Case Study 4: Hypertension and Cardiovascular Disease

I.Understanding the Disease and Pathophysiology

1. Define blood pressure and explain how it is measured.
Blood pressure is the measure of systolic blood pressure (the first and higher
number) over diastolic pressure (the second and lower number). Readings greater
than or equal to 140/90 mmHg are considered hypertensive. It is not necessary for
both systolic and diastolic to be elevated to diagnose hypertension. For example,
readings of either 140/80 mmHg or 120/90 mmHg is considered hypertensive.
2. How is blood pressure normally regulated in the body?
As blood pressure increases, the blood vessels are being stretched out,
baroreceptors that are attached to the vessels at one end and to the midbrain at the
other end, are detecting this stretch on the vessel walls and letting the brain know
how much of a stretch there is within these vessels. The more stretch there is, the
more action potential is going to be released to let the brain know that there is
higher blood pressure within the vessel(s) and vice versa. To regulate blood
pressure, it is summed up in the Autonomic Nervous System. The Sympathetic
Nervous System is used in increasing the stroke volume and heart rate, which
results when there is low blood pressure. The Parasympathetic Nervous System,
on the other hand, decreases the stroke volume and heart rate, which results when
there is high blood pressure. Stroke volume is the amount of blood that is being
pumped out of the left ventricle of the heart during one contraction, so if there is
more blood being pumped out, there will be an increase in the amount of blood
going through the vessels and if there is less blood being pumped out, the pressure
in the vessel will decrease due to the low amount of blood being pumped out.
Vasoconstriction also happens within the Sympathetic Nervous System, so it will
cause the vessel to get smaller to limit the space that the blood has to flow through
and the Parasympathetic will vasodilate to cause the vessel to widen and give
more room for the blood to flow.
3. What causes essential hypertension?
Essential hypertension, also known as primary, is idiopathic which means it has
no known causes for majority of cases. Though the causes are unknown, essential
hypertension may be a result of individual differences within the renin-
angiotensin-aldosterone control of blood pressure, differences in identified genes
that affect sodium retention, and lifestyle choices that exacerbate the problem.
4. What are the symptoms of hypertension?
Hypertension does not always have symptoms, which is why it is known as the
“silent killer.”
5. How is hypertension diagnosed?
Hypertension is categorized as either primary or secondary. Primary HTN
has no known cause. Secondary HTN is the result of kidney disease,
CVD, endocrine disorders, or neurogenic disorders. To test for
hypertension, doctors and nurses will typically use a blood pressure cuff,
also known as a sphygmomanometer, to measure the blood pressure. It
usedes the inflatable cuff to stop and release the flow of blood of the
brachial artery.
 6. List the risk factors for developing hypertension.
Risks factors associated with hypertension include:
 Excessive sodium intake
 Low potassium intake
 Excessive alcohol intake
 Lack of exercise
 Smoking
 Stress
 Obesity
 Smoking
o Does not allow for proper endothelial relaxation and
vasodilation.
 An increase in blood volume and vasodilation is also a risk
7. What risk factors does Mrs. Sanders currently have?
Risk factors that Mrs. Sanders currently has are being overweight,
cigarette smoking, alcohol consumption, elevated cholesterol and blood
sugar, family history of hypertension, dyslipidemia.
8. Hypertension is classified in stages based on the risk of developing
CVD. Complete the following table of hypertension classifications.

Category Systolic Blood Pressure Diastolic Blood Pressure

(mmHg) (mmHg)

Normal 90- 119 and 60- 79

Prehypertension 120- 139 or 80- 89

Stage 1 140- 159 or 90- 99

Hypertension

Stage 2 160- 179 or 100- 109

Hypertension

9. How is hypertension treated?

HTN can be treated in a variety of ways. Weight reduction, physical
activity, nutrition therapy, and pharmacological interventions are used as
treatment. Pharmacological interventions alter cardiac output or peripheral
resistance. Diuretics will decrease blood volume by increasing urinary
output, which inhibits renal sodium and water absorption. ACE inhibitors
are vasodilators that lower BP by decreasing peripheral vascular
resistance. This occurs due to the blockage of the angiotensin converting
enzyme.Beta 1 blockers block beta receptors in the heart to will reduce
heart rate and cardiac output. Alpha adrenergic blockers block vascular
muscle action that responds to sympathetic stimulation therefore reducing
stroke volume and BP. Calcium channel blockers reduce vasoconstriction
by affecting the movement of calcium. Aldosterone antagonists suppress
 aldosterone activity and as a result water and sodium secretion are
reduced. Angiotensin II receptors interfere with the renin angiotensin
system without causing the degradation of bradykinin.
10. Thornton indicated in this note that he will “rule out metabolic
syndrome.” what is metabolic syndrome?
Metabolic syndrome does not have universally accepted definition but it is
combination of medial disorders which increase the risk of coronary artery
disease, stroke, and type 2 diabetes. Biochemically and physiologically,
with these abnormalities, it is more likely that the person will also have
hypertension, hyperglycemia, excess fat within the body, but mostly
around the abdomen region, higher cholesterol and triglyceride levels.
11. What factors found in the medical and social history are pertinent for
determining Mrs. Sanders’s CHD risk category?
The Nurses Health Study reported among women, the relative risks for
CHD was twice as high at BMI of 25-28.9. High levels of LDL-
cholesterol and low levels of HDL-cholesterol are also major risk factors
for CHD. Consequently, Mrs. Sanders being overweight at a BMI of
greater than 25 places her at a greater risk of CHD. Other risk factors
include hypertension, high blood sugar, and cigarette smoking.
12. What progression of her disease might Mrs. Sanders experience?
Hypertension is a leading cause of chronic kidney failure. Progression of
Mrs. Sanders’s hypertension can lead her to have a stroke, myocardial
infarction, heart failure and aneurysm if left untreated. Hypertension may
also cause ventricular arrhythmias and sudden cardiac death.

II. Understanding the Nutrition Therapy

13. What are the symptoms of hypertension?
DASH stands for “Dietary Approaches to Stop Hypertension.” The main
focus of the DASH diet is to lower sodium intake and lower total saturated
fat, and at the same time increase potassium, magnesium, calcium, and
fiber within a moderate energy intake. This diet consists of the person
eating foods that are lower in saturated fats and cholesterol, like red meats,
and contain many kinds of fruits and vegetables to fuel the body with
nutrients.

14. Using the EAL, describe the association between sodium intake and
blood pressure.
According to the EAL there is multiple studies that show a positive
association between sodium intake and high blood pressure. Consuming
sodium will increase the amount that enters the bloodstream, causing an
imbalance. The kidneys will attempt to go back into homeostasis, but the
excess of salt will inhibit the ability of the kidneys to remove water.
Adults who consume higher amounts of sodium are at higher risk of
developing hypertension.
15. Lifestyle modifications reduce blood pressure, enhance the efficacy of
antihypertensive medication and decrease cardiovascular risk. List
 lifestyle modifications that have been shown to lower blood pressure.
Increased physical activity, smoking cessation, and weight loss, as well as
reduction of sodium and alcohol intakes, are primary strategies in
lowering blood pressure. Nutrition interventions that decrease dietary
sodium, saturated fat, and alcohol while increasing calcium, potassium,
and fiber can lower blood pressure.

III. Nutrition Assessment

16. What are the health implications of Mrs. Sanders’s body mass index
(BMI)?
BMI= current weight (lbs) (703)[height (in)2] → 160 lbs (703)(66)2=
25.82
BMI of 24.9 and under is considered normal healthy weight range thus
making an individual having low health risk. Mrs Sander has a BMI of
25.82 which puts her in the category of being overweight. Although Mrs
Sander’s BMI is not far from normal weight range, but being at the higher
end can put her at the risk for developing cardiovascular disease,
hypertension, diabetes, and stroke.

17. Calculate Mrs. Sanders’s resting and total energy needs.

Resting: 10 (72.57kg) + 6.25(167.64) - 5(57)-161= 1327.45 kcal
REE x Activity factor
(1327.45)(1.375)=1825.24 kcals
Total Energy Needs: 72.57kg(20-30 kcal) = 1451.4-2177.1kcal

18. What nutrients in Mrs. Sanders’s diet are of major concern to you?
I am particularly concerned about the lack of sodium, potassium,
magnesium and calcium. Mrs. Sanders’s diet also include high intake of
saturated fat and overall fat ( Noted by the Laboratory results presenting
high cholesterol, LDL and Triglycerides). She is also on low side for
folate.

19. From the information gathered within the intake domain, list possible
nutrition problems using the diagnostic terms.
 Excessive energy intake
 Excessive fat intake.
 Excessive protein intake
 Inadequate fiber intake
 Inadequate mineral (magnesium, potassium, calcium) intake.

20. Dr. Thornton ordered the following labs: fasting glucose, cholesterol,
triglycerides, creatinine, and uric acid. He also ordered EKG. in the
following table, outline the indication for these tests (tests provide
information related to a disease or condition).

Parameter Normal Pt’s Reason for Abnormality Nutrition

 Values value Implication

Glucose 70-110 115 High glucose level is - Reduce the amount

mg/dL mg/dL indicative of insulin if simple
sensitivity carbohydrates
- consume more
complex
carbohydrates
- limit alcohol intake

BUN 8-18 20 May be involved with - Reduce protein

mg/dL mg/dL decreased renal function, intake
dehydration - consume more fiber
rich foods

Creatinine 0.6-1.2 0.9 N/A - Normal levels of N/A - Normal levels

mg/dL mg/dL creatinine of creatinine

Total 120-199 270 High value is indicative of - consume more

cholesterol mg/dL mg/dL dyslipidemia omega-3 fatty acids
- reduce saturated
fats (primarily found
in read meats)

HDL >55 30 Low value is indicative of - Increase intake of

cholesterol mg/dL F mg/dL dyslipidemia healthy fats (coconut
>45 oil, olive oil, fatty
mg/dL M fish)

LDL <130 210 High value is indicative of - increase intake of

cholesterol mg/dL mg/dL dyslipidemia soluble fiber (beans,
oats, fruits,
vegetables)
- limit intake of
saturated fats
(primarily found in
red meats)

Apo A 101-199 75 Apo A helps HDL - reduce/quit

mg/dL F mg/dL cholesterol to remove bad
94-178 cholesterol; low value of
mg/dL M Apo A is indicative of low
HDL cholesterol.
smoking
- increase intake of
healthy fats (coconut
oil, olive oil, fatty
fish)

Apo B 60- 126 140 High value is indicative of - Increasing intake of

 mg/dL F mg/dL high LDL cholesterol whole plant and
63-133 fiber-rich foods
mg/dL

Triglycerides 35-135 150 High value is indicative of - limit sugar intake

mg/dL F mg/dL stroke - consumer more
40-160 fiber-rich foods
mg/dL M - avoid trans fats

21. Interpret Mrs. Sanders’s risk of CAD based on her lipid profile.
Coronary artery disease (CAD) is characterized by narrowing of arteries,
caused by plaque build up due to high consumption of fat. Based on Mrs.
Sanders’s lipid profile, she is at high risk for developing CAD. Her lipid
profile indicates cholesterol and LDL being on high side while HDL being
on low side thus putting her on risk for developing CAD. In addition, she
consumes high fat diet and has sedentary lifestyle, which further puts her
at risk for developing CAD.
22. What is the significance of apolipoprotein A and apolipoprotein B in
determining a person’s risk of CAD?
Apolipoprotein A is the main protein component in High Density
Lipoprotein
while Apolipoprotein B is the main protein component of Low Density
Lipoprotein. If HDL is low and LDL is high, then that means the risk for
developing coronary artery diseases (CAD) is significantly high, as such
was in the case of Mrs Sanders.
23. Indicate the pharmacological differences among the antihypertensive
agents listed below.

Medications Mechanism of Action Nutritional Side Effects and

Contraindications

Diuretics reduce ECF and decrease Hypokalemia, hyperuricemia, anorexia

blood volume→ lowers BP
Dysgeusia, upset stomach, may increase
Decrease blood volume by K+, avoid salt subs. Avoid excessive
increasing urinary output; potassium intake
inhibit renal sodium and
water reabsorption

Beta-blockers Block beta receptors, reduce -N/V, diarrhea, constipation, may mask
heart rate and cardiac output hypoglycemia
Calcium- Interferes with calcium -hypotension
channel movement reducing -worsen renal function, hyperkalemia,
blockers vasoconstriction and dysgeusia
-edema, heartburn, nausea
-limit caffeine and alcohol intake

ACE Block angiotensin converting Hypotension, esp. In older patients. Can

inhibitors enzymes, which converts
angiotensin I to II; results in
vasodilation, decrease
vasopressin release and
resulting decrease in BP
worsen renal function, hyperkalemia,
dysgeusia. Causes dry, nonproductive
cough, hyperkalemia. Contraindications:
pregnancy, avoid natural licorice and salt
subs. Side effects increased in African
Americans.

Angiotensin II Inhibit Angiotensin II Nausea. May increase serum potassium;

receptor enzymes, causing blood Avoid natural licorice, grapefruit, salt
blockers vessels to vasodilate, which substitutes
also results in decrease in BP

Alpha- Block vascular muscle N/V, diarrhea; constipation, mouth

adrenergic response to sympathetic dryness. avoid natural licorice
blocker stimulation; reduce stroke
volume

24. What are the most common nutritional implications of taking

hydrochlorothiazide?
Hydrochlorothiazide is a drug type that fall under the drug class thiazide
diuretics.
Most common nutritional implications of taking this medicine is that it
inhibits the reabsorption of sodium, chlorine and potassium. Low
potassium can cause muscle weakness, dizziness and dysrhythmias.
Because this medicine works by removing excess fluid from the body
thus leading to imbalance in fluid and electrolytes. This imbalance can
result in excessive thirst. And if one doesn’t keep up with their fluid
intake, it can cause constipation.
25. Mrs. Sanders’s physician has decided to prescribe an ACE inhibitor
and an HMG CoA reductase inhibitor (Zocor). What changes can be
 expected in her lipids profile as a result of taking these medications?
With both of these prescriptions, Mrs. Sander’s lipid levels should be
expected to decrease.
26. How does an ACE inhibitor lower blood pressure?
An ACE inhibitor lowers blood pressure by reducing angiotensin II levels
in the body. The inhibitor decreases peripheral resistance by causing the
blood vessels to relax and vasodilate thus allowing more flow of blood.
27. How does an HMG CoA reductase inhibitor lower serum lipid?
HMG CoA reductase inhibitor is an enzyme that works in the liver to
prevent the making of cholesterol.
28. What other classes of medications can be used to treat
hypercholesterolemia?
There are other types of medical drugs besides HMG CoA to treat
hypercholesterolemia. One option is to take cholesterol absorbing
inhibitors, which still a fairly new treatment. This inhibitor works in the
intestine by preventing the absorption of LDL cholesterol. Niacin, also
known as Nicotinic acid, raises HDL cholesterol while decreasing
triglycerides and LDL cholesterol.
29. What are the pertinent drug-nutrient interactions and medical side
effects for ACE inhibitors and HMG CoA reductase inhibitors?
Possible drug-nutrient interactions of ACE inhibitors include hypotension,
especially in elderly patients. It’s uses can worsen renal function,
hyperkalemia, dysgeusia, and dry-nonproductive cough.
Possible drug-nutrient interactions of HMG CoA reductase inhibitors
include nausea, dyspepsia, abdominal pain, constipation, diarrhea and
flatulence. It’s medical side effects include myopathy and increased liver
enzymes.
30. From the information gathered within the clinical domain, list
possible nutrition problems using the diagnostic terms.
 Overweight as indicated by having high BMI
 Hypertension as indicated by having a very high total cholesterol and LDL
value
 Hyperglycemic as indicated by having a high glucose value
 Excess triglycerides and iron due to excess intake of protein and foods
high in cholesterol.
31. What are some possible barriers to compliance?
She really likes to enjoy herself on bingo nights and is unable to contain
her hunger. Her and her husband have tried a diet guideline, but because
that guideline was not to their liking, they gave up on following the
guidelines. Seeing how she reacted to that, it will be difficult to keep her
consistent and on track with following another diet.

IV. Nutrition Diagnosis

32. Select two nutrition problems and complete the PES statement for
each.
 a. Inadequate nutrition intake related to eating a lot of snacks as
evidenced by taking multivitamins daily.
b. Excessive sodium intake related to finding foods bland and
tasteless as evidenced by consumption of crackers, canned soup
and pizza.

V. Nutrition Intervention
33. When you ask Mrs. Sanders how much weight she would like to lose,
she tells you that she would like to weigh 125, which is what she
weighed most of her adult life. Is this reasonable? What would you
suggest s a goal for weight loss for Mrs. Sanders?
% weight change: (160 lbs-125 lbs)/125= 0.28 x 100= 28%
A weight loss goal should be 10% of current weight; thus 28% weight
change is not reasonable. Ten percent of her current weight is 16 lbs, and
this is the suggested weight loss goal for Mrs. Sanders.
34. How quickly should Mrs. Sanders lose this weight?
Mrs. Sanders should lose 16 lbs in 6 months, as this is the recommended
time frame to lose 10% of weight based on her ideal weight change.
35. What are the symptoms of hypertension?
For each of the PES statement that you have written, establish an
ideal goal (based on signs and symptoms) and an appropriate
intervention (based on the etiology).
a. Inadequate nutrition intake related to eating a lot of snacks as evidenced
by taking multivitamins daily. Mrs. Sanders should replace high, empty-
calorie snacks with healthier foods, such as fruits and vegetables that are
higher in nutrients to boost vitamins and minerals in the body. It is always
better to ingest nutrients that are naturally in food rather than taking
supplements. DASH is an excellent guide to eating healthy for people with
hypertension.
b. Excessive sodium intake related to eating high-salt foods and
snack choices as evidenced by consumption of crackers, canned
soup and pizza.
Mrs. Sanders should try to cook at home more often instead of
eating out on the weekends. Toppings on pizza, such as pepperoni,
sausages and cheeses, are very high in salt. Mrs. Sander should
avoid processed foods as much as possible. Instead of eating out at
a pizza restaurant, Mrs. Sander should consider making pizza at
home with fresh ingredients. Mrs. Sanders should exchange saltine
crackers with unsalted saltines, and homemade soup instead of
canned soup.
36. Identify the major sources of sodium, saturated fat, and cholesterol in
Mrs. Sanders diet. What suggestions would you make for
substitutions and/or other changes that would help Mrs. Sanders
reach her medical nutrition therapy goals?
Major source of sodium, saturated fat and cholesterol: canned soup,
saltines, butter, ice cream, steak, milk, processed meats and cheese on
 pizza. Major sources of saturated fat come from animal products. Mrs.
Sanders should substitute butter, low fat milk, ice cream with vegetable
oil, nonfat milk and sorbet. Mrs. Sanders should also avoid high-salt foods
such as snacks and processed meats. A high fiber diet will be beneficial in
reducing serum cholesterol levels.
37. What would you want to reevaluate in three to four weeks at a follow
up appointment?
At a follow up appointment, I would want to reevaluate Mrs. Sanders’s
lipid profile to see if there has been any improvements in fat and
cholesterol levels. In addition, I would ask her to complete a 24-hour
recall to see if she has been following the recommended diet suggestions
and work on any areas of improvement that needed to be.
38. Evaluate Mrs. Sanders’s lab at six months and then at nine months.
Describe the change that has occurred.
During Mrs. Sanders first visit, her lab values were quite high indicating
increased cholesterol, LDL, BUN, Apo B, triglycerides, glucose, and
RBC. During her follow up visit at 6 and 9 months, Mrs. Sanders’s lab
results indicated a slight change in some of these but for the most part
results remained high. Lab results showed improvements in RBC, Apo B,
triglycerides and glucose. There were some drop in BUN for the first 6
months but increased again at nine months. For cholesterol and LDL, lab
values were still above the normal range, but there were little
improvements in their levels.

References

High Blood Cholesterol. (n.d.). Retrieved October 20, 2018, from

https://www.nhlbi.nih.gov/health-topics/high-blood-cholesterol#Treatment

HMGCR 3-hydroxy-3-methylglutaryl-CoA reductase [Homo sapiens (human)] - Gene -

NCBI. (n.d.). Retrieved October 18, 2018, from
https://www.ncbi.nlm.nih.gov/gene/3156