Insuficienta cardiaca

Snejana Vetrila, MD PhD

Definiie

Sindrom clinic caracterizat prin incapacitatea cordului de a asigura un debit cardiac adecvat necesitilor organismului n condiiile unei ntoarceri venoase normale sau debitul se realizeaz numai cu preul creterii presiunii de umplere ventricular
Societatea Europeana de Cardiologie, 2008

Definitie

Sindrom clinic complex caracterizat prin

disfuncia VS, VD sau ambele si modificri

patologice rezultante din dereglri

neurohumorale

Ghidul Societii Europene de Cardiologie 2012

Sindrom complex caracterizat prin A. Simptome clinice tipice: dispnee, fatigabilitate, astenie, edeme

B. Semne: tahicardie, tahipnee, edeme periferice, raluri pulmonare, lichid pleural, creterea pres. Venoase, hepatomegalie
C.Dovezi obiective de dereglri structurale sau fncionale ale cordului

Clasificare

Insuficienta cardiaca acuta

Insuficienta cardiaca cronic

Insuficienta cardiaca acuta

Clasificare: variante clinice

Edem pulmonar acut

oc cardiogen

Insuficienta cardiaca cu FEVS pstrat (anemie,

hipertirioidism, sepsis etc)

Clasificarea functionala NYHA a insuficientei cardiace cronice

Clasa I activitatea fizica uzuala este efectuata fara limitari(fara dispnee,oboseala sau palpitatii);pacientii prezinta dovada existentei unei disfunctii sistolice.
limitare moderata a activitatii fizice:fara simptome de repaus,dar simptome la eforturi uzuale simptome de repaus,dar simptome la eforturi mai mici decat cele uzuale.
Clasa IV simptomele apar la orice nivel de activitate si in

Clasa II

Clasa III limitare importanta a activitatii fizice:fara

repaus.

Clasificarea ACC/AHA a IC pe baza anomaliilor de structura cardiaca

Stadiul la risc pentru aparitia IC(prezinta factorii de risc de A exemplu,HTA,DZ,administrare de droguri cardiotoxice).Fara modificari structurale cardiace ale miocardului,pericardului sau valvelor.Fara semne sau simptome de IC Stadiul prezinta modificari structurale cardiac compatibile cu aparitia IC(de B exemplu,HVS,dilatare cardiaca,valvulopatii asimptomatice).Fara semne sau simptome. Stadiul IC simptomatica(in present sau anterior)datorata unor modificari C structurale cardiace. Stadiul modificari structurale cardiace avansate associate cu simptome severe de D IC in repaus in pofida tratamentului maximal.

Stages of HF: ACC/AHA

Stage A High Risk for developing Heart failure Stage B Asymptomatic LV dysfunction

NYHA Functional Class

Class I symptoms at activity levels that would limit normal individuals Class II symptoms of HF with ordinary exertion Class III symptoms of HF with less than ordinary exertion

Stage C Past or current Symptoms of HF Stage D End-stage HF

Class IV Symptoms of HF at rest

Etiologie
Cardiopatie ischemic Hipertensiunea arterial Cardiomiopatia dilatativ Cardiopatiiile alulare Alte: miocardita, diabetul zaharat etc

Alti factori

Predispozitia genetica Factori de mediu : fumat,alcool,droguri

Coexistenta de patologii: diabet zaharat,

HTA, boala renala, anemie,obezitate

Fisiopatologia IC
Anomalii cardiace Structurale: Miocitare Remodelarea VS Coronariene Functionale: Regurgitare mitrala Miocard hibernant Aritmii atriale si ventriculare Asincronism ventricular

Factorii precipitanti ai IC
1.Tulburari de ritm sau conducere: fibrilatie/flutter atrial, tahicardii paroxistice supraventriculare, bloc atrioventricular de grad inalt 2. Boli infectioase: sistemice si cardiace 3. Criza Hipertensiva 4. Ischemie miocardica 5.Tromboembolism pulmonar 6. Anemie

7. Hipoxemie de diverse etiologii (tulburari respiratorii in somn,altitudine >3000 m) 8. Afectiuni endocrine(hipo-/hipertiroidie) 9. Stari hiperkinetice(fistule a-v,beri-beri) 10.Non-complianta la recomandari (Consum excesiv de sare sau alcool, nerespectarea tratamentului farmacologic prescris si Efort excesiv). 11.Consum de medicamente cu efecte defavorabile: Antiinflamatoare nesteroidiene sau staroidiene, inotrop negative, toxicitate digitalica

Patogenie: mecanisme neurohumorale

Sistemul renina angiotensina aldosteron (SRAA) Sistemul nervos simpatic (SNS) Substane vasodilatatoare (bradikinin, oxid nitric, prostaglandine) Peptide natriuretice (ANP, BNP)

Citokine (endotelina, TNF, interleukine)

Metaloproteinazele

Mecanisme de adaptare cardiaca in ICC sunt eficace pe termen scrt, apoi devin contra-productive

Legea Frank-Starling Activarea sistemului nervos simpaticoadrenergic Activarea sistemului renina-angiotensinaaldosteron Remodelarea ventriculara stanga (VS) Regurgitarea mitrala Aritmiile si blocul de ramura stanga

Semne clinice caracteristice insuficientei cardiace stangi si drepte

Simptome
IC stng Dispnee(de effort,de repaus,ortopnee, dispnee paroxistica nocturna) Tuse,hemoptizii Respiratie Astenie,fatigabili tate Hepatalgii Balonari, greata, anorexie Edeme periferice

Semne
Paloare/cianoza, transpiratii Raluri pulmonare subcrepitante simetrice Tahicardie Deplasare laterala soc apexian Cresterea ariei matitatii cardiace Galop protodiastolic de VS (Zg 3) Suflu sistolic apical

IC dreapt

Edeme periferice/generalizate declive Cianoza Subicter/icter Hepatomegalie dureroasa Turgescenta jugulara Reflux hepato-jugular Revarsate lichidiene(pleural, pericardic, ascitic) Galop protodiastolic de VD(Zg 3) Suflu sistolic endapexian(regurgitare tricuspidiana secundara)

Acuzele pacienilor cu ICC

Dispnee(de effort,de repaus,ortopnee,dispnee paroxistica nocturna) Tuse,hemoptizii Dereglri de respiratie Astenie, fatigabilitate Hepatalgii Balonari, greata, anorexie Edeme periferice

Nicturia i Oliguria
Filtraia renal de sodiu i ap este sczut la pacienii cu funcie compromis a VS din cauza redistribuirii fluxului de snge la rinichi n poziie vertical i n timpul activitii fizice Oliguria este asociata debitului cardiac redus i este de obicei un semn de insuficien cardiac terminal Acesta indic un pronostic nefavorabil Din cauza cu un semnificativ

Cerebral Symptoms

Elderly patients with advanced heart failure may have confusion, memory impairment, anxiety, headaches, insomnia, nightmares and, occasionally, disorientation, delirium, and hallucinations These cerebral symptoms are predominantly related to a reduced cardiac output and poor perfusion of brain and other neurologic tissues

Abdominal Symptoms

Gastrointestinal complaints may develop in patients with heart failure as a result of hepatic congestion and edema of the abdominal wall and intra-abdominal organs Congestion of abdominal organs may be present with ascites, abdominal fullness and enlargement, early satiety, bloating, anorexia, nausea, vomiting, constipation, and upper abdominal discomfort

Physical Examination

Patients with chronic heart failure, on the other hand, frequently appear malnourished, and occasionally cachectic Evidence of increased sympathetic activity is frequent in patients with heart failure There may be pallor and coldness of the limbs and cyanosis of the digits because of vasoconstriction The patient may also have diaphoresis and abnormal distention of the superficial veins Sinus tachycardia is often observed and usually develops in an effort to maintain the cardiac output when heart failure is decompensated or the stroke volume is significantly decreased

Sustained periodic or cyclic respirations with regularly alternating phases of hyperpnea and apnea in a smooth crescendo-decrescendo manner (Cheyne-Stokes) can be seen in patients with heart failure Moist rales heard initially at the lung bases result from the transudation of fluid into the alveoli that subsequently moves into the airways In pulmonary edema, coarse bubbling rales and wheezes are heard over both lung fields and may be accompanied by frothy sputum, with or without bloodstaining Hydrothorax (pleural effusion) is usually bilateral and can intensify the severity of dyspnea by further reducing vital capacity Stony dullness on percussion is characteristic of pleural effusion on one or both sides

Approximately 5 L of extracellular fluid must accumulate before peripheral edema occurs in heart failure Pitting edema is common, with the fluid accumulating in a symmetric manner; in general, it initially involves the dependent portions of the body with higher venous pressure. This is typically noted in the feet and ankles of ambulatory patients and in the sacral area of bedridden ones Late in the course of heart failure, edema may become massive and generalized (anasarca); it can involve the upper extremities, the thoracic and abdominal walls, and the genital area Occasionally, with acute accumulation of edema or associated trauma, skin rupture and extravasation of fluid can occur

Cardiomegaly, with a laterally displaced, enlarged, and sustained ventricular impulse may be found on physical examination The decrease in ventricular compliance may initially become apparent by the presence of a late diastolic atrial sound (S4 gallop) A protodiastolic sound (S3 gallop) occurs in patients with more advanced heart failure and is caused by acute deceleration of ventricular inflow after the early filling phase The presence of a third heart sounds appears to be associated with an increased risk of death, death from pump failure, and hospitalization for heart failure Systolic murmurs are common in heart failure and are largely secondary to mitral or tricuspid regurgitation that can result from ventricular dilatation

Systemic venous hypertension can be detected by abnormal distention of the internal jugular veins The jugular venous pressure normally declines on inspiration, it can rise in patients with right-heart failure (Kussmaul sign)

Liver enlargement and tenderness on palpation

are marked by epigastric fullness and dullness to

percussion in the right upper quadrant

These findings may persist after other signs of heart failure have disappeared because it takes longer for hepatic congestion to disappear

Pulsus alternans is common in patients with CHF; when severe, it can be detected by sphygmomanometry or by palpation of peripheral pulses, particularly the femoral pulse This sign is characterized by a regular rhythm of alternating strong and weak pulsations

Teste de laborator
n insuficiena cardiac sever, mecanisme compensatorii neurohormonale frecvent duc la crestere a hematocritului, hiponatremia, hiperkaliemie, hipokaliemie congestia ficatului este adesea asociat cu anomalii ale testelor functiei hepatice cu niveluri crescute de enzime hepatice, hiperbilirubinemiei insuficienta renala

INVESTIGAII PARACLINICE: ECG

Tulburari de ritm Largirea complexului QRS (prelungit >130ms) Sechele de infarct miocardic

Electocardiograma pt cu ICC

Electrocardiograma in IM

Testul de effort ECG, preferabil combinat cu

masurarea schimburilor gazoase are valoare atat in obiectivarea initiala a simptomelor,diagnosticul etiologic posibil ischemic,cat si in urmarirea periodica a evolutiei pacientului.Un test de effort maximal fara simptome in absenta tratamentului specific infirma IC.

Monitorizarea Holter ECG poate identifica

prezenta unor aritmii atriale sau ventriculare tranzitorii.Exista studii ce au dovedit o valoare prognostica defavorabila pentru extrasistolele ventriculare si tahiaritmia ventriculara.este inca incert daca ele reprezinta numai un marcher al severitatii disfunctiei VS,sau daca sunt direct responsabile pentru aritmii fatale si riscul de moarte subita al acestor pacienti.

Investigatii imagistice

Radiografia toracica este un element important prin definirea formei si a marimii conturului cardiac, totusi un cord de dimensiuni normale radiologic nu infirma diagnosticul de IC Masurarea indicelui cardio-toracic Evaluarea arcurilor ce definesc conturul siluetei cardiace Studiul campurilor pulmonare ofera date legate de prezenta congestiei pulmonare si eventual a edemului interstitial i/sau alveolar Lichid pleural

Radiografia:

Echocardiography

The Doppler echocardiographic examination is regarded as the most useful test in evaluating patients with heart failure in establishing the type of cardiomyopathy (dilated, restrictive, hypertrophic) in evaluating the possible primary or secondary causes (valvular disease, LV aneurysm, intracardiac shunts) of heart failure provide the information about the size of all cardiac chambers and LV systolic function but also gives information about valvular function, stenotic or regurgitant lesions as well as reasonable estimates of both right- and left-sided pressures

Exercise Stress Testing can be used to classify the severity of heart failure, follow the progress of the patient, and assess the efficacy of therapeutic maneuvers

Radionuclide Ventriculography
Cardiac Catheterization

Alte investigatii paraclinice

Cateterismul cardiac Coronarografia Angiografia nucleara. Rezonanta magnetica Angio CT coronarian

Treatment

A new approach to the management of patients with heart failure incorporates a new classification of heart failure that identifies four stages (A to D) involved in the development of the heart failure syndrome

Goals of Therapy
Improve symptoms and quality of life Slow the progression of cardiac and peripheral destruction Reduce mortality

Tratamentul: Tratamentul nonfarmacologic

Masura de modificare a stilului de viata Aderenta la tratament Recunoasterea simptomatologiei Monitorizarea greutatii Restrictia de sodiu Monitorizarea aportului de lichide Limitarea aportului de alcool Reducerea greutatii < 30kg/m2 Intreruperea fumatului Imunizare antipeumococica si antigripala Activitate fizica regulata Antrenament fizic specific Consiliere de cuplu activitate sexuala Screening si tratament al depresiei Clasa de indicatie (nivel de evidenta) I (C) I (C) I (C) IIa (C) IIb (C) IIa (C) IIa (C) IIa (C) I (C) I (B) I (A) I (C) IIa(C)

Terapia farmacologica in IC - clase de medicamente Diuretice Diuretice de ansa (ex. furosemid)

Diuretice tiazidice (ex. hidroclorotiazida) Diuretice economisitoare de potasiu (ex. spironolactona)

Inhibitori ai enzimei de conversie

Captopril Enalapril Lisinopril Ramipril Trandolapril

Betablocante

Metoprolol succinat Carvedilol Bisoprolol Nebivolol

Digoxin

Antialdosteronice

Spironolactona Eplerenona

Antagonisti ai repectorilor de angiotensina

Valsartan Candesartan

Inotrop pozitive
Digoxin Dobutamina Dopamina Levosimemdan

Antiaritmice Amiodarona Anticoagulante

Acenocumarol Warfarina

Dozarea medicamentelor
Medicament Doza de initiere (mg/zi) Doza tinta (mg/zi)

Inhibitorii enzimei de conversie a angiotensinei Captopril 6,25 x 3/zi Enalapril Lisinopril Ramipril Trandolapril Diuretice Furosemid Hidroclorotiazida Betablocante Metoprolol succinat (CR/XL) Carvedilol Bisoprolol Nebivolol Digoxin antialdosteronice 2,5 x 2/zi 2,5 5 2,5 0,5 20-40 25 12,5/25 3,125 x 2 1,25 1,25

(50-100) x 3/zi (10-20) x 2/zi 20-35 5 x 2/zi 4 40-240 100 200 (25-50) x 2 10 10

Bi-v pacing if sxs

Hydralazine/nitrate or ARB if BP allows + sxs Digoxin to reduce hospitalizations Aldosterone antagonists in select patient
Diuretics for fluid retention Beta Blocker ACE-I (or ARB if ACE intolerant) Regular exercise program Sodium restriction

ICD

TRATAMENT INTERVENTIONAL Terapia de resincronizare cardiaca (TRC) este una dintre achizitiile terapeutice recente cele mai importante in tratamentul IC. Defibrilatoarele cardiace implantabile (DCI) reprezinta optiunea principala de profilaxie secundara la pacientii cu IC care au supravietuit unei morti subite cardiace, sau prezinta tahicardii ventriculare sustinute cu deteriorare hemodinamica (indicatie de clasa IA).

CRT: Cardiac Resynchronization Therapy

TRATAMENTUL CHIRURGICAL Revascularizarea miocardica, Reconstructia valvulara mitrala. Recontructie ventriculara

Ca o punte catre transplantul cardiac, au fost dezvoltate dispozitive de asistare a ventriculului stang, ele fiind actual indicate ca punte catre transplant in miocardita acuta severa si, in cazuri selectionate, ca suport hemodinamic permanent sau temporar (indicatie de clasa IIa). Utilizarea lor este limitata in special de complicatiile infectioase grave, din cauza carora aceste dispozitive pot fi mentinute mai putin de 1 an

Criterii de selectie a recipientului pentru transplant cardiac. Boala cardiaca avansata refractara la tratament farmacologic sau interventional Absenta urmatoarelor criterii:
afectare

vasculara periferica sau cerebrala severa disfunctie ireversibila a altui organ (rinichi, ficat, plaman), cu exceptia cazurilor evaluate pentru transplant multiorgan hipertensiune pulmonara severa ireversibila (> 4 U Wood) istoric de neoplazie cu probabilitate de rrecurenta non-complianta terapeutica varsta avansata infectie sistemica activa

DEFINITIE Insuficienta cardiac acuta (ICA) este definite ca debutul acut de novo sau agravarea progresiva a simptomelor si semnelor de insuficienta cardiac,necesitind interventie terapeutica imediata

Clasificarea clinica Caracteristici IC cronica Debut gradat,exista istoric de decompensate,agravata evolutie a unei IC cronice si dovezi de congestive pulmonara si sistemica Edem pulmonar acut

Hemodinamic TA:scazuta,normal,crescuta DC:scazut normal crescut PCB:usor crescut

Tinta terapeutica Normovolemie (nitrati,diuretice,ultrafiltrare)

Debut acut,dispnee TA:scazuta,normal,crescuta severa,ortopnee,tahipnee,ralur i subcrepitante,desaturare arterial(SaO290%) Debut rapid,FE TA:crescuta pastrata,congestie DC:normal pulmonara,fara congestive PCPB:18mmHg sistemica Hipoperfuzie tisulara,oligo/anurie

Normovolemie,TA ,diuretice,morfina)

(raspuns

bun

la

nitrati

IC hipertensiva

Scaderea TA (nitrati,diuretice de ansa,raspuns rapid la terapie)

Soc cardiogen

TA:90mmHg sau 30mmHg Normalizare debit cardiac (inotrop, balon de sau medie contrapulsatie) DC:scazut(1.8-2.2 l/min/m2 PCPB18mmHg Diureza0.5ml/kgc/min

IC dreapta izolata

Congestie sistemica in TA:scazuta absenta congestiei pulmonare DC:scazut si DCscazut PCPB:scazuta 15% din pacienti cu SCA prezinta semne de ICA

Normalizarea presiunii in artera pulmonara

IC asociata SCA

Corectia ischemiei (revascularea farmacologica sau interventionala)

IC cu debit cardiac crescut

Asociata tireotoxicozei,bolii DC:crescut Paget,fistulelor PCPB:crescuta arteriovenoase,anemiei

Corectia cauzei primare

ETIOLOGIE SI FACTORI PRECIPITANTI

FACTORI PRECIPITANTI: FACTORI CARDIACI:

-Ischemia miocardului(sindroame coronariene acute)

-tulburari de ritm si conducere (tahi sau bradi aritmii) -leziuni mecanice(valvulare) acute (endocardita ,ruptura de muschi papilar mitral, disectie de aorta etc.) -inflamatie(endocardita, miocardita) -toxice si medicamente inotrop negative -cresteri ale TA sistemice si pulmonare ( criza hipertensiv, embolie pulmonara)

FACTORI EXTRA CARDIACI:

-hipervolemia -disfunctie renala -sindroame hiperkinetice (anemie,febra,hipertiroidie)

-noncomplianta(regim igienodietetic si/sau medicatie)

Abuz de alcool, medicatie

FIZIOPATOLOGIE Pentru a intelege mecanismul patogenetic din ICA, aceasta trebuie privita din cel putin doua perspective:incapacitatea de a asigura functia de pompa (disfunctie sistolica) si incapacitatea de a asigura umplerea ventriculara (disfunctia diastolica). Din punct de vedere fiziopatologic trebuie avuti in vedere trei factori care influenteaza volumul bataie/debit cardiac:

presarcina, postsarcina si contractilitatea.

DIAGNOSTIC
Simptome Congestive: -dispnee (de effort,de repaos, ortopnee, -raluri pulmonare subcrepitante, colectie dispnee paroxistica nocturna) tuse pleural (de obicei bilateral) nu tolereaza decubitul dorsal -discomfort member inferioare (edeme) -edeme periferice member inferioare , pe parcursul spitalizarii pot aparea edeme pe regiunea sacrata -dicomfort abdominal, meteorism, -ascita, hepatalgie, hepatosatietate precoce, anorexie /splenomegalie, icter sclera, crestere in greutate, turgescenta jugulara, reflux hepatojugular Hipoperfuzie: -fatigabilitate -status mental alterat,confuzie, dificultati -extremitati reci, paloarea tegumentelor, de concentrare, somnolent diurnal hipotensiune(poate fid oar ortostatica ), puls slab palpabil, oligo-/anurie -ameteala, presincopa sau sincopa Semne

RADIOGRAFIA TORACICA Utilitatea clinica este de a identifica modificari cardiovasculare de tipul cardiomegaliei si congestiei pulmonare , dar si de a diagnostic patologii asociate de tipul pneumoniei sau colectiilor pleurale importante ca si acuza alternative de dispnee. Multi pacienti cu ICC acutizata au foarte putin sau deloc edem interstitial evidentiabil pe radiografia toracica

INVESTIGATII PARACLINICE Electrocardiograma: hipertrofie ventriculara. prezenta undei Q indica sechela de infarct miocardic. blocul major de ramura stinga

TESTE DE LABORATOR: ELECTROLITI. FUNCTIA RENALA. FUNCTIA HEPATICA. HEMOLEUCOGRAMA. PEPTIDELE NATRIURETICE MARKERII DE INJURIE MIOCARDICA.

OBIECTIVELE TRATAMENTULUI
CLASA AMELIORAREA REMODELAREA SUPRAVETUIRE SIMPTOMATICA + 0 0

digoxin

Diuretic de ansa
antialdosteronice IECA Blocanti ai rec angiotensinici nitrat betablocant inotrop

+
+ + +

0
+ + +

0
+ + +

+ + +

0 + 0

0 + 0

TEHNICI DE VENTILAIE Oxigenoterapia trebuie recomandat ct mai rapid pacienilor cu hipoxie n scopul meninerii unei saturaii arteriale de oxigen >i/sau= 95% indicaie de clas I (nivel de eviden C). Ventilaia non-invaziv (VNI) reprezint metodele de ventilaie pe masca facial, fr intubare orotrahial. Intubarea orotraheal i venticaia mecanic se vor utilize la pacienii la care nu se poate obine o oxigenare adecvat prin VNI, sau care prezint epuizarea muchilor respiratori

MODULATOARE DE PRE-/POST-SARCINA Diureticele Diuretice de ansa (ex. furosemid)

Diuretice tiazidice (ex. hidroclorotiazida) Diuretice economisitoare de potasiu (ex. spironolactona)

Vasodilatatoare. Nitrai. Nitroprusiat

de sodium.

Neseritide

Dozajul principalelor terapii farmacologice utilizate n ICA

Clasa Diuretice Furosemid Doza iniial Doza int Doza maxim T1/2 Clas indicaie IB Efecte adverse Hipopota semie pihonatre mie 20-40 mg iv euvolemie 240mg/zi 6h

Vasodilatatoare Morfin Nitroglicerin Neseritide

2-5mg iv bolus la 5- 30 min Variabil 5 mg 0,03mg/kg 2mg/kg bolus, 0,01 mg/kg

200mg

2-4h 3min

IB IB

Depresie respirator y hTA Hta

INOTROPE Dobutamina Dopamine Levosimendan Milrinon

1-2 mg/kg 0,05-0,1mg/kg 50mg/kg bolus 0,2-0,3mg/kg

5-15mg/kg 15 mg/kg 0,1-0,2 mg/kg 0,4-0,6 mg/kg 0,375-0,75 0,75 mg/kg mg/kg

2min 80h 2-4h

IIa, B IIb, C IIa, B IIb, B

Ischemie, aritmie hTA, tahicardie hTA, aritmie

TERAPIA NON-FARMACOLOGICA Terapia non-farmacologica- se refera la

dispozitivele de tipul balonului de contrapulsatie intraaortic si dispozitivele de asistare ventriculara, aplicabila in cazul tabloului unei IC cu soc cardiogen.

Balonul de contrapulsatie intraaortic- poate fi

montat in laboratorul de cateterism cardiac si are avantajul de a creste fluxul coronarian scade postsarcina si creste perfuzia renala fara a creste consumul miocardic de oxigen. Dispozitivele de asistare ventriculara- sunt destinate pacientilor cu IC severa, ca puncte in asteptarea transplantului pacientilor care nu sunt eligibili pentru transplant .

TERAPIA DE LUNGA DURATA Instrirea (educatia pacientilor), modificarea stilului de viata ,tratare cauzelor reversibile, optimizarea tratamentului farmacologic trebuie sa aiba loc inainte de externare. Inainte de externare se recomanda ca pacientii sa aiba cel putin 24h de medicatie administrate oral , fara diuretic sau inotrop i/v. Dupa stabilizare initiala trebuie initiat si titrat tratamentul cu impact asupra mortalitatii: betablocant, IECA, BRA(blocantii receptorilor angiotensinici) antagonisti ai aldosteronului.

SITUATII SPECIALE DE INSUFICIENTA CARDIACA ACUTA EDEM PULMONAR ACUT CARDIOGEN Exista doua tipuri de edem pulmonar acut(EPA) in practica clinica: 1) EPA cardiogen determinat de cresterea presiunii in capilarul pulmonar 2) EPA non-cardiogen

SOCUL CARDIOGEN

situatia clinica de hipoperfuzie tisulara inadecvata datorata disfunctiei cardiace caracterizat prin 1. hipotensiune persistent 2. reducerea severa a debitului cardiac 3. prezenta unor presiuni de umplere a VS normale sau crescute