Healthy eating tips for heart patients

After heart surgery most patients have a very poor appetite for the first three months.

The first month the medical advice is to eat anything. This isn’t a problem as the body needs extra fuel for healing, but in reality many don’t eat much because food doesn’t taste the same or smell the same. This is thought to be an effect from anesthesia. Most of the time is takes 1-3 months for the taste and appetite to come back to normal. After the first month, patients are instructed to eat a heart healthy diet. That can be a little vague, and different health care practitioners have conflicting ideas of what a heart healthy diet is. In my career it was challenging as one physician  might promote a Dean Ornish vegetarian diet, and the next might promote a Mediterranean  diet, or American Heart Association, Dash diet etc. There are common nutritional principles that all heart patients should try to adhere to.

 

Tip #1: Know your Caloric needs.

How many calories do you actually need every day? Here are a couple of resources that will help guide you:

Tip #2: Enjoy your food, but eat mindfully

Take the time to fully enjoy your food while you’re eating it (instead of just devouring everything on your plate). Pay attention to hunger and fullness cues before, during and after meals. Be mindful of them and use them to tell you when you’re should be full. Remember it takes about 20 minutes for the food you heave eaten to signal your brain if you are still hungry. For this reason eating slowly, and being aware of the quantity, rather than listening for your body to say it is full. It is ok not to finish everything on your plate.

#3: Avoid oversized portions.

Learn what is the true portion size of the food you are eating. If you are going to overeat eat a larger portion of vegetables. Try using a smaller plate, bowl and glass.  When you’re eating out, try splitting a dish or take home part of your meal.

Tip #4: Foods to eat more often.

 These are all the foods you know are good for you: fruits, vegetables, whole grains, low-fat dairy, etc. Make them the basis for meals and snacks. Try getting 2 cups of veggies, 1.5 cups of fruit and 3 servings of low-fat dairy or lean protein each day.

Tip #5: Decrease the unhealthy foods in the diet

Foods high in solid fats, added sugars, and salt (e.g. cakes, cookies, ice cream, pizza, fast food, sweetened drinks, etc.) should be cut back in the diet. Try to avoid these as part of your daily meal intake.

Tip #6: Hydrate with healthy fluids

Drink water, sparkling water mixed with a splash of juice, tea, or sparkling water instead of high calorie drinks. High calorie drinks include soda, alcoholic beverages, juices, energy drinks and sports drinks. If you are on a fluid limitation, poor the recommended amount of fluid in a container and use it to help you visualize the amount of liquid you should have each day.

Tip #7: Pay attention to added sodium in foods

 Read the labels and choose the lower sodium option for breads, canned goods, and soups. Choose packaged products with labels like “low sodium,” “no salt added,” or “reduced sodium.” Fresh, foods have the least sodium. If it comes from a box, a can, or is ready to eat, it is probably loaded in sodium. Water added usually means sodium added, this is common in poultry. 1500 mgs a day is the recommended amount for heart patients. I had one patient that lost 45 lbs, simply by tracking sodium and adhering to recommendations, it has so far saved him from the disabling CHF symptoms he was experiencing.

Sodium sources are not only food! The medicine cabinet is often an unrecognized source of sodium. Many prescription and non-prescription drugs, such as antacids, ibuprofen, sleep aids, heartburn relievers and cold medicines, have large amounts of sodium. Some antacids have upwards of 250 mg of sodium per tablet. Before taking any medication, it’s always best to consult a doctor, especially if you’re watching your sodium intake for health purposes.  

Most people are unaware of the amount of sodium that comes from our tap water. It varies significantly from state to state, but the public health department in any area should be able to provide information on the exact amount of sodium in the water. Even if a home employs a water-softening system, there’s still a certain amount of sodium in the drinking water, since many of these units use sodium as a softening agent. The amount is solely dependent on the type of system installed and the hardness of the water in that area. Bottled waters, especially mineral waters, can also contain significant amounts of sodium.

Tip #8: Keep your dairy low-fat 

Drinking whole milk is the equivalent of 3 pats of butter, 2% is 2 pats of butter, 1% is one pat of butter. And low-fat cheese is a good substitute for full-fat cheese, but if you are going to use regular cheese, try using a smaller quantity.

 

Tip #9: Get healthy fats in your diet every day

 When you’re cooking, choose oils high in monounsaturated fats like olive or canola oil. These are better choices, but don’t use large amounts, as oil is high in calories. A pump oil spray is a good way of adding a little oil and avoiding chemicals. Avoid products containing trans fats. Read the labels and avoid hydrogenated oil or shortening or partially hydrogenated oils. This is the same as eating shortening.

Tip #10: Get out of  your comfort zone

Many people won’t try new or unusual foods. They are stuck in a rut of eating the same foods, because it is what they know and like. Try new foods regularly. Especially try different vegetables. If you always cook your foods a certain way, challenge yourself, try sauteing, steaming, fresh, juicing, combining with other foods, adding nuts or seeds to foods.

Tip #11: Know your issues

Some heart patients have to be very aware of vitamin Kin diet, if they are on coumadinKeep your intake of foods rich in vitamin K about the same each day. For example, you may plan to eat only ½ cup of these foods per day. If you like these foods and eat them often, you can eat more, but be consistent. It is a common misconception for patients to think they have to avoid foods rich in Vitamin K, it is more important however to get these in the diet, but as mentioned be consistent and get the same amount each day.

Other’s need to be more aware of the potassium or protein contents of foods.  Certain diseases (e.g., kidney disease and gastrointestinal disease with vomiting and diarrhea) and drugs, especially diuretics (‘water pills’), remove potassium from the body. Potassium supplements are taken to replace potassium losses and prevent potassium deficiency. If you can meet with a dietitian to help you understand what the sources of these nutrients are. If you can’t meet with a dietitian do your research, but don’t ignore the recommendations as many can be life threatening if not adhered to.

http://www.cdc.gov/salt/pdfs/Salt-tistics.

http://www.vaughns-1-pagers.com/food/vitamin-k-foods.htm

 http://www.livestrong.com/article/10349-identify-sources-sodium/#ixzz27lT6ptHG

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A lesson about the heart: Cardiac Output

Here is some information that is useful to know. It is a little in-depth when it comes to heart function, but I believe education is power and/or a sense of control when it comes to managing a chronic disease.  The more you know, the better you can work with your health care provider to help to manage it. 

Why are certain tests performed? An example is an echo is often performed 3-6 months following a heart attack. This allows the heart time for recovery and remodeling, and gives the healthcare provider a good idea of your cardiac output. Is your ejection fraction diminished, is the stroke volume lower thus decreasing the output? Is the cardiac output lower because the heart chamber is stretched, and weaker – inotropic effect, or due to medications? Does this place additional risk to you? When the ejection fraction is below 30% the risk for arrhythmia increases, thus precautionary measures such as Implanted Cardiac Defibrillators become an issue. Or vise versa if the heart function improved back to safe levels since the event there may no longer be the need, or those wearing external defibrillator vests may no longer be necessary.

The following came from Jewels of Clinical Medicine

What Is Cardiac Output?
Cardiac output is defined as the amount of blood pumped by the ventricles, the lower chambers of the heart, in one minute. Two factors determine cardiac output: stroke volume and heart rate. The equation used is: heart rate x stroke volume = cardiac output. A normal adult heart will have a cardiac output of approximately 4.7 litre( 5 quart) of blood per minute. Exercise will increase cardiac output, since it increases heart rate.

Heart rate
• The number of times the heart beats in one minute is the heart rate. In adults, the average heart rate is 60 to 100 beats per minute. Heart rates are usually higher in children and women. Differences in gender, size, age and fitness can affect the heart rate, as can some medications and conditions. Very fit people have lower resting heart rates. Heart rates increase when people are upset or excited.
Stroke Volume
• Stroke volume is the amount of blood pumped by the ventricles with each heartbeat. An average resting stroke volume is about 2 ounces (60 to 80 milliliters) per beat. Usually only 65 percent of the blood is pumped out of the ventricles during each beat. This is the normal ejection fraction value. Starling’s law of the heart and the inotropic effect are two things that can alter the force of the contraction, causing more of the blood to be expelled with each beat.

Starling’s Law of the Heart
• Starling’s law depends on the amount of stretch in the cardiac muscle fibers. If there is an increase in the volume of the blood pumped into the heart, that increase causes the ventricle to stretch, which in turn increases the force of contraction and the cardiac output. If less blood volume enters the heart, the ventricle does not stretch as much, the contraction is less forceful, and the cardiac output is decreased. This is important to ensure that the heart pumps out only what it receives at a given time.

Inotropic Effect
• If the strength of the contraction is increased without increasing the stretch of the cardiac fibers, cardiac output will be increased. Certain hormones and medications can cause this to happen. Sympathetic nerve stimulation of the heart, for example when a person is scared or excited, is another mechanism of the inotropic effect. Some drugs may also cause a negative inotropic effect and will decrease the cardiac output, which can lead to heart failure. It is extremely important to closely monitor the usage of any medication that has a negative inotropic effect on the heart.

Interesting Fact
• The amount of blood pumping though the body of the average adult is about 5 liters. That is equivalent to the average cardiac output. That means that the heart pumps the total amount of blood in the body every minute.

Heart Disease Health Centre- Dr.Yaseer SK

Diabetes blood sugar and A1c elevation tied to heart disease

There  is a strong link  in people with diabetes who also have high cholesterol  Cardiovascular disease  is much more prevalent if their  Hemoglobin A1c is chronically elevated. This significant contribution by elevated HbA1c to increased CVD is independent of statin therapy, and thus requires appropriate HbA1c management in addition to lipids reduction. It is vitally important that any individual with known heart disease and diabetes gets their hemoglobin A1c measured approximately 4 times per year by their primary health care provider. Once a year is not enough. Tight control is imperative. If the blood sugars are constantly running high the vessels that deliver blood to the heart are constantly inflamed setting the stage for further heart issues.

There are many hemoglobin A1c calculators can be found on the internet. here is Medscapes version

http://reference.medscape.com/calculator/hemoglobin-a1c-est-plasma-glucose

Prevention measures to avoid blood clots

Common issues following hospitalization include blood clots. Patients often wonder why we force them to get out of bed and move. Prevention of blood clots in the legs and lungs is critical for recovery

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Peripheral Artery Disease

Heart patients often have Peripheral Artery Disease

Peripheral Artery Disease also known as PAD is when the arteries in the legs become narrowed or clogged with fatty deposits, or plaque. The buildup of plaque causes the arteries to harden and narrow, which is called atherosclerosis. It is the same process that causes heart disease. It doesn’t just happen in the heart it can occur elsewhere in the body and this is known as PAD.  When leg arteries are hardened and clogged, blood flow to the legs and feet is reduced. Lower-extremity PAD is a serious disease that affects about 8 million Americans. The hardened arteries found in people with PAD also put them at risk for hardening and narrowing of the arteries to the kidneys and the brain. That is why people with  heart disease are at risk for PAD, kidney disease and stroke.

How do I know if I have PAD?

Working in cardiac rehabilitation I would often encounter patients who ended up having peripheral artery disease and were unaware of it.  Some of the tell tale signs would be pain with walking, or complaining of wooden feeling in the legs when walking. Fatigue, tiredness or pain in your legs, thighs or buttocks that always happens when you walk but that goes away when you rest.  This discomfort often goes away within two to five minutes of rest. This is a  very classic symptom.  Another classic symptom is night pain in legs, calves, feet or toes that wakes you up. Many patients describe having to sit at the edge of the bed and dangle their feet or get up and walk to relieve the discomfort. Be alert as well for slow to heal wounds in the legs or feet, as the poor blood supply limits wound healing is another clue to peripheral artery disease. Changes in the color of your legs, or the temperature – often the limb feels cold, looks whitish or bluish.

Smoking and PAD

If  you are a heart patient and a smoker  you are very likely to have PAD.  Smoking is  the number one cause of PAD.  Studies show that smoking even half a pack of cigarettes per day may increase the risk of having PAD by 30 to 50 percent. If you do smoke it is imperative that you quit as soon as possible. A cardiologist I worked with would tell his patients if you are diabetic and smoke you will lose a limb to PAD it is a matter of when not if.

Diabetes and PAD

The other big risk factor is diabetes. Diabetes makes the arteries narrow and hard thus restricting blood flow. People with diabetes are at higher risk for having PAD.  Some studies have found that one out of three people with diabetes over age 50 has PAD, and PAD is even more common in African Americans and Hispanics who have diabetes.  The challenge of course with this is that if blood flow is reduced wounds do not heal properly, and limbs can become necrotic and require amputations. A challenge with diabetes is that often the patients with PAD will not get the classic leg pain symptoms. For this reason any diabetic with risk factors for PAD should have his/her legs checked regularly.

Testing for PAD

Testing for PAD includes palpating for pulses in the foot and ankle region. If pulses are not easily felt then the next step is a Doppler ABI – Ankle Brachial Index measurement. This is a painless test in which the blood pressure of the arms is compared to the blood pressures in the lower leg. If there is a large difference this suggests PAD.  Other imaging including CT scans may be done. The next step is a segmental MRA -magnetic resonance angiography,- like a heart catheterization  but looking at the vasculature below the heart. 

Treatment of PAD

Treatment is similar to the heart. If the disease is in the small vessels it is better to intervene with risk factor modification and exercise. Yes it hurts to walk but paradoxically walking is the best activity to help re route the blocked blood supply. The more a person walks the more likely they will develop what is known as collateral arteries around the blockage. Other risk factor modification issues include stopping smoking, lowering cholesterol, being physically active, and keeping blood pressure in control.

If the blockage is in primary arteries of the legs or kidneys then interventions include angioplasty, stenting and/or bypassing the blockages. These are all very similar to the interventions done for atherosclerosis of the heart. Once an intervention is done  it is important to understand the issue is not fixed. Like a car it will need continual maintenance. There is high probability that is will continue to develop further blockages even if you modify all the risk factors and walk regularly.

Exercise and PAD

Many Cardiac Rehabilitation programs will also offer a PAD walking program as well. This usually involves walking on a treadmill or riding a bike 5 days per week and working your way up to a one hour walk. Most patients who experience pain while walking think that sound impossible to walk one hour. The walking program is a graduated program in which one works their way up to one hour, and usually it isn’t a fast walk, but may include walking a grade. Most patients find it quite do able once started. Many find the support given through the rehabilitation programs makes all the difference, as they wouldn’t do it on their own, and the education received while attending gives them the understanding needed to cope with this chronic condition.

 From the Vascular Disease Foundation WHY WALK?

Walking can make a real difference for people with peripheral artery disease (PAD). Recent studies show that for many people with PAD, a structured walking program is one of the best treatments for reducing leg pain or cramps (claudication) when walking. In fact, studies show that over time a structured walking program is often more effective and can work better than medicine or surgery in helping people with PAD walk longer and further without having to stop due to pain.

A regular walking program will:

  • Let you do more and stay active.
  • Reduce stress and help you relax.
  • Help you control your blood glucose, blood pressure, cholesterol, and body weight.
  • Improve muscle tone.
  • Lower your chances of having a heart attack or stroke.
  • Give you peace of mind that you are taking care of your health.

For more information visit

http://vasculardisease.org/

Know your Nitro and Save your life

Nitroglycerine  Facts

One thing that always surprised me in cardiac rehabilitation was the understanding of using Nitroglycerin (nitro). I think over the years I saw and heard every way imaginable to ensure nitro tablet wouldn’t work if needed. Or the other one is when patients would carry it for years and then not use it when it is most appropriate to use. The take home message is if you are having discomfort that you suspect is heart related use a nitro ASAP.

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How Nitro works:

Nitroglycerin  dilates blood vessels that supply the areas of the heart where there is not enough oxygen thereby delivering oxygen to the heart tissue that needs it most.  The dilation of  veins and arteries  reduces the amount of blood returning to the heart so that the heart does less work and requires less blood and oxygen. Dilation of the arteries  lowers the pressure in the arteries against which the heart must pump. As a consequence, the heart works less and requires less blood and oxygen.

How to store Nitro:

Here is the thing Nitro is a very volatile compound. It breaks down rapidly with light, heat, oxygen, time and exposure to plastic. It is packed in a glass vial because plastic will leach the active ingredient out of it and all you have left is the inert ingredients that hold the tablet together. Therefore don’t transfer it to a container that is plastic, don’t put a couple in a baggy and put them in your wallet. Yes it is a pain in the butt to carry the bottle everyday, but find a way, or use a metal nitro vial which you can wear around your neck.

Heat will break down the nitro tablets. If you carry your Nitro in your pants pocket every day the heat from your body will gradually make the nitro less potent.  What I teach patients is to take a good marker and write on the bottle the date three months from when they started to carry the bottle. That is when it should be considered to replace. Sometimes it can go six months, but if you look at the bottle…hold it up to the light, don’t open it…and the tablets are looking powdery or crumbled….then replace the bottle. If you leave them in your pocket and they go through the dryer…time to replace. If you leave them in your car and your car is 100* or more…replace the bottle. That was a common one…”I leave them in the glove box in my car.”  NO NO NO!

If you have opened the bottle you have exposed the tablets to oxygen. Oxygen breaks down the nitro. Once the bottle has been opened, label the bottle for six months from the time  you opened it. Replace the bottle at six months. A story I would frequently hear that would make me cringe would be when a patients loved one or child would say ” I poured a couple in a paper cup and have them in my cupboard in case they need one while at my house”…UHG!!!! Won’t work sorry!

The bottle is brown to prevent sunlight from destroying the tablets as well. Don’t transfer them to any other bottle, there is a reason they come this way.

When to use Nitro:

The most common mistake in using nitro is when patients would tell me the pain wasn’t bad enough to use it.  The instructions for nitro don’t say wait until the discomfort is 9 out of 10, the instructions are to use the nitro if you have heart symptoms that do not go away with rest.  This means any heart discomfort, no matter how minor if is present for 5 minutes, would indicate using the nitro.  If you wait until you are really in pain, you probably will have damage done to the heart. The point of this drug is to prevent the damage to the heart by improving the blood flow preventing damage from occurring.

  • Sit down
  • Place one tablet under the tongue – most people experience a burning or tingling feeling under the tongue, a headache, a flushed feeling….If you experience this you should always experience this, as this indicates your nitro is fresh.
  • Wait 5 minutes – if the symptoms resolved rest a bit then gradually become active again
  • If the symptoms persist use a second nitro table, again wait 5 minutes, if needed take a third 5 minutes later
  • If you took a third nitro and still have symptoms call 9-1-1.Try to do some deep relaxing breathing, and thinking try not to panic. It’s a good time to use those relaxations skills.
  • Chew an adult strength aspirin while you wait for paramedics

One discussion I frequently have with patients goes as follows: You may carry your nitro faithfully for years and never need it, but if and when you do need it, you want it to be fresh so it can work. On the other hand some will need to use occasional nitro. This isn’t a bad thing. Your physician prescribed it for a reason. Use it!!!! There are common times when people need one…Exposure to cold air, Exertion that is strenuous, Emotional Stress, and after Eating a large heavy meal. Where the medical community get concerned is if you are requiring 2-3 nitro to clear your symptoms, if you are having more frequent symptoms, or if your symptoms are coming on at rest or waking your from your sleep. The escalation in symptoms should be reported to your physician ASAP.

Keep a log of your nitro  use.  Put on your log, the date, what you were doing when the symptoms occurred, and how many nitro it took to clear the symptoms. When you have a followup appointment with either your cardiologist or your primary care physician present them with the log. Sometimes we are able to find a pattern, do your symptoms come on at a certain time of day? Thus we can probably adjust medication timing to prevent this. Do they come on with a certain level of exertion? We call this your angina threshold and we watch to see is the threshold improving or worsening. Often through exercise we can improve the angina threshold.

What about long acting nitro?

There are long acting nitroglycerin medications that slowly release nitro into your system throughout the day. These are usually taken during the hours you are up and active. Rarely are they used twice a day, as your body needs a period of time in which it is free of nitro, or else it gets to where the nitro doesn’t work as effectively. It is still ok to use the fast acting nitro if you are on this medication.

What about the headache from taking Nitro? 

Take a Tylenol.  The headache won’t kill you but the heart attack might.