Transcript Présentation PowerPoint - Royal Canin

How can nutrition
help patients with
cardiac diseases
V. Biourge DVM PhD Dipl ACVN&ECVCN
Health and Nutrition Scientific Director
R&D, Royal Canin SAS, Aimargues, France
Thanks to D. Elliott, DVM PhD Dip ACVIM&CVN
Courtesy of V Chetboul
Nutrition and cardiac disease
•
•
« Let food be thy medicine »
Hippocrates (460-377 BC)
Nutrition and cardiac disease
 Strong evidences in human medicine.
 Little support in veterinary medicine.
• Poor palatibility of the historical diet.
• Na content as the main emphasis.
 Importance of Nutrition
• Anorexia will not support recovery.
• Importance of a complete and balanced diet to support animal
maintenance.
• Essential role of nutrients for normal cardiac function
– Taurine, Carnitine, n-3 fatty acids, antioxidants, …
Research & Development
Confidential information - Mars Inc
Nutrition and cardiac disease
Role of nutrition in
cardiac disease:
• Provide nutrients and
•
•
•
energy requirements.
Pharmacological actions
of nutrients.
Slow progression of
heart failure.
Extend a symptom-free
quality of life.
Energy
• Adapt energy to body weight
•
and BCS
Overweight cardiac patients
  cardiac workload and  risk of
congestive heart failure.
 Exercise intolerance.
 Weight reduction improves
respiratory function
LM Freeman
• Disproportional weight loss
 Patients with more advance disease.
 Predominate loss of lean body mass
 Cardiac cahexia: 54% of DCM cases
LM Freeman
Cardiac Cachexia
Royal Canin, Canine Clinical Encyclopedia, 2004
Cardiac Cachexia
• Pathophysiology
 Anorexia
 Metabolic alterations (cytokines)
 Increased energy expenditure
 Poor tissue perfusion
• Exacerbate weakness
and exercise intolerance
• Catabolism of cardiac
•
muscle may contribute to
progression
Associated with immune
system dysfunction
Royal Canin, Canine Clinical Encyclopedia, 2004
Cytokine dysregulation
•
•
have increased levels
of TNF
TNF correlates with
severity of cardiac
cachexia
IL-I inversely correlates
with survival
30
25
Survival (months)
• Dogs with heart failure
Changes in IL-1 and Survival
in 21 Dogs with DCM
20
15
10
5
R = -0.52
P = 0.02
0
-2
-1
0
1
2
3
Change in IL-1 (ng/ml)
Freeman et al, 1994
Freeman et al, 1998
Anorexia
•
Causes of anorexia include
 Fatigue or dyspnea
 Medication toxicity
 Poor diet palatability
 Early management may help to
reduce the risks of anorexia and
cachexia
Food Intake in 21 dogs with DCM
2500
Prevalence
 33% of CHF dogs had only fair or
poor appetite.
 84% of dogs experience anorexia
during disease.
 Dogs with DCM ate only 72-84%
of expected caloric intake.
 Important reason influencing
euthanasia decision.
Actual calorie intake
1500
1000
500
0
Week 2
Freeman et al, 1994
Freeman et al, 1998
Expected calorie intake
2000
kcal/day
•
Week 4
Week 6
Promoting Food Intake
• Target: 70 -95 Kcal/kg0,75
• Highly palatable, energy
dense foods
 Protein, Fat, Sodium
• Warm foods prior to feeding
• Texture
 Dry Vs Moist
• Assisted feeding
• Tube feeding
Protein
•
•
Some cardiac diets are
severely protein restricted
to reduce “metabolic
stress”
7
 No evidence to support this
theory
Protein restriction may
contribute to
 Muscle loss and weakness
 Cardiac cachexia
 Exercise intolerance
 Poor quality of life
Provide cardiac patients
with adequate dietary
protein
– Dogs: > 50 g/1000 Kcal ME
– Cats: 60-70 g/1000 Kcal ME
Royal Canin cardiac
Hills h/d can
6
Hills h/d Dry
Purina CV can
5
Protein (g/100 kcal)
•
AAFCO
4
3
2
1
0
Royal Canin, Canine Clinical Encyclopedia, 2004
Taurine
Essential a.a. in cats
• Beta -amino sulfonic acid
H+3 N - CH2 - CH2 - SO-3
• Not a part of proteins
• [Taurine] in cells very high
• Role:




Intracellular osmolality
Calcium concentration
Transmembrane ion fluxes
Positive inotrope
250-500 mg/1000 kcal
Pion et al, 1987
Taurine
Low level of synthesis
Research & Development
Confidential information - Mars Inc
Obligate losses
Taurine
•
Taurine deficiency reported in dogs
with DCM
– American Cocker Spaniel
– Portuguese Water Dog
– Low or poorly available Met+Cys
•
• Certain lamb based diets
• Vegetarian diets
• Severely protein restricted diets
Cardiac diets should contain
supplemental taurine
– 250-500 mg/1000 Kcal ME
Kittleson 1997; Freeman 2000, Torres 2000, Sanderson 2001
Carnitine
•
•
•
•
•
•
•
Present in highest concentrations
in the heart and skeletal muscles.
Facilitates the transport of long
chain fatty acids (LCFA) into the
mitochondria
– Normal heart obtains 60% of its
energy from fatty acid oxidation
Carnitine deficiency reported in
Boxers, Doberman Pinchers,
American Cocker Spaniels
Patients often have normal plasma
[carnitine] with low intramyocardial
levels
– ?Membrane transporter defect
Improvement within weeks of
supplementation
Carnitine may help improve
myocardial energy production
50-100 mg/kg PO TID
L-arginine
•
•
•
•
•
Essential amino acid for dogs and
cats
Precursor of nitric oxide
(endothelium-derived relaxation
factor)
 nitric oxide  endothelial
dysfunction   peripheral blood
flow  exercise intolerance
Arginine supplementation in
humans with CHF has been
reported to
–
–
–
–
–
–
Increase endothelial nitric oxide levels
Improve endothelium-dependent vasodilation
Improve cardiac output
Increase renal function
Improve exercise tolerance
Decrease dyspnea
Cardiac diets should have adequate
arginine
–
–
NRC RA = 0,88 g/1000Kcal
Cardiac diets = 3-5,6 g/1000 Kcal
Wang et al, 1997
Fat
•
•
•
•
Very good source of energy
 9 Kcal/g Vs. 4 for Prot – CHO
Essential components for life:
phospholipids, sterols, ecosanoïds,
…
Source of essential fatty acids.
 -3 and -6 fatty acids
Fish oils have been shown to
decrease TNF and IL-1 in human
patients
 Inhibition of pro-inflammatory
arachadonic acid metabolites
 Direct inhibition on gene transcription
Dogs 7%
Cats 0%
-3 Polyunsaturated Fatty Acids
Fish oil supplementation
* P < 0.05
*
Healthy (n = 5)
Heart Failure (n = 5)
*
EPA
DHA
Dogs with heart failure have low
concentrations of EPA (c20:5n-3)
and DHA (c22:6n-3)
% Baseline Change
Concentration (%)
2
1.8
1.6
1.4
1.2
1
0.8
0.6
0.4
0.2
0
– Increases EPA and DHA in
dogs with DCM
– Decreases arachidonic acid
1950
*
1750
Placebo
1550
Supplemented
1350
1150
950
750
* P < 0.05
550
350
*
150
-50
DHA
EPA
Freeman 1998
-3 Polyunsaturated Fatty Acids
•
•
Supplementation with fish
oils
– Reduced IL-1 and TNF in
dogs with DCM
– Improved cachexia and
anorexia
– Reduced arrhythmogenesis
 cytokines is associated
with a lower risk of cardiac
cachexia and increased
survival of cardiac
patients
Freeman 1998
-3 Polyunsaturated Fatty Acids
Sodium
• Sodium restriction
 Reduce fluid retention
 Minimize congestion
• When should we institute
•
sodium restriction?
What level of restriction
should we implement?
Pathogenesis of Na Retention in Heart Disease
Dietary sodium
Research & Development
Confidential information - Mars Inc
Dietary sodium
Royal Canin, Canine Clinical Encyclopedia, 2004
Research & Development
Confidential information - Mars Inc
Sodium
0,6
0,4
LS (0.4g/1000kcal)
MS (0.7g/1000Kcal)
cm
0,2
0
-0,2
-0,4
*
*
*
-0,6
-0,8
*
•
•
•
•
* = P<0.05
LA = standard left atrial dimension
maxLA = maximum left atrial dimension;
LVIDd/s = left ventricular internal dimension
in diastole / systole
Rush et al, 2000
Sodium
•
•
•
Activation of RAA system occurs
early in cardiac disease
– Increases ventricular preload and
afterload
– Cardiotoxic effects
May be exacerbated by sodium
restriction
Severe restriction in association
with ACE-inhibitor therapy in
early cardiac disease could
hasten progression
Pedersen 1995
Potassium
ACE-Inhibitors
Diuretics e.g.
furosemide
Hypokalemia
Hyperkalemia
Anorexia
High K+ diets
Muscle weakness
Arrhythmogenesis
Cardiac arrest
Digitalis toxicity
NRC RA = 1,1 g/1000 kcal
Cardiac diets = 1,8 – 2,0 g/1000 kcal
Potassium
•
•
•
60% of dogs on low
sodium/potassium diet,
furosemide, digoxin and
captopril developed
hyperkalemia
Cardiac patients should
receive a normal dietary K
content 1-1,5 g/1000 Kcal
Monitor serum potassium
concentrations
Roudebush 1994
Mark E Peterson, 2011
Magnesium
• Involved in
– Carbohydrate and fatty
acid metabolism
– Protein and nucleic acid
synthesis
– Energy conversion
– Cardiac and smooth
muscle contractility
• Cardiac drugs (i.e. loop
diuretics, digoxin) are
associated with
magnesium depletion
Magnesium
•
•
•
50% of Cavalier King Charles
Spaniels with heart failure
were magnesium deficient
Hypomagnesemia is
associated with
– Hypertension, coronary artery
disease
– Congestive heart failure
– Cardiac arrhythmias, decreased
cardiac contractility
– Muscle weakness
Cardiac patients should receive diets
with adequate magnesium
concentrations
NRC RA = 100 mg/1000 kcal
Cardiac diets = 100 – 320 mg/Mcal
Pedersen et al 1998
B-Vitamins
• B-vitamins are water
Plasma Concentrations of Vitamins
B6 and B12 in 27 Cats with
Cardiomyopathy compared with 29
Healthy Cats
soluble
– Diuresis
• Cats with
– Involved in pathogenesis
or promotion of heart
disease in cats?
pmol/ml
•
cardiomyopathy have
decreased
concentrations of
vitamin B6 and B12
B12 correlates correlates
with left atrial size
*
Healthy
HCM
4500
4000
3500
3000
2500
2000
1500
1000
500
0
*P < 0.05
*
B6
B12
McMichael et al 2000
Oxidative Stress
Oxidative Stress and Antioxidant
Concentrations in 18 Dogs With DCM
250
% of control
Vitamin E; r = -0.51, p = 0.03
*
200
* P < 0.05
MDA
Vit E
Vit C
*
150
100
50
0
*
I
II
III
Heart failure class
*
IV
Freeman et al, 1999
Antioxidants
• Free radicals
– Cytotoxic
– Negative inotropes
• Free radical injury
implicated in
development and
progression of
– Coronary artery
disease
– Myocardial infarction
– Cardiomyopathy
How Can Nutrition Help?
High palatability &
energy density
“Normal” protein
content
Maintain appetite &
avoid cachexia
Restriction may contribute
to cachexia and muscle loss
Taurine
Beneficial in DCM?
L-arginine
Improved endothelium
dependent vasodilatation
Carnitine
Improve myocyte energy
production
How Can Nutrition Help?
w-3 PUFA
Moderate potassium
content
Reduced inflammatory
cytokines, anorexia
Reduced arrhythmogenesis
Avoids hypo & hyperkalaemia
Compatible with therapy
Staged sodium
restriction
Reduced sodium and
water retention
Magnesium
Avoids deficiency
Antioxidants
Combat oxidative stress
B vitamins
Avoids deficiency
If you want to know more …
www.ivis.org
Obrigado …