1

NUTRITION of The
CARDIOVASCULER SYSTEM
SYARIF HUSIN
BLOK 10
2
INTRODUCTION
In United States; 37,3% cause of death, 1
in every 2,7 deaths.
Atherosclerosis, ischemic heart disease
and hypertension is a risk factor for all
others cardiovasculer disease.
Determined cardiovasculer disease:
hereditary, environmental and lifestyle.
Lifestyle: Prevention and treatment of
cardiovasculer disase.
3
A. HYPERTENSION
Goal treatment:
1. Reduction risk of cardiovascular and
renal disease.
2. Reduction BP to < 140/80 mmHg ( or to
130/80 mmHg with diabetes and cronic
renal disease)
Plan treatment: weight reduction, physical
activity, nutrition therapy, pharmacological
intervention.
4
NUTRITION THERAPY
Lifestyle modification and nutrition
therapy.
Increased physical activity
Smoking cessation
Weight loss
Reduction of sodium and alcohol
5
NUTRITION INTERVENTIONS
Decrease sodium, saturated fat
and alcohol.
Increase calsium, potassium and
fiber : efectife lowering of BP.
Sodium restriction reduce
incidence Cardiovascular
Disease, Renal Disease and
Stroke.

6
INCREASED PHYSICAL
ACTIVITY
DASH : Recommended 30-60
min of aerobic minimum four
days per week
7
SMOKING CESSATION
To achieve success, the
smoker should also be able to
identify his or her reasons for
quitting
8
WEIGHT LOSS
Weight loss of greater than 5 kg reduced
both diastolic and systolic.
An approximate 20 lb weight loss will
result in lowered systolic.
Waist circumference: independent
predictor of hypertension risk.
BMI > 35 risk factor.
9
REDUCTION SODIUM
The Dietary Guidelines for Americans
recommend an intake of less than 2300 mg of
sodium, equivalent 6 g sodium chloride.
Terapy hypertension:
Mild : 1,5 2,5 g Na (3,75 6,25 gNaCl)
Moderate: 0,5-1,5 g Na (1,25 - 3,75g NaCl)
Severe : < 0,5 g Na ( < 1,25 g NaCl)
10
EFFECTS of LIFESTYLE MODIFICATION to
MANAGE HYPERTENSION
RECOMMENDATION

Weight reduction (BMI 18,5-
24,9).
Diet rich fruits, vegetables
and low fat.
Intake sodium 2,4 g ( 6 g
sodium chloride)
Aerobic (walking) 30
min/day.

AVERAGE SYSTOLIC
REDUCTION
5 20 mmHg/10 Kg

8 14 mm Hg

2 - 8 mmHg

4 9 mm Hg

11
B. ATHEROSCLEROSIS
Thickening of the blood vessel
walls specifically caused by
the presence of plaque.
12
RISK FACTORS
Family history
Age
Sex
Obesity
Dyslipidemia

Hypertension
Diabetes
Physical
inactivity
Smoking

13
ALTERABLE RISK FACTORS
Obesity
Dyslipidemia
Hypertension
Physical inactivity
Atherogenic diet
Smoking

14
OBESITY
Risk factor of atherosclerosis
Waist circumference : Men >102 cm
Women > 88 cm.
Abdominal fat and insulin resistance
Hypothyroidism leading to obesity :
risk of atherosclerosis
Poorly managed hypothyroidism :
greater progression of coronary
atherosclerosis


15
INCREASING PHYSICAL
ACTIVITY
Lowering blood pressure and
triglycerides.
Increasing HDL
Improving endothelial fucntion
Decreasing platelet aggregation


16
ATHEROGENIC DIET
Westernized diet : high
saturated fat and low fiber.

Palembang diet ?
17
SMOKERS
Higher levels of serum cholesterol,
triglycerides and LDL cholesterol.
Lower HDL cholesterol
Endothelial dysfucntion, inflammation and
modification of lipids
Nitric oxide : endothelial relaxasion.
Inflammatory : increased leukocyte count
and proinflammatory cytokines
18
ATP III GUIDELINES
STEP 1
Determine lipoprotein levels (lipoprotein profile)

STEP 2
Identify presence of clinical atherosclerotic
disease that confers high risk for coronary heart
disease (CHD) events (CHD risk equivalent):
Clinical CHD
Symptomatic carotid artery disease
Peripheral arterial disease
Abdominal aortic aneursym
19
ATP III next
STEP 3
Determine presence of major risk factors
(other than LDL): Major risk factors
(Exclusive of LDL Cholesterol) that Modify
LDL Goals.
Cigarette smoking.
Hypertension (BP140/90 mmHg or on
antihypertensive medication).
Low HDL choselterol (<40mg/dL).
20
ATP III next
STEP 3
Family history of premature CHD (CHD in
male first degree relative <55 years; CHD
in female first degree relative <65years).
Age (men 45 years; women 55 years).
HDL cholesterol 60 mg/dl counts as a
negative risk factors; its presence
removes one risk factor from the total
count.
21
ATP III next
STEP 4
If 2 + risk factors (other than LDL) are
present without CHD or CHD risk
equivalent, asses 10 year (short term)
CHD risk.
Three levels of 10-year risk:
> 20% --- CHD risk equivalent
10 20%
< 10%
22
ATP III next
STEP 5
Determine risk category
Establish LDL goal of therapy
Determine need for Therapeutic
Lifestyle Changes (TLC)
Determine level for drug consideration
23
QUIDELINE THERAPY
Risk
category
CHD or
CHD Risk
Equivalent
(10-year
risk>20%)
LDL goal
< 100 mg/dl
LDL+TLC
100mg/dl
LDL+Drug
130/mg/dl
(100-
129mg/dl
+drug)
2 + Risk
factors(10-
year risk
20%)
< 130 mg/dl 130 mg/dl 10-year risk
10-20%:
130mg/dl
10-year risk
<10%:
160mg/dl
24
QUIDELINE THERAPY
Risk
category

0-1 Risk
Factor
LDL goal

< 160 mg/dl
LDL + TLC

160 mg/dl
LDL+Drug

190mg/dl
(160-189
mg/dl: LDL
lowering
drug
25
ATP III next
STEP 6
Initiate therapeutic lifestyle changes (TLC) if
above goal
TLC diet :
Saturated fat < 7% of cal, cholesterol < 200
mg/ day
Consider increased viscous (soluble) fiber (10-
15 g/day) and plant stanols/ sterols (2 g/day)
as therapeutic options to enhance LDL
lowering
Weight management
Increased physical activity
26
ATP III next
STEP 7
Consider adding drug therapy if LDL
exceeds levels shown in step 5 table :
Consider drug simultaneously with
TLC for CHD and CHD equivalents
Consider adding drug to TLC after 3
months for other risk categories
27
ATP III next
STEP 8
Identify metabolic syndrome and treat, if present, after 3
months TLC
Clinical Identification of the Metabolic Syndrome Any 3
of the risk factors defined
Treatment of the metabolic syndrome
a. Treat underlying causes (overweight/obesity and
physical inactivity)
Intensify weight management
Increase physical activity
b. Treat lipid and non-lipid factors if they persist despite
these lifestyle therapies:
Treat hypertension
Use aspirin for CHD patients to reduce prothrombotic
state
Treat elevated triglycerides and/or low HDL (as shown in
step 9 below)



28
ATP III next
STEP 9
Treat elevated triglycerides
ATP III Classification of serum Triglycerides
< 150 Normal
150-199 Borderline high
200-499 High
500 Very high
Treatment of elevated triglycerides (150mg/dl)
Primary aim of therapy is to reach LDL goal
Intensify weight management
Increase physical activity
If triglycerides are200 mg/dl after, LDL goal is reached,
set secondary goal for non-LDL cholesterol (total-
HDL)30 mg/dl higher than LDL goal
Comparison of LDL cholesterol and non-HDL cholesterol
goals for three risk categories


29
Step 9 next
Risk category

CHD and CHD
Risk
Equivalent(10-
years risk for
CHD >20%)
LDL goal (mg/dl)




< 100
Non HDL Goal
(mg/dl)



<130
Multiple(2+)
Risk factors and
10 years
risk20%

<130

<160
0-1 Risk Factors <160 <190
30
STEP 9 next
If triglycerides 200-499 mg/dl after LDL goal is
reached, consider adding drug if needed to
reach non-HDL goal :
Intensify therapy with LDL - lowering drug, or
Add nicotinic acid or fibrate to further lower
VLDL
If triglycerides 500 mg/dl, first lower triglycerides
to prevent pancreatitis :
Very- low- fat diet (15% of calories from fat)
Weight management and physical activity
Fibrate or nicotinic acid
When triglycerides < 500 mg/dl, turn to LDL
lowering therapy
31
STEP 9 next
Treatment of low HDL cholesterol
(<40mg/dl)
First reach LDL goal, then :
Intensify weight management and
increase physical activity
If triglycerides 200-499mg/dl, achieve non-
HDL goal
If triglycerides <200mg/dl (isolated low
HDL) in CHD or CHD equivalent, consider
nicotinic acid or fibrate
32
C. ISCHEMIC HEART DISEASE
Nurition Implications
Immediate medical care after MI
strives to reduce pain, stabilize
cardiac function and when
appropriate, begin the
rehabilitation post MI. Nutrition
therapy after MI will be consistent
with these medical goal.
33
IHD next
Nutrition interventions
Many institutions treatment protocols limit
initial oral intake to clear liquids with out
caffeine in order to prevent arrytmias and
to decrease risk of vomiting or aspiration.
Oral diets usually progress from liquids to
soft, easily chewed foods with smaller,
more frequent meals.
Therapy lifestyle.
34
D. HEART FAILURE
Nutrition implications
Nutritional care during CHF is difficult.
Nutritional therapy that restricts both
sodium and fluid is crucial to control
acute symptoms and may assist with
reducing with the overall work of the
heart.
Difficulty eating and cardiac cachexia.
35
CACHEXIA in HF
Cachexua in HF include myocardial nutrient
deficiencies of:
L-carnitine
Coenzyme Q10
Creatine
Thiamine
Taurine




36
Nurition interventions
Restrictions sodium and fluid.
Correction of nutrient deficiencies.
Nutrition education for increasing nutrient
density and making food choice that
enhance oral intake.
Sodium 2000 mg (Standard initial
recommendation).
Fluid requirement 1 ml/kcal or 35 ml/Kg
BB.
37
E. STROKE and ANEURYSM
Enteral nutrition support will be
necessary if an oral diet cannot
meet nutritional needs.
Evidence support early initiation
of nutritional support to prevent
complications, reduce hospital
stay and promote rehabilition.