HYPERTENSION AND HEART DISEASES

• Heart Failure
• Hypertension

 

---

Heart Failure

Adults

 

Best time to refer to the dietician:

• after diagnosis of heart failure class II, III or IV NYHA (New York Heart Association), which may be combined with unintended weight loss > 6% of the original weight in the last 6-12 months.

 

Relevant information for the dietician:

• Diagnosis: heart failure + class, any comorbid conditions
• Symptoms: edema, ascites, anorexia, dyspnea
• Medication: diuretics, ACE-inhibitors, infusion fluids
• Other: height, (changes in) weight, extent of fluid restriction.

 

Decision tree: Dietetic Diagnosis, Treatment and Care for Heart Failure

 

Determination of the diagnosis and treatment in dietetic care for heart failure   Goal and practice of dietetic care	Referral diagnosis, dietary prescription: Restricted sodium, 2400 mg [3]   Or   Restricted sodium, 2000 mg [3] and restricted fluids 1500-2000 ml [4]   In combination with: - Constipation [5]	One-time group patient education [14]
NYHA I, II and III [2]	Referral diagnosis, dietary prescription: Restricted sodium, 2400 mg [3]   Or   Restricted sodium, 2000 mg [3] and restricted fluids 1500-2000 ml [4]   In combination with: - Alcoholic cardiomyopathy [6] - Unwanted weight loss [7] - Cardiac cachexia [7] - BMI < 30 [7] - Obesity BMI > 30 [8] - Acute and/or chronic renal insufficiency [9] - Diabetes Mellitus [10] - Hypercholesterolemia [11] - Ileostomy [12]   Or, when the referring physician deems individual dietetic treatment necessary for the patient [13]	When there are problems in the practical application of sodium and fluid restriction [15]     If there is a change in the health status [15]
		Individual treatment [16]
NYHA IV [2]	Referral diagnosis, dietary prescription: Low sodium, 2000 mg [3] and fluid restriction 1500-2000 ml [4]	Click on the numbers between [ ] for more information.   Click here for a complete list of the notes referred to in the decision tree.

 

 

Aims of the diet:

• reduce fluid retention
• support blood pressure control
• maintain/improve nutritional status.

 

Characteristics of the diet:

• low salt: 2000-2400 mg. Distribute salt intake carefully over the course of the day; avoid sodium peaks.
• fluid restriction: for NYHA class III and IV, not to exceed 1.5-2 L of total fluids (including infusion fluids)
• Restricted sodium: 2000-2400 mg. Distribute salt intake carefully over the course of the day; avoid sodium peaks.
• Fluid restriction: for NYHA class III and IV, not to exceed 1.5-2 L total fluids (including infusion fluids)
• If diuretics are used which result in potassium excretion: ensure a sufficient intake of potassium.
• If potassium-retaining diuretics are used in combination with ACE inhibitors: no potassium-rich salt-replacing mineral mixtures when serum potassium is > 5.5 mmol/L
• Ensure sufficient energy
• Alcohol intake according to national Nutritional Guidelines. Alcohol abstinence in the case of alcohol-induced cardiomyopathy.
• Lifestyle recommendations:

• smoking cessation
• regular physical exercise

• If BMI > 30 kg/m²: maintain/achieve a healthy body weight.

 

Treatment time:

• Care level 2*, see “Dietician’s working methods.”

 

Specific remarks:

• Edema and ascites may mask the weight loss.
• Some medications, such as antibiotics and vitamin and mineral complexes, may contain sodium.

 

References:

ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2008. Eur J Heart Fail. 2008 Oct;10(10):933-89

 

Multidisciplinaire Richtlijn Hartfalen 2010 “in press”

 

Heart Failure was updated by Madeleine Duin, dietician at Hagaziekenhuis and Inge de Kok, dietician at Franciscus Ziekenhuis, also on behalf of Nederlandse Werkgroep Diëtisten Cardiologie (NWDC).

 

---

Hypertension

Adults

 

Best time to refer to the dietician:

• when there is:

• average (of 2 measurements) systolic blood pressure of 140 mm Hg or higher
• use of antihypertensive medications.

 

Relevant information for the dietician:

• Diagnosis: hypertension, any comorbid conditions
• Symptoms: headache, dizziness
• Medication: antihypertensive drugs, diuretics
• Other: height, (changes in) weight, risk profile (overweight, smoking, excessive alcohol consumption, too little physical exercise, incomplete nutritional intake, use of medications, familial predisposition).

 

Aims of the diet:

• reduce blood pressure
• support antihypertensive medication

 

Characteristics of the diet:

• based on national Nutritional Guidelines, with extra attention to:

• low sodium diet, up to max. 2400 mg sodium
• saturated fats: should account for 10% or less of total caloric intake
• trans-fatty acids: < 1% of total caloric intake
• 150-200 g vegetables and 2 servings of fruit per day
• fish eaten twice weekly, one of which is a fatty fish (with low sodium)
• alcohol according to recommendations (women a maximum of 1 standard glass and men a maximum of 2 standard glasses per day, spread out over the course of the week).

• restricted glycyrrhizic acid
• when potassium-retaining diuretics are being taken in combination with ACE inhibitors: no potassium-rich mineral mixtures when serum potassium is > 5.5 mmol/L
• If diuretics are used which result in potassium excretion: ensure a sufficient intake of potassium in the diet.
• lifestyle recommendations:

• if overweight, see “Overweight”
• adequate physical exercise
• smoking cessation

 

Treatment time:

• Care level 1, see “Dietician’s working methods.”

 

Specific remarks:

• Restriction of sodium in the diet always results in lowering blood pressure; the effect seems greater in those who have elevated blood pressure, the elderly, blacks and overweight individuals.
• The effect of a low salt diet depends on the individual sodium sensitivity. The greater the sodium restriction, the greater it seems to affect blood pressure.
• Some effervescent tablets contain sodium.

 

References:

CBO. Multidisciplinaire richtlijn Cardiovasculair risicomanagement. Utrecht: 2006

 

NHG. Standaard Cardiovasculair risicomanagement M84. Utrecht: 2006 Gezondheidsraad.

 

Keukenzout en bloeddruk. Den Haag: Gezondheidsraad, 2000; publicatie nr 2000/13. ISBN 90- 5549- 324- 4

 

Hypertension was updated by Antoinette Ogink-Jansman, dietician at Medisch Spectrum Twente te Enschede and Saneille Bolscher, dietician at Thuiszorg Carint, also on behalf of the Nederlandse Netwerk Diëtisten Cardiologie (NWDC).