Insuficienta cardiaca

tratament
Obiectivele tratamentului
Prognostic scaderea mortalitatii
Morbiditate ameliorarea simptomelor si semnelor
imbunatatirea calitatii vietii
eliminarea edemelor
cresterea capacitatii de efort
ameliorarea dispneei si fatigabilitatii
scaderea respitalizarii
ingrijiri paleative
Preventia aparitiei/progresiei afectarii miocardice
remodelarii miocardului
reaparitiei simptomelor/edemelor
spitalizarii



Educatia pacientului
Definitia
Simptome si semne gravitate/supraveghere G, TA, AV
Tratament farmacologic rol/doze/ajustare/efecte adverse
Factori de risc obezitate, glicemie
Dieta restrictie de Na, nu malnutritiei, nu ecesului de lichide
Exercitiu fizic incurajat
Imunizari
Aspecte psihosociale
Aderenta
Prognostic



asuri generale
!
Pacientii obezi trebuie sa piarda greutate!
!
"enunta la fumat!
!
Alcool #$$ml la zi!
!
Tratament activ al hipertensiunii% dislipidemiei%
diabet% aritmii atriale!
!
"estricitie de sare!
!
Imunizare antiinfluenza si pneumococ!
!
Exercitii aerobe!
!
I&'FiA orice efort va fi facut pentru
mentinerea ritmului sinusal sau controlul
frecventei ventriculare
!
I& ' (radicardie sau bloc ) pacema*er!
!
Anticoagulare la pacientii cu FiA si istoric de
evenim embolice
!
I& ' angina + revascularizare coronariana
asuri generale
!
"evascularizare pentru pacientii cu cardiomiopatie
ischemica cu miocard viabil
!
Dintre masurile generale probabil cea mai eficienta
este urmarirea atenta
!
I&D ) T,% Fi,
!
Antiinflamatorii nesteroidiene pot inhiba efectele
IE& si diureticelor% cu agravarea functiei cardiace si
renale
!
-u sunt evidente din studii mari pentru rolul
suplimentelor nutritionale .coenzima /0$%
carnitina1 la pacientii cu insuficienta cardiaca
asuri generale
Identificarea factorilor precipitanti
&ardiovasculari
Ischemie
2ipertensiune
,alvulopatie
Fibrilatie atriala
Aritmie ventriculara
(radicardie
-on cardiovasculari
Anemia
(oli pulmonare
(oala renala
Disfunctie tiroidiana
diabet
Tratament chirurgical
!
"evascularizare miocardica
!
,alvulopatii severe
!
Anevrismectomie
Tratament farmacologic

DRUGS
HEMODYNAMIC EFFECTS
A
I
A + V
V
D
Ventricular Filling Pressure
Str!e
Vlu"e
Nr"al
CHF

PHARMACO#OGIC THERAPY
DIURETICS

I"$r%e&
s'"$t"s
Decrease&
"rtalit'
Pre%entin
( CHF
'es )
)
Vas&il*+Nitrates,
'es 'es
)
DIGO-IN
'es .
"ini"al
INOTROPES
'es
"rt*
)
Ot/er neur/r"nal
cntrl &rugs
'es
+ 0 1
)
ACEI 'es YES
'es
Neur/u"ral
Cntrl
NO
'es
n
n
YES
YES
Crte2
Me&ulla
T/ia3i&es
In/i4it acti%e e2c/ange ( Cl1Na
in t/e crtical &iluting seg"ent ( t/e
ascen&ing l$ ( Henle
51s$aring
In/i4it rea4sr$tin ( Na in t/e
&istal cn%lute& an& cllecting tu4ule
#$ &iuretics
In/i4it e2c/ange ( Cl1Na15 in
t/e t/ic! seg"ent ( t/e ascen&ing
l$ ( Henle
#$ ( Henle
Cllecting tu4ule
DIURETICS
Vlu" circulant si $resarcina
A"elire3a si"$t"ele cngestiei
Nu au e(ect &irect $e DC6
sca&erea e2cesi%a a $resarcinii DC
A"elirea3a &istensi4ilitatea arteriala
Acti%area neur/r"nal
ni%elul NA6 Ang II an& ARP
E2ce$tie7 cu s$irnlactne
E(ectele &iureticelr
Efectele diureticelor
!
"educerea rapida a simptomelor
comparativ cu orice alta clasa de
medicamente!
!
&ontroleaza adecvat retentia hidrosalina!
!
Folosirea corecta a diureticelor influenteaza
si administrarea si actiunea celorlalte clasa
de medicamente in insuficienta cardiaca
Diureticele in insuficienta cardiaca
!
"educerea rapida a simptomelor
comparativ cu orice alta clasa de
medicamente!
!
&ontroleaza adecvat retentia hidrosalina!
!
Folosirea corecta a diureticelor influenteaza
si administrarea si actiunea celorlalte clasa
de medicamente in insuficienta cardiaca
Initierea si mentinerea tratamentului diuretic
!
3a pacientii cu retentie fluida furosemid
!
Scaderea in 4 cu $%5)0l6zi
!
Obiective reducerea simptomelor%
disparitia edemelor
!
"estricitie de -a .78g6zi1
!
Dupa disparitia edemelor se va mentine
tratamentul diuretic
!
A9ustarea dozelor in functie de greutate
zilnic .ideal1
Tratamentul cu diuretice
!
Tulburarile hidroelectolitice tratate si
diureza continuata!
!
Asocierea diuretic de ansa +
spironolactona pentru a combaterea hipo
:% g!
!
A9ustarea dozelor in caz de retentie
azotata sau hipotensiune!
Diuretice in insuficienta cardiaca severa
!
Absorbtia prep orale incetinita de edem
intestinal sau hipoperfuzie
!
Disponibilitatea influentata de afectarea
functiei renale!
!
Solutii;
0! cresterea dozelor!
#! administrarea intravenoasa!
8! combinatia de diuretice!
<! asocierea diuretic inotrop pozitiv!!
"iscurile tratamentului diuretic
!
Depletie electrolitica :% g + aritmii severe
!
Activarea neurohormonala ) sistemul renina
angiotensina
!
2ipotensiune si retentie azotata + sd
cardiorenal
Efectele IE& asupra simptomelor
!
Ameliorarea dispneei!
!
Toleranta la efort este crescuta!
!
Scade agravarea insuf cardiace!
!
Scade necesarul de diuretic!
!
Ameliorarea FE,S!
Efectele IE& pe morbiditate si mortalitate
=>$$$pac cu I&
=8$ trialuri clinice
Scad riscul de deces si riscul combinat
deces ) respitalizari
IE& ) avanta9e
Inhiba remodelarea ,S postinfarct
odifica progresia I& cronice
Supavietuirea
spitalizarile
Imbunatatesc calitatea vietii
In contrast cu alte vasodilatatoare nu
determina activarea S"AA sau
tahicardie reflexa
-u apare toleranta

Place4
Enala$ril
89 88 8: ; < = > ?
PRO@A@I#ITY
OF
DEATH
MONTHS
:*8
:*<
:
:*9
:*A
:*=
:*B
:*?
:*>
$C :*::8
$C :*::9
CONSENSUS
N Engl J Med 1987;316:1429
ACEI SURVIVA#
B A 9 8 :

?:
B:
A:
9:
8:
:
Mnt/s
: > 89
$ . :*::A>
D
MORTA#ITY
9B 8< A: A> B9 B<
Enala$ril
n.89<?
Place4
n.89<B
SO#VD +Treat"ent,
N Engl J M 1991;325:293
ACEI SURVIVA#
n . 9?<;
CHF
1 NYHA II1III
1 EF C A?

ISIS1B
GISSI1A
SAVE
SMI#E
AIRE

ACEI @ene(it Pt Selectin
Ca$t$ril
#isin$ril
Ca$t$ril
E(en$ril
Ra"i$ril
:*? 0 ? F!
:*< 0 > F!
B*9 0 A*? 'r
B*8 0 8 'r
> 0 8 'r
All Fit/ AMI
All Fit/ AMI
EF C B:
as'"$t"atic
Ant* AMI6 N TR#
Clinical CHF
TRACE
Tran&la$ril =*> 0 A 'r
Vent D's(2 0 Clinical CHF
EF C A?
ACEI
SURVIVA# POST MI
IEC
INDICATII
Insu(icienta car&iaca clinic "ani(esta
1 tti $acientii
Dis(unctie %entriculara stanga
asi"$t"atica
1 #VEF C B: D
IE&
&O-T"AI-DI&ATII;
0! TAS 7?$mm2g!
#! &reatinina =#%5mg6d3!
8! Stenoza bilaterala a renala !
<! : seric =5!5 mmol63!
Initierea si mentinerea tratamentului cu IE&
!
&aptopril ) @!#5mg A #)86zi
!
Enalapril ) #!5mg A #6zi
!
Dublarea dozei la 8)> zile
!
Functia renala si : seric la 0)# saptamani
dupa initiere
!
Doze tinta )
&aptopril 05$)8$$mg6zi!
Enalapril #$)<$mg6zi!
Tratamentul cu IE&
!
"aspunsul clinic maxim necesita 0)# luni
!
Tratamentul trebuie mentinut pentru
efectele asupra mortalitatii si
respitalizarii
Problemele trat cu IE&
2ipotensiune + problematic daca se insoteste de
disfunctie renala% sincopa! ai frecvent in
primele zile!

Pacientii cu activarea marcata a sistemului
renina angiotensina au cel mai frecvent
hipotensiune! Acestia sunt identificati prin
hiponatremie .-a708$mmol631!
Solutia; doze mici de IE&!
oprirea adm de diuretic 0)# zile
Problemele tratamentului cu IE&
Agravarea functiei renale )
&resterea creatininei .=$!5mg6d31 la 05)8$B din
pacientii cu insuficienta cardiaca severa si 5)05B
din pacientii cu simptome usoare!
"iscul este crescut la pacientii cu stenoza a renala
sau pacientii in trat cu antiinflamatorii
nesteroidiene!
Problemele tratamentului cu IE&
2iper*alemia pac cu afectarea functiei renale%
varstici% in trat cu spironolactona% la diabetici!
Tusea ) 5)05B din pacienti! Apare in primele lunii
ale tratamentului! Dupa oprirea tratamentului in
0)# saptamani!
Angioedem .70B1

ANGIOTENSIN II INHI@ITORS
MECHANISM OF ACTION
RENIN
Angitensingen Angitensin I
ANGIOTENSIN II

ACE
Ot/er $at/s
Vascnstrictin Prli(erati%e
Actin
Vas&ilatatin Anti$rli(erati%e
Actin
AT8 AT9
AT8
RECEPTOR
@#OC5ERS
RECEPTORS
AT8 RECEPTOR @#OC5ERS
DRUGS
#sartan
Valsartan
Ir4ersartan
Can&ersartan
C"$etiti%e an& selecti%e
4lc!ing ( AT8 rece$trs
(locantii de receptori de angiotensina ) sartani
In caz de intoleranta la IE&
-u s)a dovedit superioritatea lor fata de IE&
Au aceleasi contraindicatii
Effects of chronic beta adrenergic
stimulation in the failing heart
@eta rece$tr @eta rece$tr
&Fn regulatin &Fn regulatin
Re&uce& Re&uce&
$er(r"ance $er(r"ance
Heart Heart
(ailure (ailure
Car&iac Car&iac
&'s(unctin &'s(unctin
M'c'te M'c'te
&a"age &a"age
Hig/ $las"a Hig/ $las"a
nra&renaline nra&renaline
Efecte adverse ale activarii simpatice in
insuficienta cardiaca
&is(unctia si "artea car&i"icitelr
&is(unctia si "artea car&i"icitelr
$r%carea isc/e"iei "icar&ice
$r%carea isc/e"iei "icar&ice
$r%carea arit"iilr
$r%carea arit"iilr
cresterea (rec%entei car&iace
cresterea (rec%entei car&iace
,)2eFT II studC; "elationship betDeen plasma
norepinephrine and mortalitC
Cu"ulati%e "rtalit' +D, Cu"ulati%e "rtalit' +D,
: : 8< 8< A: A: B9 B9 >: >:
Mnt/s Mnt/s
8:: 8::
<: <:
>: >:
B: B:
9: 9:
: :
> > 89 89 9B 9B A> A> B< B< ?B ?B
PNE G;:: $g0"l PNE G;:: $g0"l
PNE >::H;:: $g0"l PNE >::H;:: $g0"l
PNE C>:: $g0"l PNE C>:: $g0"l
TF 'ear TF 'ear
p pC:*:::8 C:*:::8
O%erall O%erall
p pC:*:::8 C:*:::8
Vas&ilatr1Heart Failure Trial II* Francis +8;;A, Vas&ilatr1Heart Failure Trial II* Francis +8;;A,
"enin sCstem hormones before and during
)bloc*ade in individual hCpertensive patients
O((.4e(re 14lc!a&eI .&uring 14lc!a&e
J $C:*:?
E $C:*:8 %s* (( 14lc!a&e "ean %alue
O(( O(( O(( O((
:
8
9
A
B
? >:
?:
B:
A:
9:
8:
: :
?
8:
8?
9: A?
A:
9?
9:
8?
8:
?
:
Renin
+ng0"l0/,
Prrenin
+ng0"l0/,
Angitensin II
+$g0"l,
Al&sterne
+"cg09B/,
E
E
J
@lu"en(el& et al +8;;;, @lu"en(el& et al +8;;;,
E((ects (
E((ects (

4lc!a&e
4lc!a&e
@arrece$tr restratin @arrece$tr restratin
@ra&'car&ia @ra&'car&ia
Antiarr/'t/"ic e((ects Antiarr/'t/"ic e((ects
Energetic i"$r%e"ent Energetic i"$r%e"ent
Paras'"$at/etic Paras'"$at/etic S'"$at/etic S'"$at/etic
restratin restratin Fit/&raFal Fit/&raFal
&arvedilol vs placebo in mild%
moderate and severe &2F
:aplan+eier analCsis of survival ) the FS StudC Program
Car%e&ill Car%e&ill
Place4 Place4
Pr4a4ilit' ( sur%i%al Pr4a4ilit' ( sur%i%al
Nu"4er ( $atients at ris!7 Nu"4er ( $atients at ris!7
Da's Da's : : ?: ?: 8:: 8:: 8?: 8?: 9:: 9:: 9?: 9?: A:: A:: A?: B:: A?: B::
Car%e&ill Car%e&ill >;> >;> >A= >A= ?<8 ?<8 ?B> ?B> A8B A8B 8A8 8A8 8:> 8:> <A <A 88 88
Place4 Place4 A;< A;< A?A A?A A9; A9; A:? A:? 8>A 8>A =8 =8 ?? ?? BA BA A A
Da's ( t/era$' Da's ( t/era$'
: : ?: ?: 8:: 8:: 8?: 8?: 9:: 9:: 9?: 9?: A:: A:: A?: A?: B:: B::
8*:: 8*::
:*;: :*;:
:*<: :*<:
:*=: :*=:
:*>: :*>:
Pac!er +8;;>, Pac!er +8;;>,
8*:: 8*::
Pr4a4ilit' ( Pr4a4ilit' (
e%ent1(ree e%ent1(ree
sur%i%al sur%i%al
Da's ( t/era$' Da's ( t/era$'
:*;? :*;?
:*;: :*;:
:*<? :*<?
:*<: :*<:
:*=? :*=?
:*=: :*=:
:*>? :*>?
:*>: :*>:
:*?? :*??
: : ?: ?: 8:: 8:: 8?: 8?: 9:: 9:: 9?: 9?: A:: A:: A?: A?: B:: B::
J Jp pC:*::8 C:*::8
Car%e&ill Car%e&ill
Place4 Place4
Patients at ris!7 Patients at ris!7
>;> >:= ?9; B;8 9=: 88= ;9 =: ; Car%e&ill >;> >:= ?9; B;8 9=: 88= ;9 =: ; Car%e&ill
A;< AA> 9;9 9>: 8AB >A B? A? 9 Place4 A;< AA> 9;9 9>: 8AB >A B? A? 9 Place4
* *
&arvedilol vs placebo in patients Dith
mild% moderate and severe &2F
The FS StudC Program
:aplan+eier analCsis of survival Dithout hospitalisation
Pac!er +8;;>, Pac!er +8;;>,
Effect of carvedilol vs placebo
on e9ection fraction in &2F
FS StudC Program
"jection
fraction #$%
Pac&er #'(()%
9A 9A
9? 9?
99 99
A8 A8
: :
?: ?:
Placebo
#n*+(,%
-arvedilol
#n*./)%
p*0100
0'
B: B:
A: A:
9: 9:
8: 8:
2aseline "ndpoint 2aseline "ndpoint
$.ns $.ns
&arvedilol vs placebo in patients
Dith severe &2F
:aplan+eier analCsis of ris* of cardiovascular events
8*: 8*:
:*; :*;
:*< :*<
:*= :*=
:*? :*?
Car%e&ill +n.AA, Car%e&ill +n.AA,
Place4 +n.8>, Place4 +n.8>,
p= p=:*:9< :*:9<
5ru" +8;;?, 5ru" +8;;?,
Pr$rtin ( $atients Fit/ut e%ent Pr$rtin ( $atients Fit/ut e%ent
:*> :*>
: : 9: 9: B: B: >: >: <: <: 8:: 8::
Ti"e +&a's, Ti"e +&a's,
Patient su4gru$ Patient su4gru$ Place4 Place4 Car%e&ill Car%e&ill
+D, +D, +D, +D,
Mil& /eart (ailure Mil& /eart (ailure A*= A*= :*; :*;
M&erate /eart (ailure M&erate /eart (ailure =*> =*> B*? B*?
Se%ere /eart (ailure Se%ere /eart (ailure ?*= ?*= 9*; 9*;
AgeC?; 'ears AgeC?; 'ears ?*< ?*< 9*: 9*:
Age Age

?; 'ears ?; 'ears ;*> ;*> B*A B*A

Male Male =*9 =*9 A*9 A*9
Fe"ale Fe"ale ;*> ;*> A*8 A*8
Isc/ae"ic cause Isc/ae"ic cause ;*: ;*: A*; A*;
Nn1isc/ae"ic cause Nn1isc/ae"ic cause >*= >*= 9*? 9*?
FS &arvedilol 2eart Failure Program
B deaths in patient subgroups
Pac!er +8;;>, Pac!er +8;;>,
Effect of carvedilol% bisoprolol and metoprolol on
mortalitC in &2F
!
0$G< patients Dith class II+I, &2F randomised to
placebo or carvedilol for up to 05 months
!
@5B in all)cause mortalitC .stopped bC DS(1
US Car%e&ill Heart Failure Prgra" US Car%e&ill Heart Failure Prgra"
CI@IS II trial CI@IS II trial
!
#@<> patients Dith class III+I, &2F randomised to
placebo or bisoprolol for up to 8 Cears
!
8<B in all)cause mortalitC .stopped bC DS(1
MERIT1HF trial MERIT1HF trial
!
8GG0 patients Dith class III+I, &2F randomised to
placebo or metoprolol for up to 8 Cears
!
H8<B in all)cause mortalitC .stopped bC DS(1
Pac!er +8;;>,I CI@IS1II +8;;;,I MERIT1HF +8;;=, Pac!er +8;;>,I CI@IS1II +8;;;,I MERIT1HF +8;;=,
)adrenergic bloc*ing drugs in heart failure
Principal randomized trials ) more than #5$ patients%
greater than @ months folloD)up
Annuali3e& "rtalit' rate Annuali3e& "rtalit' rate
Place4 "rtalit' Place4 "rtalit'
rate +annuali3e& D, rate +annuali3e& D,

1 14lc!er "rtalit' 4lc!er "rtalit'
rate +annuali3e& D, rate +annuali3e& D,
US Car%e&ill US Car%e&ill
8?DJ 8?DJ >DJ >DJ
CI@IS1II CI@IS1II
8A*9D 8A*9D <*<D <*<D
MERIT1HF MERIT1HF
88*:D 88*:D =*9D =*9D
J Jesti"ate& (r" = "nt/ &ata esti"ate& (r" = "nt/ &ata
Trial na"e Trial na"e Agent Agent NYHA NYHAK su4Lects K su4Lects 891"nt/ $lace4 891"nt/ $lace4 891 891
"nt/ "nt/
Class Class enrlle& enrlle& "rtalit'6 D "rtalit'6 D e((ect si3e6 D e((ect si3e6 D
ACE1Is ACE1Is
CONSENSUS1I CONSENSUS1IEnala$ril Enala$ril IV IV 9?A 9?A ?9 ?9 A8 A8
SO#VD1R2 SO#VD1R2 Enala$ril Enala$ril I1III I1III 9?>; 9?>; 8? 8? 98 98
SO#VD1As2 SO#VD1As2 Enala$ril Enala$ril I1II I1II B99< B99< ? ? : :
Ttals Ttals I1IV I1IV =:?: =:?: 88 88 8> 8>
14lc!ers 14lc!ers
CI@IS1I CI@IS1I @is$rll @is$rll III6IV III6IV >B8 >B8 88 88 9: 9:
Car%e&ill US Car%e&ill USCar%e&ill Car%e&illII6III II6III 8:;B 8:;B 8: 8: >? >?
CI@IS1II CI@IS1II @is$rll @is$rll III6IV III6IV 9>B= 9>B= 8A 8A AB AB
MERIT1HF MERIT1HFMet$rll CR Met$rll CRII1IV II1IV A;;A A;;A 88 88 AB AB
Ttals Ttals II1IV II1IV <A=? <A=? 88 88 A< A<
C"4ine& "rtalit' re&uctin6 ACE1I+ C"4ine& "rtalit' re&uctin6 ACE1I+ 14c!ers 14c!ers B< B<
EFECTE#E @ENEFICE A#E M@#OCANTE#OR
Densitatea M
8
rece$trs
In/i4a car&it2icitatea catecla"inelr
acti%area neur/r"nal
(rec%entei car&iace
Anti/i$ertensi% si antiangins
Antiarit"ic
Anti2i&ant
Anti$rli(erati%
In&icatiile I4lcantelr
FEVSCB:D
Si"$t"e usare1 se%ere IC +NYHA II1IV,
D3a $ti"a IEC0sartan +si antagnist
&e al&stern,
Clinic sta4ili +(ara "&i(icare recenta
&e &iuretic,

Vas&ilatatin
%enasa
MI-TE
Antagnists &e calciu
1a&renergic @lc!ers
IEC
SARTANI
acti%atri canale 5
+

Nitr$rusiat
VENOASE
Nitrati
Mlsi&"in
ARTERIA#E
Min2i&il
H'&rala3ine
C#ASIFICAREA
VASODI#ATOARE#OR
Vas&ilatatie
arteriala

81 VASODI#ATATIE VENOASA

Prela&
91 %as&ilatatie crnariana
$er(u3ie "icar&ica
A1 %as&ilatatie arteriala
A(terla&
B1 altele
cngestia $ul"nara
&i"ensiunea %entriculului
Stress $arietal
MVO
9
NITRATI
EFECTE HEMODINAMICE
N DC
N @P

9: "g 0 </
B
Fee!s
8::
9::
A::
B::
E-ERCISE
TIME6
ISOSOR@IDE ? 1 MONONITRATE
Jansen W et al
Med Welt 1982;33:1756
NITRATES
FUNCTIONA# CAPACITY
Cntrl
8
ST
&se
secn&s
9>=
A<B
A;9
JJ
JJ
n.9B

:*>
PRO@A@I#ITY
OF
DEATH
:
Place4 +9=A,
Pra3sin +8<A,
H3 + ISDN +8<>,
MONTHS
:*=
:*?
:*A
:*B
:*9
:*8
VHe(T18
N Engl J Med 1986;314:1547
NITRATES
SURVIVA#
: > 89 8< 9B A: A> B9

NITRATI
INDICATII
cngestie $ul"nara
Ort$nee an& &is$nee $ar2istica
ncturna
IC crnica cu isc/e"ie "icar&ial
IC acuta si e&e" $ul"nar7
NTG s*l* sau i*%*

A#DOSTERONE
Retentia Na
+
Retentia H
9
O
E2cretia 5
+
E2cretia Mg
9+
De$3itie &e
clagen
Fi4r3a
1 "icar&
1 %ase
S$irnlactne
E&e"
Arit"ii
Antagnist c"$etiti% al rece$trilr
&e al&stern
+"icar&6 $ereti arteriali6 rinic/i,
INHI@ITORI DE A#DOSTERON

INDICATII#E INHI@ITORI#OR DE A#DOSTERON
Pentru e(ect &iuretic
N cngestie $ul"nara +&is$nee,
N cngestie siste"ica+e&e"e,
Pentru e(ectele asu$ra electrlitilr
N Hi$ 5
+
6 H'$ Mg
+
N Arit"ii
N "ai 4ine &ecat su$li"ente &e 5
+
Pentru e(ecte neur/r"nale
N stu&iul RA#ES
N Engl O Me& 8;;;7AB87=:;1=8=

N Hi$er!ale"ia
N Insu( renala se%era
N aci&3a "eta4lica
Cntrai&icatiile in/i4itrilr &e al&stern

DIGO-IN
e(ecte /e"&ina"ice
DC
FEVS
PTDVS
tleranta la e(rt
natriure3a
acti%area neur/r"nala

DIGO-IN
EFECTE NEUROHORMONA#E
Plas"a Nra&renalinei $las"atice
acti%itatea siste"ului ner%s $eri(eric
acti%itatea SRAA
tnus %agal
Nr"ali3ea3a 4arrece$trii arteriali

D
PORSENING
OF CHF
$ . :*::8 DIGO-IN7 :*89? 1 :*? "g 0&
+:*= 1 9*: ng0"l,
EF C A?D
Class I1III +&ig2in+&iuretic+ACEI,
Als signi(icantl' &ecrease& e2ercise
ti"e an& #VEF*
DIGO-IN
EFFECT ON CHF PROGRESSION
RADIANCE
N Engl J Med 1993;329:1
Place4 n.;A
DIGO-IN
Pit/&raFal
DIGO-IN n.<?
A:
8:
:
9:
8:: <: 9: : B: >:
Da's

?:
B:
A:
9:
8:
:
Place4
n.AB:A
DIGO-IN
n.AA;=
B< : 89 9B A>
OVERA## MORTA#ITY
D
DIG
N Engl J Med 1997;336:525
Mnt/s
p = 0.8

DIGO-IN
C#INICA# USES
AF Fit/ ra$i& %entricular res$nse
CHF re(ractr' t t/er &rugs
Ot/er in&icatins)
Can 4e c"4ine& Fit/ t/er &rugs
Ivabradina + blocant al canalului I
f
Studiul S2IFT
"educerea end point combinat mortalitate
respitalizari
Pacienti in ritm sinusal% aflati sub doza maxim
tolerata de betablocant

@lcante &e calciu
E(ecte
Antiisc/e"ic
Vas&ilatatie $eri(erica
Sca& intr$is"ul

@lcante &e calciu
Diltia3e" cntrain&icat
Vera$a"il an& Ni(e&i$ine
nerec"an&ate
Vasselecti%e +a"l&i$ine6 nisl&i$ine,6
Utile in isc/e"ie + ICC
A"l&i$ine $ate (i utila in IC nnisc/e"ic

Anticagulante
E$isa&e e"4lice in antece&ente
Fi4rilatie atriala
Tr"43a intracar&iaca
Ane%ris" VS +A1> luni $stin(arct,
Clasa III1IV in $re3enta7
1 FE C A:D
1 Ane%ris" sau VS (arte &ilatat
Fle4ita
Re$aus la $at $relungit

Antiarit"ice
TV sustinut6 cu0(ara si"$t"e
1 M @lcante
1 A"i&arne
Nu Ic $r$a(enne
ICD

(radicardia
Indicatiile de pacing aceleasi ca pentru orice Indicatiile de pacing aceleasi ca pentru orice
alta patologie alta patologie
Pacing fiziologic DDD% nu ,,I Pacing fiziologic DDD% nu ,,I
Detectarea indicatiilor pentru I&D% &"T) P% &"T) D Detectarea indicatiilor pentru I&D% &"T) P% &"T) D
inainte de implantarea unui pacema*er pentru inainte de implantarea unui pacema*er pentru
tulburare de conducere A, tulburare de conducere A,
Pacing ,D induce asincronism si agraveaza Pacing ,D induce asincronism si agraveaza
Simptomele Simptomele
Stimularea in vederea initierii sau titrarii betablocant Stimularea in vederea initierii sau titrarii betablocant
nu este indicat nu este indicat
DA
Diuretic ' IE& .sartan1 6 Titrare pana la stabilizare
I& simptomatica cu FE redusa
betablocant
Persista semne si simptomeJ
DA -F
Antagonist de aldosteron sau sartan
Persista simptomeJ
DA
-F
/"S=0#$ms
FE,S785B
-F DA
I&D
-ici un alt
tratament
-F
De evaluat pt
&"T)P sau &"T)D
Digoxin6hidralazin)nitrat%
3,AD% transplant

3nsuficienta cardiaca cronica
3nsuficienta cardiaca cronica
Mrtalitatea H 4ligatriu &e a incerca utili3area
Mrtalitatea H 4ligatriu &e a incerca utili3area

IEC sau sartani

IEC sau sartani

Betablocante
Betablocante

Spironolactona sau eplerenona

Spironolactona sau eplerenona

Isosorbid - hidralazina
Isosorbid - hidralazina
A"elirea3a si"$t"ele H &e (lsit cn(r"
Lu&ecatii clinice

Diuretice

Nitrati

Pre$arate &e (ier

Pre$arate acti%e "eta4lic +tri"eta3i&ina6 $er/e2ilina,

i%a4ra&ina
Opie Drugs for the Heart
3nsuficienta cardiaca cronica
3nsuficienta cardiaca cronica
Pt &auna7 (lsire cu $ru&enta &u$a cantarire
4ene(iciu0risc

Intr$e si intr$e &ilatatare

Antiarit"ice cu e2ce$tia 44lcantelr

si a"i&arnei

@lcantele &e calciu

Dig2in +&ig2ine"ie :6?18ng0"l

Opie Drugs for the Heart