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MNT for Heart Failure and Transplant. Congestive Heart Failure (CHF). A clinical syndrome characterized by progressive deterioration of left ventricular function, inadequate tissue perfusion, fatigue, shortness of breath, and congestion. Congestive Heart Failure (CHF) —cont’d.

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MNT for Heart Failure and Transplant

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Mnt for heart failure and transplant l.jpg

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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Congestive Heart Failure (CHF) —cont’d

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

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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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  • 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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  • 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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  • 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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  • 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 FreeLess than 5 mg

Very Low Sodium35 mg or less

Low Sodium140 mg or less

Reduced SodiumAt least 25% less sodium than regular food

Light Sodium50% less sodium

Unsalted,No salt added during processing Without Added Salt, No Salt Added

Lightly Salted50% 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 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


Thiamin supplementation

Small frequent feedings


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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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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

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ADA Nutrition Care Manual Education Resources


  • Heart failure Nutrition Therapy

  • Hypertension Nutrition Therapy

  • DASH Diet guidelines

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  • 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.

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