per deciliter, below the ideal normal range of 37-70
milligrams per deciliter for men. The patient also shows low levels of Apo A, an apolipoprotein
associated with HDL. Since the patient has a low HDL level, a low Apo A status is expected. The
patients cholesterol values do not fall into the ideal range. The patients elevated LDL levels and
low HDL levels are characteristic of dyslipidemia, in which increases the risk of atherosclerotic
plaque development. This is important as plaque build-up leads to occlusion of arteries resulting
in a myocardial infarction. It is important to reduce LDL levels and increase HDL levels to
prevent plaque development, thus reducing the risk for future heart attacks for this patient.
The patients labs also show increased levels of SGPT (ALT), SGOT (AST), CPK,
Troponin I, and Troponin T. Increased levels are expected following tissue damage, such as in a

Myocardial Infarction

myocardial infarction. SGPT, SGOT, and CPK are cardiac enzymes, and when cardiac cells die
as a result of oxygen deprivation from a myocardial infarction, these enzymes leak out into the
blood. Similarly, Troponin I and T are proteins that are released from cardiac cells following a
cardiac injury. These elevated lab values are consistent with the patients condition, and indicate
a cardiac injury occurred.
All other lab values are within normal limits.
Physical Findings
The patient appears overweight, and suffering acute chest pain. His skin appears pale and
diaphoretic, resulting from current myocardial infarction. He does not present any abnormal fluid
accumulation or impaired musculoskeletal function. Reflexes are normal, and there is no
evidence of muscle loss. The patient presents scars on his right lower quadrant of the abdomen
and midline supra-pubic area from previous surgical procedures. Bowel sounds were within
normal limits.
Client History
Patient is Lutheran minister with BS degree. He works forty hours per week. He reports
his ethnic background as German. Patient is married to woman of same age, 61 years old. His
wife is responsible for purchasing and preparing food in the home. She states she has been trying
to cook healthier, substituting butter for corn oil and limiting fried foods. Patient reports smoking
one pack of cigarettes per day for forty years and consumes one alcoholic drink per day. His past
medical history includes surgical removal of his gallbladder ten years ago, removal of his
appendix thirty years ago, and emphysema/lung problems. His family history includes Coronary
Artery Disease (CAD), in which his father suffered a myocardial infarction at the age of 59, and

Myocardial Infarction

cancer, which he reports his maternal grandmother had. Patient reports previous medical
nutrition therapy last year with a community dietitian.
Special Nutrient Requirements
The patient suffered from a myocardial infarction. To reduce plaque development, the
patient should decrease saturated fat and cholesterol in the diet, limiting saturated fat to no more
than 7% of total calories per day and cholesterol to no more than 200 milligrams per day. Sodium
should also be limited to less than 2000 milligrams per day. Additionally, the patient should
consume a diet rich in fruits, vegetables, and whole grains. To avoid drug-nutrient interaction,
potassium consumption should be consistent and minimal, avoiding salt substitutes and natural
licorice.
Kcal/Protein Requirements
Using the Mifflin-St. Jeor formula to estimate energy requirements, the patients ideal
weight of one hundred sixty-six pounds was used as the patient is currently overweight and at
increased risk for associated health problems and diseases. An activity factor of 1.3 and injury
factor of 1.0-1.3 was used. The patients estimated energy requirements are 2035 to 2650 calories
per day.
The protein requirements were calculated based on the patients ideal body weight of one
hundred sixty-six pounds. At 1.0-1.3 grams of protein per kilogram of body weight, the patient
requires 76 to 98 grams of protein per day.

Medications
Once the patient was discharged, they were put on fifty milligrams of lopressor and ten
milligrams of lisinopril everyday. They were also started on nine milligrams of nitro-bid twice a

Myocardial Infarction

day, as well as four milligrams of nitroglycerin sublingually as needed for pain. Lastly, the
patient was prescribed eighty-one milligrams of aspirin daily and ten milligrams of lipitor every
night at bedtime.
When it comes to drug nutrient interactions, each drug interacts differently to food. For
Lopressor, it should be taken with or after meals to be absorbed more effectively. Lisinopril and
high amounts of potassium in the diet are not recommended. A patient should avoid taking a salt
substitute while on lisinopril. When it comes to lipitor, grapefruit and grapefruit juice should be
avoided. Together, the two can cause adverse effects on the organs of the body. Alcohol should
be avoided when taking any medication. No one should stop taking medication without speaking
to their doctor first.
Long Term Plan
The patient has been NPO since surgery. A clear liquid diet is recommended post-surgery.
At this time, caffeine should be avoided. Diet progression to soft foods as tolerated. The soft diet
should be low in sodium (less than 2300 milligrams per day), saturated fat (less than 7% total
calories per day), and cholesterol (less than 200 milligrams per day). Dietary needs should be
provided as four to six small, frequent meals each day. As this diet is tolerated, patient should
progress to a Therapeutic Lifestyle Change diet for long-term nutritional support.
It is recommended that the patient adapt to following the Therapeutic Lifestyle Change
(TLC) dietary guidelines to improve his overall health status and reduce his risk for future heartrelated problems and diseases. A diet of 2035 calories per day is recommended for gradual
weight loss of to a pound per week. To aid with weight loss and to increase HDL levels,
increased physical activity is recommended in the form of cardiac rehabilitation in which the
patient was referred post-surgery, and increased as part of daily activities as tolerated with doctor

Myocardial Infarction

approval, working up to thirty minutes, five times per week. Smoking cessation is highly
recommended to reduce risk and improve patients cardiovascular health.
The TLC diet focuses on restricting saturated fat and cholesterol, which are largely
associated with heart disease. Specific recommendations include consuming no more than 7% of
calories from saturated fat, and no more than 200 milligrams of cholesterol per day. To limit
saturated fat, the acronym CAGE may help in recognizing common foods that are high in
saturated fat and which should be avoided. CAGE stands for cheese, animal fat, got it away
from home, and extra high-fat commercial products. Such foods should be avoided and replaced
with monounsaturated or polyunsaturated fats that may be more beneficial. Being that saturated
fat has the greatest influence on increasing LDL levels, it is very important to limit it in the diet
to reduce the risk for plaque development which may lead to a stroke or heart attack.
Omega 3 fatty acids, soluble fiber, and plant sterols are recommended for their ability to
improve cholesterol status. Omega 3 fatty acids, found in salmon and other fatty fish, help lower
LDL cholesterol, and should be included in the diet. Meats, fish, and poultry should not be
consumed in excess of five ounces per day. Soluble fiber, found in oats, apples, soy, barley, and
legumes are recommended as they help lower LDL cholesterol levels as well. It is recommended
that the patient consume 20 to 30 grams of fiber per day. Lastly, plant sterols may inhibit
cholesterol absorption and lower the risk of heart disease, and 1.3 grams should be consumed
with other foods in two separate meals per day. These recommendations are suggested in
addition to 2 to 4 servings of fruit, and 3 to 5 servings of vegetables per day.
The patients blood lipids should be monitored on a regular basis, along with his weight
and waist circumference. To ensure acceptable adherence to the dietary changes and success in
weight reduction, continuation of nutritional counseling for the patient and his wife is

Myocardial Infarction

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recommended to address any challenges or intolerances that may arise. It is important to include
the patients wife in the nutritional counseling as she is responsible for purchasing and preparing
food for the patient.
Alternative Therapies
Various vitamin, mineral, and herbal supplements have been suggested and used as
alternative methods to treat and prevent myocardial infarctions, also known as heart attacks.
Individuals at high risk for heart disease, or those who already have heart disease may benefit
from supplementation as a means to lower or reduce risk factors, or better manage the disease to
reduce symptoms and improve health.
There has been conflicting evidence on the effect of supplementing B vitamins and a
reduced risk for heart disease. Some B vitamins, such as folate, B6, and B12, lower plasma
homocysteine levels, an amino acid that has been linked to increased risk of heart disease and
stroke (5). While some research suggests supplementing these B vitamins will result in decreased
risk of heart disease and prevent cardiovascular events, other researchers have found this is not
the case. Galan et. al found that while supplementation resulted in decreased plasma
homocysteine levels as expected, it had no effect on preventing major cardiovascular events,
such as myocardial infarctions or strokes (5). While supplementing these B vitamins may not
reduce risk for heart disease, they are useful in lowering homocysteine levels. To reduce plasma
homocysteine levels, supplement folic acid at 400 micrograms per day, B6 at 25 to 100
milligrams per day, and B12 at 2 to 100 micrograms per day (6).
Supplementing 1 to 4 grams per day of omega 3 fatty acids in the form of fish oil, may
reduce risk factors such as preventing atherosclerotic plaque formation, and lowering blood
pressure and serum triglyceride levels (6). It is also suggested that omega-3 fatty acids have an

Myocardial Infarction

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anti-arrhythmic effect which may protect against cardiovascular events (5). However, there is
still conflicting research on whether omega 3 supplementation actually prevents cardiovascular
events from occurring rather than reducing risk factors. Omega 3 fatty acids thin the blood, and
should be used with caution and under doctor supervision if used in conjunction with
medications aimed at thinning the blood as well. At least two servings of fatty fish per week will
provide substantial omega-3 fatty acids as well.
The amino acid, L-carnitine, may protect against future heart attacks as well as prevent
heart failure if taken immediately following a heart attack (6). Supplementation of 4 to 6 grams
per day of L-carnitine is recommended, however, it may interfere with other medications
(thyroid and blood-thinners).
Hawthorn, or Crataegus monogyna, is an herb that contains important polyphenols
rutin and quercetin, and has been used to treat cardiovascular diseases for many years (6). This
herb is administered in multiple doses totaling 160 to 1800 milligrams per day. Hawthorn
exhibits antioxidant properties that lower high cholesterol and blood pressure, and may also
prevent plaque development. This herb may interfere with medications used to treat heart disease
and hypertension.
Garlic, either fresh or in supplemental form, has been shown to help lower cholesterol,
remove plaque, and prevent blood clots. Additionally, in individuals who have already had a
heart attack, research has shown garlic supplementation may reduce the likelihood of a second
heart attack. An effective dose of 900 milligrams per day of garlic powder is recommended.
Garlic supplementation may interfere with other medications (blood-thinners and those used to
treat HIV/AIDS).

Myocardial Infarction

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Bilberry, also known as Vaccinium myrtillus, has been used for many years to treat heart
disease, but has also been used to prevent diabetes (6). A fruit, bilberry contains flavonoids that
exhibit antioxidant properties. The flavonoids in bilberries may strengthen blood vessels,
improve circulation, and prevent the formation of blood clots in arteries by preventing damage to
LDL cholesterol. Consuming this fruit may interfere with other medications (blood-thinners).
Consuming green tea on a regular basis may help individuals lose weight and lower
cholesterol. These beneficial effects may in turn lower the risk of having a heart attack (6).
Answers to questions
1. Mr. Klosterman had a myocardial infarction. Explain what happened to his heart.
When a person has a myocardial infarction their heart has lost oxygen supply. The coronary
arteries have had an obstruction of sorts. The arteries become narrow and rigid, usually from a
build up of plaque over time. Sometimes plaque can break into pieces, causing blood to rush to
the site. Blood begins to clot around the broken pieces of plaque, causing a blood clot. Blood
transports oxygen to the heart, but with a lack of blood flow, the amount of oxygen getting to the
heart is not enough to supply it. Also, because the tissue is inflammed, enzymes can leak into the
blood. There is usually damage to the heart after a myocardial infarction, but the amount of
damage depends on the size of artery, how much blood flow was coming through that artery, and
the time between injuring the heart and receiving treatment.
4. After his infarction and procedure on admission, Mr. Klosterman was hospitalized.
What diet should he be prescribed initially?
After the shock of the myocardial infarction resolves, Mr. Klosterman should be prescribed a
clear liquid diet with no caffeine. If he is tolerating a clear liquid diet, he can advance to a soft
diet with low sodium. Small, frequent meals are ideal to slowly reintroduce food into the body

Myocardial Infarction

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while still getting plenty of nutrients. Mr. Klosterman would need to be tested for dysphagia as
well.
9. This 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 need. How many grams of
protein should he have daily?
10(166/2.2) + 6.25(70X2.54) - 5(61) + 5 = 1566
1566(1.3)= 2035

2035(1.3) = 2646

EER: 2035 - 2650 calories per day

166/2.2 = 76(1.0) = 76

76(1.3) = 98

Protein Needs: 76-98 grams or protein daily

10. What is the range of a healthy body weight at a normal BMI?
Mr. Klostermans current BMI at one hundred eighty-five pounds is 26.6. A normal BMI ranges
from 18.5 to 24.9 in adults. The range of a healthy body weight at a normal BMI is between one
hundred thirty-two and one hundred seventy-three.
11. Calculate the total number of calories he consumed as well as the energy distribution
of calories for protein, carbohydrate, and fat. Use the exchange system.
Meal/Snack

Exchanges

Mid-Morning

1 large cinnamon raisin

bagel
1 tbsp fat-free cream
cheese
8 oz orange juice

CHO

Protein

Fat

15

15

Myocardial Infarction
Meal/Snack

Exchanges
coffee

Lunch

CHO

Protein

Fat

1 c. canned vegetable soup

15

sandwich with 4oz roast

beef

30

34

12

lettuce, tomato, dill pickles

10

10

1 small apple

15

8 oz 2% milk

12

42

18

60

12

2 tsp margarine

10

1/2 c. green beans

1/2 c. coleslaw (cabbage

with 1 tbsp salad dressing)

45

10

2 tsp mayonnaise

Dinner

14

2 lean pork chops (3oz

each)
1 large baked potato

1 slice of apple pie

Myocardial Infarction

15

Meal/Snack

Exchanges

CHO

Snack

8 oz. 2% milk

12

1 oz. pretzels

15

254

118

75

1016

472

675

46.9%

21.8%

31.2%

Total Grams

Total Kcals
Total %

2163

Protein

Fat

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Reference Page
1. NCM Nutrition Care Manual eat right. Public Home Page. Available at:
https://www.nutritioncaremanual.org/topic.cfm?ncm_toc_id=8580. Accessed February 25, 2016.
2. Fanaroff AC, Rymer JA, Goldstein SA. Acute Coronary Syndrome. Journal of the American
Medical Association 2015;314(18).3.
3. Heart Failure. EAL. Available at:
http://www.andeal.org/topic.cfmcat=1533&evidence_summary_id=250205&highlight=mnt with
myocardial infarction&home=1. Accessed February 25, 2016.
4. Tchwenko S, Fleming E, Perry GS. Aspirin Use for the Primary Prevention of Myocardial
Infarction Among Men in North Carolina, 2013. Prev Chronic Dis 2015;12:150342.
5. Galan P, Kesse-Guyot E, Czernichow S, Briancon S, Blacher J, Hercber S. Effects of B
vitamins and omega 3 fatty acids on cardiovascular diseases: a randomized placebo controlled
trial. BMJ. 2010;341:c6273.

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6. Myocardial infarction. University of Maryland Medical Center. 2016.

Available at: http://umm.edu/health/medical/altmed/condition/myocardialinfarction. Accessed March 14, 2016.

ADIME NOTE
Assessment:
Patient is a 510, 185lb male, 61 yo.
BMI 26.6
Medical Dx: Myocardial infarction
Labs: Cholesterol 200 mg/dL, HDL-cholesterol 33 mg/dL, LDL-cholesterol 141 mg/dL.
Medications: None.
Allergies: Sulfa drugs.
Diet History: 2163 total kcals- 46.9% kcals from carbohydrates, 21.8% kcals from
protein, 31.2% kcals from fat.
Current Diet: NPO.
EER: 2035-2650 kcals per day.
Protein requirements: 76-98 grams per day.

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Diagnosis:
Inappropriate intake of food fats, specifically saturated fat and cholesterol (NI-51.3) as
related to dietary consumption of animal fats, dairy fats, and high-fat dessert, as evidenced by an
estimated oral intake of saturated fat greater than 7% total daily kcals, cholesterol intake greater
than 200mg per day, and LDL levels greater than 100 mg/dL.
Intervention:
Recommend clear liquid diet, without caffeine, and progress to soft foods to standard diet
as tolerated.
Recommend 2,035 kcal per day.
Recommend 80 grams of protein per day.
Recommend no more than 200mg of cholesterol per day.
Recommend 4-6 smaller, more frequent meals per day.
Recommend no more than 15 grams saturated fat per day.
Recommend 25-30 grams of fiber per day, such as apples, oats, whole grains, barley, soy,
and legumes.
Recommend blood lipid panel in three weeks.
Recommend 2 grams plant sterols per day.
Recommend gradual physical activity under physician supervision.
Recommend quit smoking.
Recommend 2650 mLs fluid per day.
Recommend 2-3 servings of fruit per day.
Recommend 3-5 servings of vegetables per day.
Recommend to 1 cup of nuts per day.

Myocardial Infarction
Monitoring/Evaluation:
Monitor blood lipid levels.
Monitor weight, weight changes, and waist circumference.
Monitor tolerance to diet.
Monitor physical activity patterns.

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