2009 RCC ICC1 Anexa 2 - 8815 - 6780

Revista Romn de Cardiologie | Vol. XXIV, Nr.
1, 2009
Ghidul ESC pentru diagnosticul i tratamentul insuficienei

cardiace acute i cronice 2008 Partea I
Comitetul de lucru pentru Diagnosticul i Tratamentul Insuficienei Cardiace
Acute i Cronice 2008 al Societii Europene de Cardiologie. Realizat n colaborare cu Asociaia de Insuficien Cardiac a ESC (HFA) i revizuit de Societatea
European de Terapie Intensiv (ESCIM)
Autori/Membrii Grupului de Lucru: Kenneth Dickein (Preedinte) (Norvegia)*, Alain Cohen-Solal (Frana),
Gerasimos Filippatos (Grecia), John J.V. McMurray (Marea Britanie), Piotr Ponikowski (Polonia), Philip Alexander Poole-Wilson (Marea Britanie), Anna Stromberg (Suedia), Dirk J van Veldhuisen (Olanda), Dan Atar
(Norvegia), Arno W Hoes (Olanda), Markku Nieminen (Finlanda), Silvia Giuliana Priori (Italia), Karl Swedberg
(Suedia).
Comitelul ESC pentru ghiduri practice (CPG): Alec Vahanian (Preedinte) (Frana), John Camm (Marea Britanie), Raffaele De Caterina (Italia), Veronica Dean (Frana), Kenneth Dickstein (Norvegia), Gerasimos Fillipos
(Grecia), Cristian Funck-Bretano (Frana), Irene Hellemans (Olanda), Steen Dalby Kristensen (Danemarca),
Keith McGregor (Frana), Udo Sechtem (Germania), Sigmund Silber (Germania), Michal Tendera (Polonia), Petr
Widimski (Republica Ceh), Jose Luis Zamorano (Spania).
Revizori ai documentului: Michal Tendera (CPG Coordonator) (Polonia), Angelo Auricchio (Elveia), Jeroen
Bax (Olanda), Michael Bohm (Germania), Ugo Corra (Italia), Paolo della Bella (Italia), Perry M. Elliot (Marea
Britanie), Ferenc Follath (Elveia), Mihai Komjda (Frana), Ran Kornowski (Israel), Massimo Piepoli (Italia),
Bernard Prendergast (Marea Britanie), Luigi Tavazzi (Italia), Jean-Luc Vachiery (Belgia), Freek W.A. Verheugt
(Olanda), Jose Luis Zamorano (Spania), Faiaz Zannad (Frana).
*Autor pentru coresponden: Preedinte Kenneth Dickstein, Universitatea din Bergen, Departamentul de Cardiologie, Spitalul Universitar Stavanger, N-4011 Stavanger, Norvegia. Tel +4751519453. Fax+47519921.Email: Kenneth.dikstein@med.uib.no
Acest ghid a fost prima oar publicat pe Web Site-ul Societii Europene de Cardiologie pe 30 August 2008. Acest articol a fost co-publicat n European Journal of Heart
Failure doi:10.1016/, ejheart2008.08.005
Coninutul acestui Ghid al Societii Europene de Cardiologie (ESC) a fost publicat doar pentru scop personal i educaional. Nu este autorizat nici o utilizare comercial. Nici
o parte din Ghidurile ESC nu poate tradus sau reprodus fr acordul scris al ESC. Permisiunea poate obinut prin trimiterea unei cereri scrise la Oxford University Press,
editorul European Heart Journal i parte autorizat s nmneze astfel de permisiuni n numele ESC.
Clauz: Ghidul ESC reprezint opinia ESC i a fost realizat dup analizarea atent a dovezilor disponibile n momentul n care a fost scris. Lucrtorii din domeniul sanitar
sunt ncurajai s in cont pe deplin de el cnd realizeaz judecata clinic. Ghidul totui nu trece peste responsabilitatea individual a lucrtorilor din domeniul sanitar de a lua
deciziile adecvate, consultndu-se cu pacientul, i unde este portivit i necesar cu aparintorul pacientului. Este de asemenea responsabilitatea lucrtorului n domeniul sanitar de
a verica regulile i regulamentele aplicabile la medicamente i dispozitive n momentul prescrierii.
Societatea European de Cardiologie 2008. Toate drepturile rezervate. Pentru permisiune v rugm contactai email:journals.permission@oxfordjournals.org
Traducerea: Oana Mihilescu, Cati Istrate, Rzvan Ticulescu, Victor Iorga, sub coordonarea Ovidiu Chioncel
Ghidul Societii Europene de Cardiologie.

Diagnosticul i tratamentul insuficienei cardiace acute i cronice 2008
PREAMBUL
Ghidurile i Documentele Consens al Experilor sumarizeaz i evalueaz toate evidenele disponibile despre
o anume problem cu scopul de a ajuta medicii i ali
furnizori de servicii medicale n a selecta cele mai bune
strategii de tratament pentru un anume pacient, suferind de o afeciune dat, innd cont de impactul asupra evoluiei, ca i de raportul risc-beneficiu al anumitor modaliti diagnostice i terapeutice. Ghidurile nu
nlocuiesc manualele. Implicaiile legale ale ghidurilor
medicale au fost discutate anterior.
Un mare numr de Ghiduri i Documente Consens
ale Experilor au fost publicate n ultimii ani de Societatea European de Cardiologie (ESC), ca i de alte societi si organizaii. Din cauza impactului asupra practicii
clinice, criterii de calitate pentru elaborarea ghidurilor
au fost stabilite pentru a face toate deciziile clare pentru utilizator. Recomandrile pentru formularea i producerea Ghidurilor ESC i Documentelor Consens ale
Experilor pot fi gsite pe Web Site-ul ESC la seciunea
de ghiduri (www.escardio.org).
Pe scurt, experii n domeniu sunt selectai i desfoar o revizuire cuprinztoare a datelor publicate
despre managementul i/sau prevenia unei anumite
afeciuni.
Este realizat o evaluare critic a procedurilor diagnostice i terapeutice, incluznd aprecierea raportului
risc-beneficiu. Sunt incluse estimri despre consecinele asupra sntii pentru grupuri mai mari, acolo unde
exist date. Nivelul de eviden i importana recomandrilor pentru o anume opiune de tratament sunt
apreciate i gradate n acord cu scale predefinite, dup
cum este artat n Tabelele 1 i 2.
Tabelul 1: Clase de recomandare
Clase de
recomandare
Clasa I
Clasa II
Clasa II a
Clasa II b
Clasa III
Definiie
Dovada i/sau acordul general ca un tratament sau o procedur date
sunt benefice, folositoare, eficiente.
Dovezi conflictuale i/sau o divergen de opinii cu privire la utilitatea/
eficiena unui tratament sau procedur date
Aprecierea dovezilor/opiniilor este n favoarea utilitii/eficacitii
Utilitatea/eficacitatea este mai puin stabilit de ctre dovezi/opinii.
Dovad sau acord general ca un tratament sau procedur date nu este
util/eficient i n anumite cazuri poate fi duntor
Tabelul 2: Nivele de eviden

Nivel de eviden A
Nivel de eviden B
Nivel de eviden C
Date obinute din trialuri clinice multiple randomizate sau metaanalize

Date obinute dintr-un singur trial clinic randomizate sau studii mari
nerandomizate
Consens de opinii ale experilor i/sau studii mici, studii retrospective,
registre
Revista Romn de Cardiologie

Vol. XXIV, Nr. 1, 2009
Experii din comitetul de redactare au pus la dispoziie declaraii cu privire la toate legturile pe care le-ar
putea avea i care ar putea fi percepute ca surse reale sau
poteniale de conflict de interes. Aceste declaraii sunt
pstrate n dosar la Casa European a Inimii, centru al
ESC. Orice schimbare n ceea ce privete conflictul de
interes care apare n perioada redactrii trebuie s fie
anunat la ESC. Raportul Comitetului de redactare a
fost susinut financiar n ntregime de ctre ESC, i a
fost produs fr orice implicare a industriei.
Comitetul ESC pentru Ghiduri de Practic (CPG)
supervizeaz i coordoneaz pregtirea unui nou Ghid
sau Document Consens al Experilor produs de Comitetele de redactare, grupuri de experi sau liste pentru
elaborarea de consens-uri. Comitetul este de asemenea responsabil pentru procesul de aprobare al acestor
Ghiduri, Documente Consens al Experilor i Declaraii. Odat ce documentul a fost finalizat i aprobat de
toi experii implicai n Comitetul de Redactare, acesta
este prezentat specialitilor din afar pentru a fi revizuit. Documentul este revizuit i n cele din urm aprobat
de ctre CPG i ulterior publicat.
Dup publicare, difuzarea mesajului este de o importan capital. Versiuni de buzunar i versiuni personal digital assistant (PDA) ce pot fi descrcate de pe
internet sunt utile la locul de munc. Anumite studii au
artat c destinatarii finali nu tiu uneori de existena
ghidurilor sau pur i simplu nu le transpun n practic,
i din acest motiv, programele de implementare pentru
noile ghiduri formeaz o component important a rspndirii informaiei. Sunt organizate ntlniri de ctre
ESC destinate Societilor Naionale i liderilor principali de opinie din Europa. ntlnirile de implementare
pot fi desfurate i la nivel naional, odat ce ghidurile
au fost aprobate de societile membre ale ESC i traduse n limbile naionale. Programele de implementare
sunt necesare pentru c s-a demonstrat c evoluia bolii
poate fi influenat favorabil de aplicarea contiincioas
a recomandrilor clinice.
Astfel, scopul redactrii Ghidurilor i Documentelor
Consens al Experilor acoper nu numai integrarea celor mai recente cercetri, dar i crearea de instrumente
educaionale i implementarea de programe pentru recomandri. Legtura dintre cercetarea clinic, redactarea de ghiduri i implementarea lor n practica clinic
poate fi complet doar dac sunt realizate studii i registre pentru a verifica dac practica de zi cu zi din viaa real este n acord cu ceea ce este recomandat de ctre ghiduri. Astfel de studii i registre fac de asemenea
posibil evaluarea impactului implementrii ghidurilor

asupra evoluiei pacientului. Ghidurile i recomandrile ar trebui s ajute medicii i alte persoane implicate n
furnizarea de servicii de sntate s ia decizii n practica zilnic. Totui, judecata ultim cu privire la ngrijirea
fiecrui pacient n parte trebuie s fie fcut de ctre
medicul responsabil de ngijirea lui.
INTRODUCERE
Ghiduri de insuficien cardiac

Scopul acestui document este s ofere un ghid practic
pentru diagnosticul, evaluarea i tratamentul insuficienei cardiace (IC) acute i cronice. Acest ghid constituie o dezvoltare i o revizuire a ghidurilor publicate
n 19951, 19972, 20013 i 20054,5. Au aprut multe informaii noi referitoare la insuficiena cardiac. Aceasta a dus la necesitatea unei revizuiri a recomandrilor
anterioare. Recomandrile sunt legate de practica clinic, studiile epidemiologice, studii observaionale i
trialuri clinice. O atenie deosebit a fost acordat n
aceast revizuire simplitii i claritii i problemelor
legate de implementare. Intenia a fost de a mbina i
a modifica documentele anterioare legate de IC. Ghidul intenioneaz s fie un suport pentru medici i alte
persoane implicate n furnizarea serviciilor de sntate,
oferind sfaturi despre cum s abordeze aceti pacieni,
incluznd recomandri pentru trimiterea lor mai departe. Dovezi documentate i publicate despre diagnosticul, eficacitatea i sigurana interveniilor terapeutice
reprezint baza principal a acestui ghid. Acolo unde
dovezile lipsesc sau nu rezolv o problem clinic, este
prezentat o opinie consensual.
Ghidul se adreseaz celor 51 de state membre, cu
economii diferite, i de aceea recomandrile bazate pe
cost eficien au fost n general evitate. Politica naional de sntate, ca i judecata clinic, poate dicta ordinea prioritilor n implementare. Recomandrile din
acest ghid trebuie ntotdeauna s fie avute n vedere n
lumina politicilor naionale i a reglementrilor locale
cu privire la folosirea oricarei proceduri diagnostice, a
medicaiei i a diferitelor dispozitive.
Acest raport a fost schiat de un Grup de Redactare
al Comitetului (vezi pagina de titlu), desemnat de ctre
CPG al ESC. n cadrul acestui Comitet de Redactare
au fost strnse declaraiile cu privire la conflictul de interese, acestea fiind disponibile la biroul ESC. Schia a
fost trimis la CPG i la cei responsabili cu verificarea
documentului (vezi pagina de titlu). Dup consideraii
despre datele introduse, documentul a fost modificat,
revizuit i apoi aprobat pentru publicare de ctre ntreg
Comitetul de Redactare. O abordare bazat pe dovezi

a fost folosit pentru generarea gradului oricrei recomandri din ghid, cu o evaluare adiional a calitii
evidenei. Pentru diagnosticul IC, dovezile sunt incomplete. Acolo unde se ntmpl acest lucru, recomandrile i declaraiile se bazeaz pe un consens al opiniilor
experilor.
Definiie i diagnostic
Definiia insuficienei cardiace
Multe definiii ale IC au fost prezentate n ultimii
50 de ani6. Acestea scot n eviden una sau mai multe caracteristici ale acestui sindrom complex, cum ar fi
hemodinamica, consumul de oxigen sau capacitatea de
efort. n ultimii ani, cele mai multe definiii au subliniat nevoia de a fi prezente att simptomele de IC, ct i
semnele clinice ale reteniei de fluide5,7-9.
IC este un sindrom n care pacienii trebuie s aib
urmtoarele caracteristici: simptome de IC: tipic dispnee de repaus i n timpul efortului, i/sau oboseal;
semne de retenie hidric cum ar fi congestia pulmonar i edemaierea gleznelor i dovad obiectiv a unei
anomalii de structur sau funcie a cordului n repaus
(Tabelul 3). Doar un rspuns clinic la tratament intit
pentru IC nu este suficient pentru diagnostic, dar este
de ajutor atunci cnd diagnosticul rmne neclar dup
investigaiile corespunztoare. Pacienii cu IC ar trebui
n mod obinuit s prezinte o ameliorare a simptomelor
i semnelor ca rspuns la acele tratamente de la care
ar putea fi anticipat o mbuntire relativ rapid (ex.
administrarea de diuretic sau vasodilatator). Manifestrile clinice majore i comune n IC sunt prezentate n
Tabelul 4.
Tabelul 3. Definiia insuficienei cardiace
Insuficiena cardiac este un sindrom clinic n care pacienii au urmtoarele caracteristici:
Simptome tipice de insuficien cardiac
(respiraie dificil n repaus sau n timpul exerciiului, fatigabilitate, oboseal, umflarea gleznelor)
i
Semne tipice de insuficien cardiac
(tahicardie, tahipnee, raluri pulmonare, revrsat pleural, presiune venoas jugular crescut,
edeme periferice, hepatomegalie)
i
Dovad obiectiv de anomalie a cordului n repaus, structural sau funcional
(cardiomegalie, zgomot trei, sufluri cardiace, anomalii ale ecocardiogramei, concentraie crescut
a peptidului natriuretic)
Anomaliile cardiace structurale i funcionale asimptomatice sunt considerate ca precursori ai IC simptomatice i sunt asociate cu o mortalitate ridicat10,11.
Exist tratament pentru aceste situaii cnd sunt diagnosticate, i din acest motiv ele sunt incluse n ghidul
de fa.
Un avantaj al definiiei IC folosite aici este faptul c
este practic i permite o abordare mai corect att n

practica clinic, ct i atunci cnd se desfoar studii

observaionale, epidemiologice sau trialuri clinice. IC
nu trebuie niciodat s fie un diagnostic solitar. Cauza
trebuie ntotdeauna avut n vedere.
Tabelul 4. Manifestri clinice obinuite ale insuficienei cardiace
Caracteristici clinice
dominante
Edeme/congestie periferic
Simptome
Dispnee
Oboseal, fatigabilitate
Anorexie
Edem pulmonar
Dispnee sever n repaus
oc cardiogen (sindrom de
debit sczut)
Confuzie
Slbiciune
Periferie rece
Dispnee
Tensiune arterial crescut

(insuficien cardiac hipertensiv)
Insuficien cardiac dreapt
Dispnee
Fatigabilitate
Semne
Edeme periferice
Presiune venoas jugular crescut
Edem pulmonar
Hepatomegalie, ascit
Suprancrcare de fluide (congestie)
Caexie
Raluri pulmonare, revrsat
Tahicardie, tahipnee
Perfuzie periferic sczut
TAs<90 mmHg
Anurie sau oligurie
De obicei TA crescut, hipertrofie
VS, i FE prezervat
Dovada disfunciei VD
PVJ crescut, edeme periferice, hepatomegalie, congestie intestinal
Termeni descriptivi n insuficiena cardiac

Insuficiena cardiac acut i cronic
Multe cuvinte sau fraze suplimentare sunt folosite
pentru a caracteriza pacienii cu IC. Aceti termeni se
pot suprapune, i medicii folosesc uneori cuvinte cu un
neles uor diferit. Cuvntul acut n contextul IC
acute a devenit surs de confuzii deoarece unii clinicieni folosesc cuvntul pentru a defini severitatea (urgena medical sau edem pulmonar amenintor de via),
i alii folosesc cuvntul pentru a indica IC decompensat, cu debut recent sau de novo4. Cuvntul este atunci
un indicator al timpului mai degrab dect al severitii. Cuvintele acut, avansat i decompensat nu trebuie folosite interschimbabil cnd este vorba de IC.
O clasificare util a IC bazat pe natura prezentrii
clinice este artat n Tabelul 5. Este fcut o distincie
ntre IC nou instalat, IC tranzitorie i IC cronic. IC
nou instalat aa cum i spune i numele se refer la
prima prezentare. IC tranzitorie se refer la IC simptomatic pentru o perioad limitat de timp, dei tratamentul pe termen ndelungat poate fi indicat. Exemple
ar fi pacienii cu miocardit la care recuperarea este
aproape complet, pacienii cu infarct de miocard (IM)
care necesit diuretice n unitatea de terapie intensiv
coronarian, dar la care tratamentul pe termen lung nu
este necesar, sau IC tranzitorie produs de ischemie i
rezolvat prin revascularizare. Agravarea IC pe un fond
de IC cronic (decompensarea) este de departe cea mai

obinuit form de IC care duce la internarea n spital,

fiind responsabil pentru 80% din cazuri. Tratamentul
ar trebui individulizat n funcie de prezentarea clinic pentru care terapia specific este indicat (ex. Edem
pulmonar, urgen hipertensiv, IM acut).
Tabelul 5. Clasificarea insuficienei cardiace
Nou aparut
Tranzitorie
Cronic
Prima prezentare
Acut sau cu debut lent
Recurent sau episodic
Persistent
Stabil, agravat sau decompensat
Tabelul 6. Clasificarea insuficienei cardiace dup anomaliile structurale

(ACC/AHA), sau dup simptome legate de capacitatea funcional (NYHA)
Stadii ACC/AHA de insuficien cardiac
Stadii ale insuficienei cardiace bazate pe structura i
afectarea muchiului cardiac
Stadiul A La risc nalt pentru dezvoltarea
insuficienei cardiace.Fr anomalie structural sau
funcional identificat; fr semne sau simptome
Stadiul B Boal cardiac structural dezvoltat care
este strns legat de posibilitatea apariiei insuficienei cardiace, dar fr semne sau simptome
Clasificarea funcional NYHA

Severitate bazat pe simptome i
activitate fizic
Clasa I Fr limitare a activitii fizice.
Activitatea fizic obinuit nu produce
oboseal, palpitaii sau dispnee
Clasa II Uoar limitare a activitii fizice.
Confortabil n repaus, dar activitatea fizic
obnuit produce oboseal, palpitaii,
dispnee
Stadiul C Insuficiena cardiac simptomatic asociat Clasa III Limitare marcat a activitii
cu boal cardiac structural subiacent
fizice. Confortabil n repaus, dar o activitate mai mic dect cea obinuit produce
oboseal, palpitaii, dispnee
Stadiul D Boal structural cardiac avansat i

Clasa IV Incapabil s desfoare orice
simptome marcate de insuficien cardiac n repaus activitate fizic fr discomfort. Simptome
n ciuda terapiei medicale maximale
n repaus. Dac se desfoar orice
activitate fizic, discomfortul crete
ACC=Colegiul American de Cardiologie; AHA=Asociaia American a Inimii. Hunt SA et al. Circulation
2005;112:18251852.
Comitetul de Criterii al Asociaiei Inimii din New York. Nomenclatura i Criteriile de Diagnostic al Bolilor Inimii i
Marilor Vase. 9th ed. Little Brown & Co; 1994. pp 253256.
Insuficien cardiac sistolic vs. diastolic

Se face frecvent o distincie ntre IC sistolic i diastolic12,13. Distincia este pe undeva arbitrar14,16. Pacienii cu IC diastolic au simptome i/sau semne de
IC i o fracie de ejecie a ventriculului stng prezervat (FEVS) >40-50%. Nu exist un consens cu privire
la valoarea limit pentru FE prezervat. FE reprezint
volumul btaie mprit la volumul telediastolic al cavitii ventriculare respective i de aceea este n mare msur determinat de volumul telediastolic al cavitii
ventriculare (deci de cordul dilatat). O FE sub sau peste
40% face distincia ntre volume telediastolice mari sau
normale. Distincia a aprut pentru c n trecut cei mai
muli pacieni internai n spital pentru investigaii sau
intrai n trialuri clinice aveau inimi dilatate cu o FE
redus <35 sau 40%. Cei mai muli pacieni cu IC au
dovezi de disfuncie att sistolic, ct i diastolic n repaus sau n timpul exerciiului. IC diastolic i sistolic

nu trebuie considerate ca entiti separate18. Alte sintagme au fost folosite pentru descrierea IC diastolice,
cum ar fi IC cu fracie de ejecie prezervat (ICFEP),
IC cu fracie de ejecie normal (ICFEN), sau IC cu
funcie sistolic prezervat (ICFSP). Am ales s folosim
abrevierea ICFEP n acest document.
Ali termeni descriptivi n insuficiena cardiac
Multe alte fraze au fost folosite pentru descrierea pacienilor cu IC i care nu au semnificaie etiologic. IC
anterograd i retrograd sunt termeni vechi folosii
pentru a exprima conceptul conform cruia, perfuzia
tisular i presiunea crescut n atriul stng pot n anumite circumstane, cum ar fi IC acut sau ocul cardiogen, s contribuie la fiziopatologie19,20. Presarcina i
postsarcina sunt termeni legai de presiunea n atriul
stng i/sau drept (adesea reflectnd suprancrcarea
volemic) i munca miocardului (adesea reflectnd suprasarcina de presiune i impedana crescut). Totui,
msurtorile acestor parametrii sunt adesea imprecise. IC dreapt sau stng se refer la sindroame ce se
prezint predominant cu congestie a venelor sistemice
sau pulmonare, ducnd la semne de retenie hidric cu
edeme ale gleznelor i, respectiv, edem pulmonar. Cea
mai frecvent cauz de insuficien cardiac dreapt
este o presiune crescut n artera pulmonar datorit
insuficienei VS, ducnd la hipoperfuzie a rinichiului,
retenie de sare i ap i acumularea de fluide n circulaia sistemic. IC cu debit cardiac crescut i sczut se
refer la observaia c un numr de situaii medicale
specifice duc la un tablou clinic care mimeaz semnele i simptomele de IC. Cauze obinuite ale condiiilor
cu debit crescut, mimnd IC sunt anemia, tireotoxicoza, septicemia, insuficiena hepatic, unturile arterio-venoase, boala Paget i beri-beri. n aceste situaii,
anomalia primar nu este boala de inim i starea este
reversibil cu tratament. Situaiile sunt mai bine clasificate ca IC secundar debitului circulator crescut i sunt
importante pentru c sunt tratabile i ar trebui excluse
cnd este diagnosticat IC.
IC uoar, moderat sau sever sunt termeni folosii
pentru o descriere clinic, simptomatic, n care termenul uoar este folosit pentru pacieni care se pot deplasa fr o limitare important legat de apariia simptomelor (dispnee, oboseal), sever pentru pacieni care
sunt marcat simptomatici i necesit ngrijiri medicale
frecvente, i moderat pentru cohorta de pacieni rmas. Dou clasificri (Tabelul 6) ale severitii IC sunt
ntrebuinate frecvent. Una se bazeaz pe simptome i
capacitatea de efort (clasificarea funcional New York
Heart Association NYHA21,22). Clasificarea funcional
NYHA s-a dovedit a fi util clinic i este folosit de ru-

tin n majoritatea trialurilor clinice. Cealalt descrie

IC n stadii bazate pe afectarea structural i simptome.
Toi pacienii cu IC franc sunt n stadiul C i D7.
Epidemiologie
Multe date sunt cunoscute despre epidemiologia
IC23-27. ESC reprezint ri cu o populaie de >900 milioane de locuitori, i sunt cel puin 15 milioane de pacieni cu IC n aceste 51 de ri. Prevalena disfunciei
ventriculare asimptomatice este similar, astfel nct IC
sau disfuncia ventricular asimptomatic este prezent la ~4% din populaie. Prevalena IC este ntre 2 i 3%
i crete brusc la ~75 de ani, astfel nct prevalena la
persoanele ntre 70 i 80 de ani este ntre 10 i 20%. La
grupurile de vrst mai tnr IC este mai frecvent la
brbai deoarece cea mai frecvent cauz, boala cardiac ischemic, apare la decade mai timpurii. La vrstnici, prevalena este egal ntre sexe.
Prevalena general a IC este n cretere datorit
mbtrnirii populaiei, succesului n prelungirea supravieuirii pacienilor care au suferit evenimente coronariene, i succesului n amnarea evenimentelor coronariene datorit preveniei eficiente la cei cu risc nalt
sau la cei care au supravieuit deja unui prim eveniment
(prevenie secundar)28,29. n unele ri mortalitatea
ajustat la vrst legat de IC este n scdere, n parte datorit tratamentului modern28,30-32. Vrsta medie
a pacienilor cu IC n comunitate n rile n curs de
dezvoltare este 75 de ani. ICFEP este mai frecvent la
vrstnici, femei, i la cei cu hipertensiune sau diabet.
IC este cauza a 5% din internrile de urgen n spital, este responsabil de 10 % din paturile ocupate i
este rspunztoare de ~2% din cheltuielile naionale de
sntate, n special datorit costurilor spitalizrilor33.
Subestimarea substanial a prevalenei IC se datoreaz
preferinei clinicienilor pentru diagnostice etiologice
(ex. stenoza aortic) sau diagnosticul unei comorbiditi majore (ex. diabet).
Perspectiva este n general ntunecat, dei unii pacieni pot tri muli ani23,29,34,35. n general 50% dintre pacieni sunt decedai la 4 ani. Patruzeci la sut dintre pacienii internai cu IC sunt decedai sau reinternai pn
ntr-un an. Studiile arat c acurateea diagnosticului
de IC doar prin mijloace clinice este adesea inadecvat,
mai ales la femei, vrstnici i obezi36,37. ICFEP (FE >4550%) este prezent la o jumtate dintre pacienii cu IC.
Prognosticul n studiile mai recente s-a dovedit a fi n
cele din urm similar cu cel al IC sistolice38,39.
Etiologia insuficienei cardiace
Exist doar un numr limitat de modaliti prin care
funcia inimii poate fi afectat. Cele mai obinuite cau

ze de deteriorare funcional a inimii sunt lezarea sau

pierderea de esut cardiac, ischemia acut sau cronic,
creterea rezistenei vasculare n cadrul hipertensiunii,
sau dezvoltarea unei tahiaritmii cum ar fi fibrilaia atrial (FA). Boala cardiac ischemic este de departe cea
mai frecvent cauz de afectare miocardic, fiind cauza
declanatoare la ~70% dintre pacienii cu IC38,40. Valvulopatiile sunt responsabile de 10% i cardiomiopatiile
de nc 10% (Tabelul 7).
Tabelul 7. Cauze obinuite de insuficien cardiac datorat afectrii
muchiului cardiac (boli miocardice)
Boal cardiac ischemic
Hipertensiune
Cardiomiopatii*
Droguri
Toxine
Endocrine
Nutriional
Infiltrative
Altele
Multe manifestri
Adesea asociat cu hipertrofie de ventricul stng i fracie de ejecie
prezervat
Familiale/genetice sau non-familiale/non-genetice (incluznd dobndite ex miocardite)
Hipertrofic (CMH), dilatativ(CMD), restrictiv(CMR), aritmogen de
ventricul drept (CAVD), neclasificate
- blocante, antagoniti de calciu, antiaritmice, ageni citotoxici
Alcool, medicaie, cocain, urme de elemente (mercur, cobalt,
arsenic)
Diabet zaharat, hipo/hipertiroidism, sindrom Cushing, insuficiena
adrenal, exces de hormon de cretere, feocromocitom
Deficien de tiamin, selenium, carnitin. Obezitate, caexie
Sarcoidoz, amiloidoz, hemocromatoz, boal de esut conjunctiv
Boala Chagas, infecia HIV, cardiomiopatia peripartum, insuficiena
renal terminal

Simpome i semne de insuficien cardiac

Simptomele i semnele de IC sunt cheia detectrii precoce, deoarece ele i fac pe pacieni s caute ngrijire
medical. Luarea unei bune anamneze i examenul fizic
atent sunt ndemnri esenial de a fi stpnite (Tabelul
8). Dispneea, oboseala i fatigabilitatea sunt simptomele caracteristice, dar evidenierea i evaluarea acestor
simptome, n special la vrstnici, necesit experien i
ndemnare44-46. Semnele clinice de IC (Tabelul 9) trebuie evaluate n cadrul unei examinri clinice atente,
incluznd observaia, palparea i auscultaia47-51. Ca i
simptomele, semnele de IC pot fi greu de interpretat,
nu doar la pacienii vrstnici, dar i la obezi. Suspiciunea clinic de IC trebuie deci s fie confirmat de teste
mai obiective, direcionate n mod special spre evaluarea funciei cardiace.
Tabelul 8. Aspecte cheie ale istoricului clinic la pacienii cu insuficien
cardiac
Simptome
Evenimente cardiovasculare
*Vezi textul pentru detalii
O cardiomiopatie este o afectare miocardic n care

muchiul cardiac este structural i funcional anormal,
[n absena bolii cardiace ischemice (BCI), hipertensiunii, bolii valvulare sau bolii cardiace congenitale], suficient pentru a cauza anomalia miocardic observat41.
O clasificare a cardiomiopatiilor a fost recent publicat de Grupul de Lucru pentru Boli Miocardice i
Pericardice al ESC41. Asociaia American a Inimii a
emis o declaraie tiinific42. Amndou in cont de
progresele mari realizate recent n nelegerea originii
genetice i a biologiei cardiomiopatiilor. Propunerea
european a fost ghidat de semnificaia noii clasificri
pentru practica clinic de zi cu zi i menine fenotipurile morfofuncionale definite anterior, care sunt mai
departe subdivizate n forme familiale/genetice i nonfamiliale/non-genetice. Clasificarea european a abandonat vechea difereniere ntre cardiomiopatii primare i secundare i nu include canalopatiile ionice
ntre cardiomiopatii.
Diagnosticul insuficienei cardiace
n 1933 Sir Thomas Lewis scria n tratatul su de boli cardiace c lucrul esenial n medicina cardiovascular este recunoterea insuficienei cardiace n stadiile precoce42.
Profilul de risc
Dificultate n respiraie
(Ortopnee, dispnee,
Fatigabilitate
paroxistic nocturn)
Angin, palpitaii, sincop
(oboseal, extenuare)
Infarct miocardic
Tromboliz
Intervenional
PCI
Alte chirurgii
CABG
Stroke sau boal vascular periferic
Boal
sau disfuncie valvular
Istoric familial, fumat, hiperlipidemie, hipertensiune, diabet
Rspuns la tratamentul
curent sau anterior
Tabelul 9. Aspecte cheie ale examinrii clinice la pacienii cu
insuficien cardiac
Aspect
Puls
Tensiune arterial
ncrcare volemic
Plmni
Cord
Stare de alert, status nutriional, greutate

Frecven, ritm i caracter
Sistolic, diastolic, presiunea pulsului
Presiune venoas jugular
Edeme periferice (glezne i sacrum) hepatomegalie, ascit
Frecven respiratorie
Raluri
Revrsat pleural
Deplasarea apexului
Ritm de galop, zgomot trei cardiac
Suflu sugernd disfuncie valvular
Algoritm pentru diagnosticul insuficienei cardiace

Un algoritm pentru diagnosticul IC i al disfunciei
VS este prezentat n Figura 1. Diagnosticul de IC nu
este de ajuns singur. Investigaiile adecvate sunt necesare pentru a stabili cauza IC, deoarece tratamentul
general al IC este acelai pentru cei mai muli pacieni,
unele etiologii necesit tratamente specifice i pot fi corectate.


de simptome. Pacienii ar trebui titrai pn la dozele

optime tolerate.
Severitatea insuficienei cardiace este cel mai frecvent clasificat folosind clasificarea funcional NYHA.
O clasificare mai recent se bazeaz att pe structura
cordului, ct i pe simptome. n contextul IM sunt folosite alte dou clasificri ale severitii IC, clasificrile
Killip57 i Forrester58 (Tabelul 10).
Tabelul 10. Dou clasificri ale severitii insuficienei cardiace n
contextul infarctului miocardic acut
Clasificare Kilip
Creat s ofere o estimare clinic a severitii afectrii
circulaiei n tratamentul infarctului miocardic acut
Figura 1. Schem pentru diagnosticul IC prin peptidele natriuretice la
pacienii fr tratament i cu simptome sugestive de IC.
Stadiul I
Cauzele simptomelor n insuficiena cardiac

Originea simptomelor n IC nu este pe deplin neleas52-55. Creterea presiunii capilare pulmonare este
fr ndoial responsabil de edemul pulmonar i dispnee n contextul IC acute cu eviden de suprancrcare de fluide. Din contr, studii efectuate n timpul exerciiului la pacieni cu IC cronic demonstreaz doar o
slab legtur ntre presiunea capilar i performana
fizic. IC este o afeciune care n cele din urm duce
la determinri patologice n toate organele corpului.
Oboseala i fatigabilitatea sunt simptome frecvent relatate, dar sunt nespecifice, cu multiple cauze. Pierderea
masei i a forei muchilor scheletici este o manifestare
tardiv55,56. Semnalele de la muchii scheletici sunt adesea interpretate de ctre creier ca dispnee sau oboseal.
Acest lucru poate explica de ce rspunsul la tratament
poate fi lent la pacienii cu IC, deoarece calitatea muchilor scheletici trebuie refcut. Variaii ale gradului
regurgitrii mitrale sau disritmii tranzitorii, obinuite
n IC, vor exacerba de asemenea dispneea.
Stadiul II
Simptomele i severitatea insuficienei cardiace

Exist o relaie slab ntre simptome i severitatea
disfunciei cardiace. Simptomele sunt legate mai strns
de prognostic dac persist dup terapie, i pot fi folosite pentru a clasifica severitatea IC i pentru a monitoriza efectele terapiei. Totui, doar simptomele nu
trebuie s ghideze titrarea optim a inhibitorilor neuro-hormonali cum ar fi inhibitorii de enzim de conversie ai angiotensinei (IECA), blocanii receptorilor
de angiotensin (BRA), -blocante i antagonitii de
aldosteron, deoarece aceste medicamente influeneaz
mortalitatea ntr-o manier care nu e legat ndeaprope
Stadiul III
Stadiul IV
Clasificare Forrester
Creat s descrie statusul clinic
i hemodinamic n infarctul
miocardic acut
Fr insuficien cardiac
1. Perfuzie i presiune capilar
Fr semne clinice de decompensare
pulmonar blocat normal
cardic
(PCPB estimare a presiunii din
atriul stng)
Insuficien cardiac
2. Perfuzie slab i PCPB sczut
Criteriile diagnostice includ raluri, galop Z3 (hipovolemic)
i hipertensiune venoas pulmonar
3. Perfuzie aproape normal i
Congestie pulmonar cu raluri umede
PCPB crescut (edem pulmonar)
n jumtatea inferioar a cmpurilor
pulmonare
Insuficien cardiac sever
4. Perfuzie sczut i PCPB
Edem pulmonar franc cu raluri pe toat
crescut (oc cardiogen)
suprafaa cmpurilor pulmonare
oc cardiogen
Semnele includ hipotensiune (TAS <90
mmHg) i eviden de vasoconstricie
periferic cum ar fi oliguria cianoza i
transpiraia
Kilip T., 3rd, Kimball JT. Treatment of myocardial infarction in a coronary care unit. A two-year experience with 250
patients. Am J Cardiol 1967; 20: 457-464. Forrester JS, Diamond GA , Swan HJ. Correlative clasification of clinical
and haemodynamic function after acute myocardial infarction. Am J Cardiol 1977; 39: 137-145.
TEHNICI DIAGNOSTICE
Teste diagnostice n insuficiena cardiac
Mai multe teste diagnostice sunt folosite de rutin pentru a confirma sau exclude diagnosticul de IC (Tabelul
11).Testele diagnostice sunt de obicei cel mai sensibile
pentru decelarea pacienilor cu IC i FE redus. Constatrile diagnostice sunt adeseori mai puin pronunate la pacienii cu ICFEP. Ecocardiografia este cea mai
util metod pentru evaluarea disfunciei sistolice i
diastolice.
Urmtoarele investigaii sunt considerate potrivite
pentru pacienii cu IC. Totui, recomandrile reprezint n mare msur un consens al opiniilor experilor,
fr evidene documentate adecvat. Se aplic nivelul de
eviden C, dac nu este altfel precizat.
Electrocardiograma
O electrocardiogram (ECG) trebuie efectuat la fiecare pacient cu suspiciune de insuficien cardiac.

Tabelul 11. Evaluri diagnostice care susin prezena insuficienei
cardiace
Evaluare
Simptome compatibile
Semne compatibile
Disfuncie cardiac la ecocardiografie
Rspuns al simptomelor sau semnelor la
terapie
EKG
Normal
Anormal
Disritmie
Laborator
BNP/ NT-proBNP crescute
BNP/NT-proBNP sczute sau normale
Hiponatremie
Disfuncie renal
Cretere uoar a troponinei
Radiografie toracic
Congestie pulmonar
Capacitate de exerciiu redus
Teste pulmonare funcionale anormale
Hemodinamic anormal n repaus
Diagnosticul insuficienei cardiace

Susine dac prezent
Se opune dac normal
sau absent
++
++
++
+
+++
+++
+++
++
++
+++
++
+
+
+++
+
+
+
+
+
+++
+
+
+
+++
+++
+
+++
+
++
+
++
+ = importan mic; ++ = importan intermediar; +++ = importan mare
Tabelul 12. Anomalii EKG obinuite n insuficiena cardiac

Anomalie
Cauze
Tahicardie sinusal IC decompensat, anemie, febr,
hipertiroidism
Bradicardie
blocad, digoxin
sinusal
Antiaritmice
Hipotiroidism
Boal de nod sinusal
Tahicardie atrial/ Hipertiroidism, infecie, boala
flutter/fibrilaie
valvei mitrale
IC decompensat, infarct
Aritmie ventriIschemie, infarct, cardiomiopacular
tie, miocardit, hipokaliemie,
hipomagneziemie
Supradozaj digitalic
Ischemie/infarct
Und Q
Hipertrofie VS
Bloc AV
Microvoltaj
Durata QRS >120
ms i morfologie
de tip BRS
Infarct, cardiomiopatie
hipertrofic
BRS, preexcitaie
Hipertensiune, boala valvei aortice, cardiomiopatie hipertrofic
Infarct, toxicitate medicamentoas, miocardit, sarcoidoz,
boala Lyme
Obezitate, emfizem, revrsat
pericardic, amiloidoz
Dissincronie electric i
mecanic
Implicaii clinice
Evaluare clinic
Investigaii de laborator
Evaluarea terapiei medicamentoase
ncetinirea conducerii AV, conversie

medical, electroconversie, ablaie cu
cateterul, anticoagulare
Test de efort, studii de perfuzie, angiografie coronarian, test electrofiziologic,
ICD
Eco, troponine, angiografie coronarian,
revascularizare
Eco, angiografie coronarian
Eco/Doppler
Evaluarea terapiei medicale, pacemaker,
boal sistemic
Eco, radiografie toracic
Eco
CRT-P, CRT-D
Modificrile electrocardiografice sunt obinuite la

pacienii suspectai ca avnd IC (Tabelul 12). Un ECG
anormal are o valoare predictiv sczut pentru pre

zena IC. Dac ECG-ul este prefect normal, IC, n special cu disfuncie sistolic, este improbabil (<10%).
Radiografia toracic
Radiografia toracic este o component esenial n
conturarea diagnosticului n insuficiena cardiac. Ea
premite aprecierea congestiei pulmonare i poate arta
cauze importante pulmonare i toracice de dispnee.
Radiografia toracic (n dou incidene) este util
pentru detecia cardiomegaliei, congestiei pulmonare i
acumulrii de lichid pleural, i poate arta prezena bolii pulmonare sau infeciei care a cauzat sau a contribuit
la dispnee (Tabelul 13). n afara congestiei, constatrile
sunt predictive pentru IC doar n contextul semnelor i
simptomelor tipice. Cardiomegalia poate fi absent nu
doar n IC acut, dar i n cea cronic.
Tabelul 13. Anomalii obinuite ale radiografiei toracice n insuficiena
cardiac
Anomalie
Cardiomegalie
Hipertrofie ventricular
Aspect pulmonar
normal
Congestie venoas
pulmonar
Edem interstiial
Revrsat pleural
Cauze
VS, VD, atrii dilatate
Revrsat pericardic
Hipertensiune, stenoz aortic,
cardiomiopatie hipertrofic
Congestie pulmonar improbabil
Implicaii clinice
Eco/doppler
Reconsider diagnosticul (dac netratat)

Boal pulmonar grav improbabil
Presiune de umplere VS crescut
Insuficien cardiac stng confirmat
Eco/doppler
Presiune de umplere VS crescut

Presiune de umplere crescut
IC probabil dac bilateral
Infecie pulmonar, chirurgie sau
revrsat malign
Insuficien cardiac stng confirmat

Dac abundent
a se avea n vedere etiologia noncardiac
Dac abundent, a se avea n vedere
centre diagnostice sau terapeutice
Linii Kerley B
Presiune limfatic crescut
Stenoz mitral sau IC cronic
Cmpuri pulmonare Emfizem sau embolism pulmonar CT spiral, spirometrie, Eco
hipertransparente
Infecie pulmonar Pneumonia poate fi secundar
Trateaz att infecia ct i IC
congestiei pulmonare
Infiltrat pulmonar Boal sistemic
Plan diagnostic
Teste de laborator
O evaluare diagnostic de rutin a pacienilor cu
IC suspectat include o hemoleucogram complet
(hemoglobin, leucocite, plachete), electrolii serici,
creatinin seric, rata de filtrare glomerular (RFG),
glicemia, testele funcionale hepatice i sumarul de
urin. Teste adiionale trebuie luate n calcul n funcie
de tabloul clinic (Tabelul 14). Anomalii hematologice
sau electrolitice marcate sunt neobinuite n IC uoar
sau moderat netratat, dei o anemie uoar, hiponatremie, hiperkaliemie, i funcie renal redus sunt
obinuite, n special la pacienii tratai cu diuretice i
terapie cu IECA/BRA/antagoniti de aldosteron. Monitorizarea de laborator adecvat este esenial n timpul


iniierii, titrrii i etapelor de urmrire la pacienii care

primesc terapie medicamentoas pentru IC.
Tabelul 14. Anomalii obinuite ale testelor de laborator n insuficiena
cardiac
Anomalie
Creatinin
seric crescut
(>150mol/L)
Anemie (<13g/dl
brbai, <12g/dl
femei)
Cauze
Boal renal
IECA/BRA, blocad
aldosteronic
Implicaii clinice
Calcularea RFG (rata filtrrii glomerulare)
A se avea n vedere reducerea IECA/BRA
sau a dozei de blocant de aldosteron
Plan diagnostic
A se avea n vedere tratamentul
IC cronic, hemodiluie,
pierdere sau utilizare deficitar
a fierului, insuficien renal,
boal cronic
Hiponatremie(<135 IC cronic, hemodiluie, elibera- A se avea n vedere restricia de ap,
mmol/L)
re AVP, diuretice
reducerea dozajului de diuretice
Ultrafiltrare, antagonist de vasopresin
Hipernatremie
Hiperglicemie
Evaluarea aportului de ap
(>150 mmol/L)
Deshidratare
Plan diagnostic
Hipokaliemia (<3,5 Diuretice, hiperaldosteronism
Risc de aritmie
mmol/L)
secundar
A se avea n vedere supliment de potasiu, IECA/BRA, blocante de aldosteron
Stop tratament care economisete potaHiperkaliemie (>5,5 Insuficiena renal, supliment
mmol/L)
de potasiu, blocante de sistem siu (IECA/BRA, blocante de aldosteron)
renin-angiotensin-aldosteron Evaluarea funcie renale i pH
Risc de bradicardie
Hiperglicemie (>6,5 Diabet, rezisten la insulin
Evaluarea hidratrii, tratarea intoleranmmol/L)
ei la glucoz
Hiperuricemie
Tratament diuretic, gut,
Allopurinol
(>500 mol/L)
malignitate
Reducerea dozei diuretice
BNP>400 pg/mL,
Stres parietal ventricular crescut IC probabil
NT pro-BNP>2000
Indicaie de eco
pg/mL
A se avea n vedere tratament
BNP<100 pg/mL,
Stres parietal normal
Reevaluare diagnostic
NT-pro-BNP<400
IC improbabil n lipsa tratamentului
pg/mL
Albumin crescut
Deshidratare, mielom
Rehidratare
(>45g/L)
Albumin sczut
Nutriie deficitar, pierdere
Plan diagnostic
(<30 g/L)
renal
Cretere de transa- Disfuncie hepatic
Plan diagnostic
minaze
Insuficien cardiac dreapt
Congestie hepatic
Toxicitate medicamentoas
Reconsiderarea terapiei
Troponine crescute Necroz miocitar
Evaluarea gradului de cretere (cretere
Ischemie prelungit, sever
uoar obinuit n IC sever)
IC, miocardit, sepsis,
Angiografie coronarian
insuficiena renal, embolie
Evaluare pentru revascularizare
pulmonar
Teste tiroidiene
Hiper/hipotiroidism
Tratarea disfunciei tiroidiene
anormale
Amiodaron
Sumar de urin
Proteinurie, glicozurie,
Plan diagnostic
bacteriemie
A se exclude infecia
INR>2,5
Supradozaj anticoagulant
Evaluarea dozajului anticoagulant
Congestie hepatic
Aprecierea funciei hepatice
Aprecierea dozei anticoagulante
PCR>10 mg/L, Leu- Infecie, inflamaie
Plan diagnostic
cocitoz neutrofilic
Peptidele natriuretice
Concentraia plasmatic a peptidelor natriuretice reprezint un biomarker util n diagnosticul IC i n managementul pacienilor cu IC cronic confirmat. Exis-
t dovezi n favoarea folosirii lor pentru diagnosticarea,

stadializarea i luarea deciziilor de internare/extrenare
i identificarea pacienilor la risc pentru evenimente
clinice. Dovezile pentru folosirea lor pentru monitorizarea i ajustarea terapiei medicamentoase sunt mai puin clar stabilite. O concentraie normal la un pacient
netratat are o mare valoare predictiv negativ i face
ca IC s fie o cauz improbabil a simptomelor. Acest
lucru poate avea un rol important n asistena primar.
Niveluri crescute ale peptidelor natriuretice n ciuda
tratamentului optim arat un prognostic prost.
Msurarea peptidului natriuretic tip B (BNP) i
N-terminal pro-BNP(NT-proBNP) au fost introduse
ca instrumente de diagnostic59 i management60 al IC
(Figura 1). Ele cresc ca rspuns la creterea stresului
peretelui miocardic. De obicei nivelurile mai sczute
se gsesc la pacienii cu funcie sistolic VS prezervat.
Nu exist o valoare cut-off recunoscut pentru niciunul dintre cele dou peptide natriuretice dozate n
mod obinuit pentru diagnosticul IC n departamentul
de urgen. Datorit perioadei de njumtire relativ
lung a peptidelor natriuretice, schimbri abrupte ale
presiunii de umplere VS pot s nu fie reflectate de modificri rapide ale peptidelor. Alte condiii diferite de
IC asociate cu valori crescute ale peptidului natriuretic
sunt: hipertrofia VS, tahicardia, ncrcarea ventricular dreapt, ischemia miocardic, hipoxemia, disfuncia
renal, vrsta avansat, ciroza hepatic, sepsis-ul i infecia. Obezitatea i tratamentul pot scdea nivelurile
peptidului natriuretic. Peptidele natriuretice pot fi de
asemenea utile n aprecierea prognosticului nainte de
externarea din spital i n monitorizarea eficienei terapiei IC61,62.
Troponinele
Troponina I sau T trebuie dozat la pacienii cu IC
suspectat cnd tabloul clinic sugereaz un sindrom
coronarian acut (SCA). O cretere a troponinelor cardiace indic necroza miocitelor i, dac este indicat,
posibilitatea revascularizrii trebuie avut n vedere i
efectuat un plan diagnostic adecvat. O cretere a troponinei poate apare i n miocardita acut. Creteri
uoare ale troponinelor sunt frecvent ntlnite n IC
sever sau n timpul episoadelor de decompensare IC
la pacieni fr dovezi de ischemie miocardic datorat
SCA i n situaii cum ar fi sepsis-ul. Un nivel crescut al
troponinei reprezint un marker de prognostic puternic n IC, mai ales n prezena unor peptide nariuretice
crescute63.
Markeri neurohormonali
IC este nsoit de o cretere a altor diferii markeri
neurohormonali (norepinefrin, renin, aldosteron,

endotelin, arginin vasopresin). Dei util n cercetare, evaluarea activrii neuroendocrine nu este necesar
pentru scopuri diagnostice sau prognostice la fiecare
pacient n parte.
Ecocardiografia
Termenul ecocardiografie este folosit referitor la toate tehnicile de imagistic cardic legate de ultrasunete,
incluznd Doppler continuu i pulsat, Doppler color i
imagistica prin Doppler tisular (TDI). Confirmarea prin
ecocardiografie a diagnosticului de insuficien cardiac i/sau disfuncie cardiac este obligatorie i trebuie
efectuat la scurt timp dup suspiciunea diagnostic de
IC. Ecocardiografia este larg disponibil, rapid, noninvaziv i sigur i ofer informaii extinse despre anatomia cardiac (volume, geometrie, mase) micarea pereilor i funcia valvular. Investigaia ofer informaii
eseniale despre etiologia IC. n general, un diagnostic
de IC trebuie s includ o ecocardiogram.
Tabelul 15. Anomalii ecocardiografice obinuite n insuficiena cardiac
Msuratoare
Fracie de ejecie VS
Funcie VS, global i
regional
Diametru tele-diastolic
Anomalie
Implicaii clinice
Redus (<45-50%)
Akinezie, hipokinezie,
diskinezie
Crescut (>55-60 mm)
Disfuncie sistolic
Infarct miocardic/ischemie
Cardiomiopatie, miocardit
Suprancrcare volemic
IC probabil
Diametru tele-sistolic
Crescut (>45 mm)
Suprancrcare volemic
IC probabil
Fracia de scurtare
Redus (<25%)
Disfuncie sistolic
Dimensiunea atriului
Crescut (>40 mm)
Presiuni de umplere crescute
stng
Disfuncie de valv mitral
Fibrilaie atrial
Grosimea ventricului
Hipertrofie (>11-12 mm) Hipertensiune, stenoz aortic, cardiomistng
opatie hipertrofic
Poate fi cauza primar a IC sau o
Structura i funcia
Stenoz sau regurgitare
valvular
valvular (n special ste- complicaie
noza aortic i insuficiena Aprecierea gradientului i a fraciei de
regurgitare
mitral)
Aprecierea consecinelor hemodinamice
A se avea n vedere chirurgia
Profilul fluxului diastolic Anomalii ale pattern-ului Indic disfuncia diastolic i sugereaz
mitral
de umplere diastolic
mecanismul
precoce i tardiv
Velocitatea maxim de
Crescut (>3 m/sec)
Presiune sistolic ventricul drept crescut
regurgitare tricuspidian
Suspectarea hipertensiunii pulmonare
Pericard
Revrsat, hemopericard, A se avea n vedere tamponad, uremie,
ngroare
malignitate, boal sistemic, pericardit
acut sau cronic, pericardit constrictiv
Integrala velocitate-timp Redus (<15 cm)
Volum btaie sczut
n tractul de ejecie aortic
Vena cav inferioar
Dilatat. Flux retrograd
Presiune atrial dreapt crescut
Disfuncie ventricular dreapt
Congestie hepatic
Cea mai practic msurtoare a funciei ventriculare

pentru diferenierea pacienilor cu disfuncie sistolic

i a pacienilor cu funcie sistolic prezervat este FEVS

(normal >45-50%). Acest cut-off este ntr-un fel arbitrar. FEVS nu este sinonim cu indicele de contractilitate pentru c este strns dependent de volume, presarcin, postsarcin, frecven cardiac i funcia valvular. Volumul btaie poate fi meninut prin dilatare
cardiac i volume crescute. Tabelele 15 i 16 arat cele
mai frecvente anomalii ecocardiografice i Doppler n
IC.
Aprecierea funcie diastolice a ventriculului stng
Aprecierea funciei diastolice folosind evaluarea
pattern-ului de umplere ventricular este important
pentru detectarea anomaliilor de funcie diastolic sau
de umplere la pacienii cu IC. Acestea pot fi anomalia
funcional predominant a cordului, astfel ndeplinind
a treia component necesar pentru diagnosticul de insuficien cardiac. Acest lucru este mai ales adevrat la
pacienii simptomatici cu FEVS prezervat. Un consens
recent al Asociaiei de Insuficien Cardiac s-a concentrat pe evaluarea disfunciei diastolice la ICFEP64.
Tabelul 16. Indicatori ecocardiografici Doppler i umplerea ventricular
Indicator Doppler
Raportul undelor E/A
Pattern
Restrictiv (>2, timp de
decelerare scurt <115150 ms)
Relaxare ntrziat (<1)
Crescut (>15)
Redus (<8)
Intermediar (8-15)
>30 ms
Presiuni de umplere normale

Complian sczut
Neconcludent deoarece poate fi pseudonormal
Presiuni de umplere mari
Presiuni de umplere sczute
Neconcludent
Presiuni de umplere normale
<30 ms
>unda D
<45 cm/s
>2,5
<2
Schimbarea pattern-ului
de umplere pseudo normal
n anormal

Relaxare ntrziat
Demascarea presiunii crescute de
umplere n contextul disfunciei sistolice
i diastolice
Normal (>1)
E/Ea
Durata (A mitral
Apulm)
Unda S pulmonar
Vp
E/Vp
Manevra Valsalva
Consecin
Presiuni de umplere crescute
Suprancrcare de volum
Sunt trei tipuri de umplere anormal recunoscute

convenional la pacienii n ritm sinusal.
1. Un model de relaxare miocardic alterat cu
o scdere a velocitii maxime a undei E transmitrale, cu o cretere compensatorie a velocitii
atrial-indus (A), i, astfel, o scdere a raportului E/A, poate fi ntlnit ntr-un stadiu precoce
a disfunciei diastolice; este frecvent ntlnit n
hipertensiune i la subiecii vrstnici normali, i
este n general asociat cu presiuni de umplere VS
normale sau sczute.

2. La pacienii cu presiune atrial crescut (complian VS sczut, suprancrcare volemic,

insuficien mitral), poate fi un pattern de umplere restrictiv, cu o velocitate maxim a undei
E crescut, un timp de decelerare a undei E scurt
i un raport E/A marcat crescut.
3. La pacieni cu un pattern intermediar ntre
relaxare alterat i umplere restrictiv, raportul
E/A i timpul de decelerare poate fi normal, i
poate fi ntlnit aa numitul pattern de umplere pseudo-normalizat. Acest pattern poate fi
difereniat de cel normal prin analiza altor variabile Doppler cum ar fi fluxul venos pulmonar
sau TDI al micrii planului mitral.
Ecocardiografia Doppler permite estimarea presiunii arteriale pulmonare sistolice.
Acest parametru provine din calcularea presiunii
ventriculare drepte estimat pe baza velocitii maxime
a jetului de regurgitare tricuspidian prezent la majoritatea subiecilor. Permite de asemenea o apreciere a
volumului btaie i a debitului cardiac prin msurarea
integralei velocitate-timp (VTI) a fluxului aortic.
Evaluarea insuficienei cardiace cu fracie de ejecie prezervat (ICFEP)
Ecocardiografia joac un rol major n confirmarea
diagnosticului de ICFEP. Diagnosticul de ICFEP cere
s fie satisfcute trei condiii:
1. Prezena semnelor i/sau simptomelor de IC cronic
2. Prezena unei funcii sistolice VS normale sau
doar uor alterat (FEVS 45-50%).
3. Dovada disfunciei diastolice (relaxare VS anormal sau rigiditate diastolic).
Ecocardiografia transesofagian
Ecocardiografia transesofagian (ETE) este recomandat la pacienii care au o fereastr transtoracic
inadecvat (obezitate, pacieni ventilai), la pacienii
valvulari complicai (n special aortic, mitral i valve
mecanice), la suspiciunea de endocardit, la bolile cardiace congenitale, sau pentru a exclude un tromb n
urechiua atriului stng la pacienii cu FA.
Ecocardiografia de stres
Ecocardiografia de stres (dobutamin sau exerciiu)
este folosit pentru a detecta disfuncia ventricular
provocat de ischemie i pentru a evalua viabilitatea
miocardic n prezena hipokineziei sau akineziei marcate. Poate fi de asemenea util n identificarea stunning-ului miocardic sau a miocardului hibernant, i n

legarea simptomelor de IC de anomaliile valvulare. La

pacienii cu IC, eco de stres poate avea o specificitate i
sensibilitate mai mici datorit dilatrii de VS sau prezenei blocului de ramur.
Teste imagistice non-invazive adiionale
La pacienii la care ecocardiografia de repaus nu a
oferit informaii adecvate i la pacienii suspeci de
BCI, imagistica non-invaziv ulterioar poate include
imagistica prin rezonan magnetic cardiac (RMC),
CT cardiac sau imagistica cu radionuclizi.
Imagistica prin rezonan magnetic cardiac
(RMC)
RMC este o tehnic imagistic noninvaziv, foarte
exact, reproductibil pentru aprecierea volumelor ventriculare stng i drept, funciei globale, micrii regionale a pereilor, grosimii miocardice, maselor i tumorilor miocardice, valvelor cardiace, defectelor congenitale i afeciunii pericardice65,66. A devenit standard
de aur de precizie i reproductibilitate pentru evaluarea
volumelor, maselor i micrii pereilor. Folosirea agenilor de contrast paramagnetici cum ar fi gadolinium
poate aduce dovada inflamaiei, infiltrrii i cicatricei la
pacienii cu infarct, miocardit, pericardit, cardiomiopatii, boli infiltrative i de depozit. Limitrile includ
costul, disponibilitatea, pacienii cu disritmie i dispozitive implantabile i intolerana pacienilor.
Explorarea CT
La pacienii cu IC diagnosticul nonivaziv al anatomiei coronariene poate fi valoros i ajut n luarea deciziilor privind angiografia coronarian. Angiografia
CT poate fi considerat la pacienii cu probabilitate
pretest sczut sau intermediar pentru BCI i un test
de efort sau imagistic de stres echivoc66. Demonstrarea
aterosclerozei la examenul CT confirm BCI dar nu
implic n mod necesar ischemia.
Ventriculografia radionuclidic
Ventriculografia radionuclidic este recunoscut ca
o metod cu acuratee relativ de determinare a FEVS
i, de cele mai multe ori realizat n contextul scintigramei miocardice de perfuzie, furniznd informaii
privind viabilitate i ischemie. Are o valoare limitat n
evaluarea volumelor sau indicilor mai subtili ai funciei
sistolice sau distolice.
Teste funcionale pulmonare
Msurtorile funciei pulmonare au o valoare limitat n diagnosticul IC. Totui, aceste teste sunt utile
pentru demonstrarea sau excluderea cauzelor respiratorii de dispnee i evaluarea contribuiei poteniale a

bolii pulmonare la dispneea pacientului. Spirometria

de rutin evalueaz extinderea bolii obstructive a cilor
aeriene. Prezena congestiei pulmonare poate influena
rezultatul testelor. Gazele sanguine sunt normale n IC
cronic bine compensat. O reducere a saturaiei arteriale a oxigenului trebuie s conduc la cutarea altor
diagnostice.
Testul de efort
Testul de efort este util pentru evaluarea obiectiv a
capacitii de efort i a simptomelor de efort, cum ar fi
dispneea i fatigabilitatea. Testul de mers 6 minute este
o metod simpl, reproductibil, disponibil, la care se
recurge frecvent pentru evaluarea capacitii de efort
submaximale i a rspunsului la tratament. Un test de
efort maximal normal la un pacient care nu primete
tratament exclude diagnosticul de IC simptomatic.
Poate fi utilizat un test de efort la biciclet sau la covor
rulant, cu un protocol modificat pentru IC, cu creterea
progresiv a efortului. Este de preferat analiza schimburilor gazoase n timpul efortului deoarece furnizeaz
msurtori nalt reproductibile ale limitrii la efort i
face diferenierea ntre cauzele cardiace sau respiratorii
de dispnee, evalund eficiena ventilatorie i avnd rol
prognostic. Consumul maxim de oxigen (VO2 maxim)
i pragul anaerob sunt indicatori utili pentru capacitatea funcional a pacientului, iar VO2 maxim i panta VE/VCO2 (rspunsul ventilator la efort) reprezint
variabile majore de prognostic. Raportul maxim de
schimburi gazoase este un index util pentru gradul de
anaerobioz obinut. Exist totui o corelaie slab ntre capacitatea de efort, FE i majoritatea msurtorilor
hemodinamice n repaus.
Monitorizarea ambulatorie ECG (Holter)
Monitorizarea ECG ambulatorie este valoroas pentru evaluarea pacienilor cu simptome sugestive pentru
aritmii (ex. palpitaii sau sincop) i n monitorizarea
controlului frecvenei ventriculare la pacienii cu FA.
Poate detecta i cuantifica natura, frecvena i durata
aritmiilor atriale i ventriculare, precum i episoadele
de ischemie silenioas, care pot cauza sau exacerba
simptomele IC. Episoade de tahicardie ventricular nesusinut (TV) simptomatice sunt frecvente n IC i se
asociaz cu un prognostic prost.
Cateterismul cardiac
Cateterismul cardiac nu este necesar pentru diagnosticul de rutin i tratamenul pacienilor cu IC. Investigaiile invazive sunt frecvent indicate pentru elucidarea
etiologiei, pentru obinerea informaiilor privind prognosticul i, dac este considerat revascularizarea.

Angiografia coronarian
Angiografia coronarian trebuie luat n considerare
la pacienii cu IC i istoric de angin de efort sau suspiciune de disfuncie VS ischemic, dup stop cardiac i
la cei cu profil de risc crescut pentru boal coronarian,
i poate fi necesar de urgen la pacienii selectai cu
IC sever (oc sau edem pulmonar acut) i la pacienii
care nu rspund adecvat la tratament. De asemenea,
angiografia coronarian i ventriculografia VS sunt indicate la pacienii cu IC refractar de etiologie necunoscut i la pacienii cu semne de regurgitare mitral
sever sau valvulopatie aortic potenial corectabil
prin chirurgie.
Cateterismul cordului drept
Cateterismul cordului drept furnizeaz informaii
hemodinamice valoroase privind presiunile de umplere, rezistena vascular i debitul cardiac. Rolul su n
diagnosticul IC este limitat n practica zilnic. St la
baza clasificrii Forrester i este metoda cu acurateea
cea mai mare n evaluarea hemodinamicii la pacienii
refractari la tratament, naintea transplantului cardiac,
sau n cercetarea clinic care evalueaz diverse intervenii.
Monitorizarea variabilelor hemodinamice prin intermediul unui cateter arterial pulmonar (CAP) poate
fi considerat la pacienii spitalizai cu oc cardiogen/
noncardiogen sau pentru monitorizarea tratamentului
la pacienii cu IC sever care nu rspund la msurile
obinuite. Totui, utilizarea CAP nu s-a dovedit a mbunti evoluia.
Biopsia endomiocardic
Bolile miocardice specifice pot fi diagnosticate prin
biopsie endomiocardic (BEM). Decizia clinic trebuie
luat pe baza studiilor caz-control disponibile i opinia
experilor. O declaraie recent publicat a AHA/ACC/
ESC privind indicaiile BEM67 sugereaz c procedura
trebuie considerat la pacienii cu IC acut sau fulminant de etiologie necunoscut care se deterioreaz
rapid, cu aritmii ventriculare i/sau bloc AV, sau la pacienii care nu rspund la terapia convenional a IC.
BEM poate fi considerat la pacienii cu IC cronic i
suspiciune de proces infiltrativ, cum ar fi amiloidoza,
sarcoidoza, hemocromatoza, ca i n miocardita eozinofilic i cardiomiopatia restrictiv de etiologie necunoscut.
Prognosticul
Determinarea prognosticului n IC este complex.
Etiologii diverse, vrsta, comorbiditi frecvente, variaii ale progresiei i evoluia individual variabil


(moartea subit versus deces prin IC progresiv) trebuie luate n considerare. Impactul tratamentelor specifice asupra prognosticului la un anumit pacient cu IC
este deseori dificil de prezis. Variabilele cel mai frecvent
citate ca predictori independeni de prognostic sunt
raportate n Tabelul 17.
Tabelul 17. Condiii asociate cu prognostic sever n insuficiena cardiac
Demografice
Clinice
Electrofiziologice
Vrsta
avansat*
Hipotensiune* Tahicardie
Unde Q
Etiologie
ischemic*
Moartea
subit resuscitat*
Clasa funcional NYHA

III-IV*
Istoric de
spitalizri
pentru IC*
Compliana Tahicardie
redus
Disfuncie
renal
Raluri
pulmonare
Diabet
Stenoza
aortic
Scderea indexului de mas
corporal
Anemie
BPCO
Funcionale/de
efort
Capacitate
redus,
consum
maxim
VO2 max
redus*
QRS larg*
Hipertrofie VS
Aritmii
ventriculare
complexe*
Reducerea
variabilitii
frecvenei
cardiace
Fibrilaia
atrial
Alternana
undei T
Distan
mic la
testul de
mers 6 min
Laborator
Imagistic
Cretere
FEVS sczut*
marcat a BNP
/NTproBNP*
Hiponatremie*
Creterea
troponinei*
Creterea
biomarkerilor,
activare
neurohormonal*
Creterea
Creterea volumecreatininei
lor VS
/BUN
z Se recomand ca personalul medical s ofere o

educaie i consiliere complet n insuficiena
cardiac.
Pagina web heartfailurematters.org reprezint o modalitate furnizat de Asociaia de Insuficien Cardiaca (Heart Failure Association) a ESC care permite
pacienilor, rudelor acestora i personalului care i
ngrijete s obin informaii utile i practice ntrun format uor de neles.
Urmtoarele opiuni de management sunt considerate adecvate la pacienii cu IC simptomatic. Recomandrile reprezint n mare parte opinia experilor
fr dovezi clar documentate.
Tabelul 18. Subiecte eseniale n educaia pacientului i comportamente
adecvate de autongrijire
Subiecte educaionale
Tehnici i comportamente de autongrijire
Definiia i etiologia insuficienei cardiace

Simptome i semne de
insuficien cardiac
nelegerea cauzei de insuficien cardiac i de ce apar

simptomele
Monitorizarea i recunoaterea semnelor i simptomelor
nregistrarea zilnic a greutii i recunoaterea creterii rapide
n greutate
Cunoaterea modului i momentului notificrii furnizorului de
servicii medicale
Utilizarea unui tratament diuretic flexibil atunci cnd este necesar
nelegerea indicaiilor, dozelor i efectelor medicamentelor
Recunoaterea efectelor secundare comune ale fiecrui medicament prescris
nelegerea importanei renunrii la fumat
Monitorizarea tensiunii arteriale la hipertensivi
Meninerea unui control glicemic bun la diabetici
Evitarea obezitii
Restricia de sodiu atunci cnd este prescris
Evitarea aportului lichidian excesiv
Aport modest de alcool
Monitorizarea i prevenirea malnutriiei
Asigurarea n legatur cu activitatea fizic
nelegerea beneficiilor efortului
Efectuarea de antrenament fizic regulat
Asigurarea n legatur cu activitatea sexual i discutarea
problemelor cu personalul specializat
nelegerea problemelor sexuale specifice i diferite strategii de
rezolvare
Imunizarea mpotriva infeciilor precum gripa i boala pneumococic
Cunoaterea msurilor preventive precum scderea n greutate a
obezilor, ncetarea fumatului i abstinena la alcool
Cunoaterea opiunilor terapeutice atunci cnd acestea exist
nelegerea importanei respectrii recomandrilor terapeutice i
meninerea motivaiei de a urmrii planul terapeutic
Tratament farmacologic
Creterea
pantei VE/
VCO2
Respiraie
periodic
Creterea
bilirubinei
Anemie
Creterea
acidului uric
Tulburri de
respiraie n
somn
Index cardiac
sczut
Modificarea factorilor de risc
Presiuni de umplere VS crescute
Pattern restrictiv
de umplere mitral, hipertensiune
pulmonar
Alterarea funciei
ventriculului drept
Depresie
* = predictori puternici
Recomandri privind dieta
Recomandri privind efortul
Activitatea sexual
MANAGEMENTUL NON-FARMACOLOGIC
Autongrijirea
z Autongrijirea este o parte a tratamentului IC i
poate avea un impact semnificativ asupra simptomelor, capacitii funcionale, a strii de bine,
a morbiditii i a prognosticului. Autongrijirea poate fi definit prin aciuni ce au ca scop
meninerea stabilitii fizice, evitarea obiceiurilor
ce pot agrava condiia clinic i detectarea precoce a simptomelor de agravare68.
z Sfaturi importante de autongrijire n insuficiena
cardiac sunt prezentate n Tabelul 18.
Imunizarea
Tulburri de somn i
respiratorii
Compliana
Aspecte psiho-sociale
Prognostic
Cunoaterea faptului c simptomele depresive i disfuncia

cognitiv sunt comune la pacienii cu insuficien cardiac i
importana suportului social
Cunoaterea opiunilor terapeutice atunci cnd acestea exist
Cunoaterea factorilor prognostici importani i luarea unor
decizii realiste
Suport psiho-social dac este necesar

Aderena la tratament
Dovezi majore
O aderen bun s-a dovedit a scdea morbiditatea
i mortalitatea i a mbuntii starea de bine69. Datele
din literatur sugereaz c doar 20-60% din pacienii
cu IC ader la tratamentul farmacologic i non-farmacologic prescris70,71. Date din Euro-Heart Failure Survey
demonstreaz c o proporie mare din pacieni fie neleg greit, fie au probleme n a-i aminti c au primit recomandri privind autongrijirea, cum ar fi instruciuni
asupra medicaiei sau dietei72.
z O relaie strns ntre personalul medical i
pacieni, ca i suportul social suficient al unei reelei sociale active s-a dovedit a mbunti aderena la tratament. Este recomandat ca membrii
familiei s fie invitai s participe la programele
educaionale i decizia privind tratamentul i ngrijirea73.
z Pacienii trebuie s aib cunotine adecvate
despre tratamentul medical, n special asupra
efectelor, reaciilor adverse i, despre modul de
administrare i modificare a dozelor medicaiei.
Aceasta poate fi o problem pentru pacienii cu
disfuncie cognitiv74.
z Pacienii trebuie s fie contieni c efectele benefice ale terapiei pot ntrzia i s nu aib ateptri nerealiste privind rspunsul iniial la tratament. Trebuie explicat c efectele adverse sunt
frecvent tranzitorii i poate dura luni de zile
pn la creterea dozelor i evaluarea efectelor
complete ale medicamentului.
z Sunt recomandate interveniile pentru mbuntirea aderenei, ele fiind stabilite de furnizorul
de servicii medicale.
Clasa de recomandare I, nivel de eviden C
Recunoaterea simptomelor
Simptomele deteriorrii n IC pot varia considerabil75,76.
Pacienii i/sau furnizorii de servicii medicale trebuie s nvee s recunoasc simptomele deteriorrii i s
ia masuri adecvate, cum ar fi creterea dozei de diuretic
prescris i/sau s contacteze personalul medical.
z Dozele flexibile de diuretic bazate pe simptomatologie i echilibrul lichidian trebuiesc recomandate n limite prestabilite, dup instruciuni detaliate i educare.

Monitorizarea greutii
Creterea n greutate se asociaz frecvent cu agravarea IC i retenia de fluide76. Pacienii trebuie s tie c
deteriorarea poate aprea i fr creterea n greutate77.
z Pacienii trebuie s se cntreasc singuri n
mod regulat pentru monitorizarea modificrilor
de greutate, preferabil n cadrul rutinei zilnice.
n cazul creterii neateptate n greutate cu >2 kg
n 3 zile, pacienii i pot crete doza de diuretic
i trebuie s alerteze echipa medical. Riscurile
depleiei de volum prin utilizarea excesiv de
diuretic trebuiesc explicate.
Dieta i nutriia
Aportul de sodiu
Restricia de sodiu este recomandat la pacienii cu
IC simptomatic pentru prevenirea reteniei de lichide.
Dei nu exist ghiduri specifice, aportul excesiv de sare
trebuie evitat. Pacienii trebuiesc educai privind coninutul de sare din alimentele obinuite.
Clasa de recomandare IIa, nivel de eviden C
Aportul de lichide
Restricia de lichide la 1,5-2 l/zi poate fi considerat la pacienii cu simptome severe de IC, n special
cu hiponatremie. Restricia de lichide de rutin la toi
pacienii cu simptome uoare pn la moderate nu pare
s confere beneficiu clinic78.
Clasa de recomandare IIb, nivel de eviden C
Alcoolul
Alcoolul poate avea un efect inotrop negativ i se
poate asocia cu creteri ale tensiunii arteriale (TA) i cu
risc de aritmii. Utilizarea excesiv poate fi duntoare.
z Aportul de alcool trebuie limitat la 10-20 g/zi
(1-2 pahare de vin/zi).
z Pacienii cu suspiciune de cardiomiopatie indus
de alcool trebuie s se abin complet de la consumul de alcool79.
Reducerea greutii
Reducerea greutii la persoanele obeze cu IC [index
de mas corporal (IMC) >30kg/m2] trebuie luat n
considerare pentru a preveni progresia IC, ameliorarea
simptomelor i mbuntirea strii de bine.
n IC moderat i sever reducerea greutii nu trebuie recomandat de rutin, deoarece scderea ponde-

ral neintenionat i anorexia sunt probleme obinuite.

Scderea ponderal neintenionat
Malnutriia clinic i subclinic sunt frecvente la pacienii cu IC sever. Fiziopatologia caexiei cardiace n
insuficiena cardiac este complex i incomplet elucidat, dar alterarea metabolismului, aportul alimentar
insuficient, scderea absorbiei nutriionale, congestia
intestinal i mecanismele inflamatorii reprezint factori importani. Caexia cardiac este un predictor important al supravieuirii reduse80.
z Dac scderea ponderal n ultimele 6 luni este
>6% din greutatea stabil anterioar n lipsa evidenelor de retenie de lichide, pacientul este
definit ca fiind caectic81. Statusul nutriional al
pacientului trebuie evaluat cu atenie.
Fumatul
Fumatul este un factor de risc cunoscut pentru bolile
cardiovasculare. Niciun studiu prospectiv nu a evaluat
efectele ntreruperii fumatului la pacienii cu IC. Studii
observaionale susin relaia dintre ntreruperea fumatului i reducerea morbiditii i mortalitii82,83.
z Se recomand ca pacienii s primeasc suport i
sfaturi i s fie motivai s ntrerup fumatul.
Imunizarea
z Vaccinarea pneumococic i vaccinarea anual
antigripal trebuiesc considerate la pacienii cu
IC simptomatic n lipsa contraindicaiilor84.
Activitatea i antrenamentul fizic
Sedentarismul este frevent la pacienii cu IC simptomatic i contribuie la progresia acesteia85. Antrenamentul fizic de rezisten sau anduran efectuat n
mod regulat, iniial supervizat optimizeaz controlul
autonom prin creterea tonusului vagal i reducerea
activrii simpatice, mbuntind tonusul muscular,
capacitatea vasodilatatorie i disfuncia endotelial i
scznd stressul oxidativ. Cteva recenzii i metaanalize a unor studii mici au artat reducerea mortalitii i
a spitalizrilor prin condiionare fizic, comparativ cu
ngrijirea obinuit singur, i mbuntete tolerana
la efort i calitatea vieii86-90. Programele de reabilitare cardiac dup un eveniment cardiovascular sau un
episod de decompensare reprezint o opiune de tratament eficient pentru pacienii cu IC.

z Activitatea fizic zilnic, moderat i regulat

este recomandat la toi pacienii cu insuficien
cardiac.
Clasa de recomandare I, nivel de eviden B
z Antrenamentul fizic este recomandat, dac este
disponibil, la toi pacienii stabili cu IC cronic.
Nu exist evidene c antrenamentul fizic trebuie
limitat n cazul unor subgrupe particulare de
pacieni cu IC (etiologie, clasa NYHA, FEVS sau
medicaie). Programele de antrenament fizic par
s aib efecte similare fie c sunt efectuate n spital sau la domiciliu.
Clasa de recomandare I, nivel de eviden A
Activitatea sexual
Problemele sexuale legate de bolile cardiovasculare,
tratamentul medical (-blocante) sau factori psihologici ca fatigabilitatea i depresia sunt comune la pacienii cu IC. Exist dovezi limitate privind influena activitii sexuale asupra statusului clinic al pacientului cu
simptomatologie uoar sau moderat. S-a raportat o
uoar cretere a riscului de decompensare declanat
de activitatea sexual la pacienii cu clasa NYHA III-IV.
Simptomele cardiovasculare, cum ar fi dispneea, palpitaiile sau angina n timpul activitii sexuale apar rar
la pacienii care nu prezint asemenea simptome la un
nivel moderat de efort91.
Pacienii trebuiesc sftuii s utilizeze nitroglicerina
sublingual, ca profilaxie a dispneei sau durerii toracice
n timpul activitii sexuale.
z Inhibitorii 5 fosfodiesterazei (PDE5) (ex. sildenafil) reduc presiunea pulmonar, dar nu se
recomand n mod curent la pacienii cu IC
avansat. Acetia nu trebuiesc utilizai niciodat
n combinaie cu nitrai.
Clasa de recomandare III, nivel de eviden B
z Consilierea individualizat se recomand att
pentru pacienii de sex masculin i feminin, ct
i pentru partenerii lor.
Sarcina i contracepia
z Sarcina poate agrava IC prin creterea volumului
sanguin i a debitului cardiac, ct i prin creterea
substanial a lichidului extravascular. Important, multe medicamente utilizate n tratamentul
IC sunt contraindicate n timpul sarcinii.
z Riscul unei sarcini este considerat mai mare
comparativ cu cel al utilizrii contraceptivelor.
Se recomand ca femeile cu insuficien cardiac


s discute cu medicul metodele contraceptive i

sarcina planificat, pentru a lua o decizie informat, bazat pe evaluarea riscurilor poteniale.
Cltoriile
Altitudinile nalte (>1500 m) i cltoriile spre destinaii foarte calde i umede trebuiesc descurajate la
pacienii simptomatici. Planificarea unei cltorii trebuie discutat cu echipa de IC. Ca o regul, cltoriile
aeriene sunt preferate cltoriilor lungi cu alte mijloace
de transport.
Tulburrile somnului
Pacienii cu IC simptomatic au frecvent tulburri
respiratorii n somn (apnee n somn central sau obstructiv). Aceste condiii se pot asocia cu morbiditate
i mortalitate crescute92.
Scderea ponderal la persoanele cu obezitate sever, ntreruperea fumatului i abstinena la consumul de
alcool pot reduce riscul i sunt recomandate.
z Tratamentul de ventilaie continu cu presiune
pozitiv (CPAP) trebuie considerat n apneea
obstructiv n somn documentat prin polisomnografie93.
Depresia i tulburrile de dispoziie
Prevalena depresiei semnificative clinic s-a dovedit
a fi de pn la 20% la pacienii cu IC i poate fi mult mai
mare la pacienii investigai prin metode mai sensibile
sau la pacienii cu IC mai avansat. Depresia se asociaz cu creterea morbiditii i mortalitii94.
z Exist dovezi limitate privind metodele de screening i evaluare, ct i eficacitatea interveniilor
psihologice i farmacologice la pacienii cu IC.
Totui, screening-ul depresiei i iniierea tratamentului adecvat trebuiesc considerate la pacienii cu simptome sugestive.
Prognosticul
Dei dificil de discutat, este important ca pacientul
s neleag factorii importani de prognostic. Recunoaterea impactului tratamentului asupra prognosticului poate motiva pacienii s adere la recomandrile
terapeutice. O discuie deschis cu familia poate ajuta
n luarea deciziilor realiste i informate cu privire la
tratament i planuri viitoare.
TRATAMENT FARMACOLOGIC
Obiective n managementului insuficienei cardiace
Scopul diagnosticului i tratamentului IC nu este
diferit de cel al altor afeciuni medicale, i anume, de
a reduce mortalitatea i morbiditatea (Tabelul 19).
ntruct mortalitatea anual a IC este att de mare, n
studiile clinice accentul s-a pus n mod particular pe
aceste obiective finale. Totui, pentru muli pacieni, n
special vrstnici, capacitatea de a duce o via independent, lipsa simptomelor n exces i evitarea spitalizrii
sunt inte care ocazional pot fi echivalente cu dorina
de a maximiza durata vieii. Prevenirea bolii cardiace
sau a progresiei sale rmn o parte esenial a managementului. Multe studii clinice randomizate n IC au
evaluat pacieni cu disfuncie sistolic bazat pe o FE
<35-40%. Acesta este un prag relativ arbitrar i dovezile sunt limitate n populaia cu IC simptomatic i FE
ntre 40 i 50%.
Figura 2 furnizeaz o strategie de tratament pentru
utilizarea medicamentelor i dispozitivelor la pacienii
cu IC simptomatic i disfuncie sistolic. Este esenial
detectarea i considerarea tratamentului comorbiditilor comune cardiovasculare i non-cardiovasculare.

legat de un prognostic foarte prost. Mortalitatea

pacienilor caectici cu IC este mai mare dect n
majoritatea bolilor maligne202.
z Nu a fost nc stabilit dac prevenia i tratamentul caexiei care complic IC, trebuie s fie o int
de tratament. Optiunile includ hrnire hipercaloric, stimulani ai apetitului, antrenamente fizice, i ageni anabolici (insulin, steroizi anabolizani)202.
GUTA
z Pacieni cu IC sunt nclinai s dezvolte hiperuricemie ca rezultat al folosirii terapiei cu diuretice de ans i disfunciei renale. Hiperuricemia
confer un prognostic sever n IC. n guta acut
un scurt tratament cu colchicin pentru supresia
durerii i inflamaiei poate fi considerat. AINS
trebuie evitate, dac este posibil, la pacienii
simptomatici. Terapia profilactic cu inhibitor
de xantin oxidaz (allopurinol) este recomandat
pentru prevenirea recurenei.
ADULI CU BOAL CARDIAC CONGENITAL

z La copii, insuficiena cardiac este cel mai des
legat de situaiile cu debit cardiac crescut datorate unturilor intracardiace. Acestea sunt mai
puin frecvent observate la aduli. Leziuni complexe asociate cu cianoz secundar afectrii
perfuziei pulmonare pot face diagnosticul de
IC dificil. De aceea, msurarea peptidelor natriuretice trebuie inclus regulat la aceti pacieni.
Pacienii cu sindrom Eisenmenger ridic probleme speciale, ca insuficiena ventricular dreapt
asociat i reducerea presarcinii VS n timpul
efortului. Pacienii Fontan sunt incapabili de a
crete perfuzia pulmonar. Muli dintre aceti
pacieni beneficiaz de reducerea postsarcinii
chiar nainte ca simptome semnificative de IC s
fie manifeste clinic203,204.
VRSTNICII
z Majoritatea trialurilor clinice au inclus pacieni
mai tineri cu vrsta medie de ~61 ani i frecvent
70% din pacieni au fost brbai. Jumtate din
pacienii cu IC n populaie sunt >75 de ani, i numai n grupurile cu vrst mai tnr predomin
brbaii. IC cu FE prezervat este mai frecvent
la vrstnici i femei.
z IC la vrstnici este frecvent nediagnosticat,
deoarece simptomele principale de intoleran la

efort sunt deseori atribuite mbtrnirii, comorbiditilor coexistente, i statusului slab al sntii. Comorbiditile frecvente care pot avea impact asupra managementului includ insuficien
renal, diabet, accident vascular cerebral, disfuncie cognitiv i BPOC.
z Polifarmacia crete riscul interaciunilor adverse i al efectelor secundare care pot reduce
compliana. Alterarea proprietilor farmacocinetice i farmacodinamice ale medicamentelor
trebuie ntotdeauna luate n considerare. Alterarea funciei renale este o consecin natural
a mbtrnirii. De aceea, dozele de IECA, BRA,
spironolacton i digoxin pot necesita ajustare.
z Pentru pacienii vrstnici cu IC care sufer de
disfuncie cognitiv, programe de IC individuale
structurate multidisciplinar pot fi extrem de folositoare i pot mbunti aderena la tratament
i prevenirea spitalizrii.
z Contraindicaiile relative la proceduri diagnostice i intervenii, trebuie evaluate cu atenie i
cntrite mpotriva indicaiilor.
GLOSAR
ACC
ECA
IECA
SCA
FA
AHA
ICA
AAN
RA
BRA
RRA
SA
ATP
AV
AVP
b.i.d.
BNP
TA
b.p.m.
BUN
CABG
BCI
UTC
ICC
Clasa 1c
RMC
BPCO
PCPC
CR
PCR
CRT
CRT-D
Colegiul American de Cardiologie

enzima de conversie a angiotensinei
inhibitor al enzimei de conversie a angiotensinei
sindrom coronarian acut
fibrilaie atrial
Asociaia American a Inimii
insuficien cardiac acut
anticorpi antinucleari
regurgitare aortic
blocant al receptorilor de angiotensin
reducerea riscului absolut
stenoz aortic
adenozin trifosfat
atrioventricular
arginin vasopresin
de dou ori pe zi
peptid natriuretic tip B
tensiunea arterial
bti pe minut
ureea seric
by-pass aortocoronarian
boal coronarian ischemic
unitate terapie coronarian
insuficien cardiac cronic
clasificarea antiaritmicelor Vaughan Williams
rezonan magnetic cardiac
boal pulmonar cronic obstructiv
presiune continu pozitiv a cilor aeriene
eliberare prelungit
proteina C reactiv
terapie de resincronizare cardiac
terapie de resincronizare cardiac defibrilator

CRT-P
TC
DDD
CMD
dl
DZ
SESD
ECG
ED
FE
BEM
FiO2
FRG
h
IC
ICFEP
H-ISDN
HIV
IABP
ICD
ICU
INR
ISDN
i.v.
PVJ
BRS
VS
DAVS
FEVS
IM
mg
mmHg
mmol
RM
ms
ng/ml
VNPP
NNT
AINS
NTG
NT-proBNP
NYHA
o.d.
CAP
PCI
PDEI
PEEP
PET
pCO2
PCWP
pH
pg
p.o.
CMR
SCR
RRR
VD
S3
TAs
SPECT
STEMI
terapie de resincronizare cardiac- pacemaker

tomografie computerizat
stimulare cameral dual
cardiomiopatie dilatativ
decilitru
diabet zaharat
Societatea European pentru Studiul Diabetului
electrocardiogram
urgen
fracie de ejecie
biopsie endomiocardic
fraciunea de oxigen inspirat
rata filtrrii glomerulare
or
insuficien cardiac
insuficien cardiac cu fracie de ejecie prezervat
hidralazin i isosorbid dinitrat
virusul imunodeficienei umane
balon de contrapulsaie intraaortic
defibrilator cardiac implantabil
unitate de terapie intensiv
international normalized ratio
isosorbid dinitrat
intravenos
presiune venoas jugular
bloc de ramur stng
ventricul stng
dispozitiv de asistare a ventriculului stng
fracie de ejecie a ventriculului stng
infarct miocardic
miligrame
milimetri coloan mercur
milimoli
regurgitare mitral
milisecunde
nanograme per mililitru
ventilaie nonivaziv cu presiune pozitiv
numr necesar de tratat
antiinflamatorii nestroidiene
nitroglicerin
fragmentul N- terminal al peptidului natriuretic
tip B
New York Heart Association
o dat pe zi
cateter n artera pulmonar
intervenie coronarian percutan
inhibitor ai fosfodiesterazei
presiune pozitiv endexpiratorie
tomografie cu emisie de pozitroni
presiune parial a dioxidului de carbon
presiunea capilarului pulmonar
echilibru acido-bazic
picograme
oral
cardiomiopatie restrictiv
studiu clinic randomizat
reducerea riscului relativ
ventriculul drept
zgomot cardiac diastolic
tensiune arterial sistolic
tomografia cu emisie de un singur foton
infarct miocardic cu supradenivelarea segmentului

ST
SvO2
t.i.d.
TDI
ETE
RT
mol
V
AV
VE/VCO2
BCV
VO2
TV
VVI
saturaia mixt a oxigenului venos

de trei ori pe zi
Doppler tisular
ecocardiografie transesofagian
micromol
receptor de vasopresin
aritmie ventricular
ventilaie pe minut/ producia de dioxid de carbon
boal cardiac valvular
consum de oxigen
tahicardie ventricular
pacing cardiostimularea ventriculului drept
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legat de un prognostic foarte prost. Mortalitatea

pacienilor caectici cu IC este mai mare dect n
majoritatea bolilor maligne202.
z Nu a fost nc stabilit dac prevenia i tratamentul caexiei care complic IC, trebuie s fie o int
de tratament. Optiunile includ hrnire hipercaloric, stimulani ai apetitului, antrenamente fizice, i ageni anabolici (insulin, steroizi anabolizani)202.
GUTA
z Pacieni cu IC sunt nclinai s dezvolte hiperuricemie ca rezultat al folosirii terapiei cu diuretice de ans i disfunciei renale. Hiperuricemia
confer un prognostic sever n IC. n guta acut
un scurt tratament cu colchicin pentru supresia
durerii i inflamaiei poate fi considerat. AINS
trebuie evitate, dac este posibil, la pacienii
simptomatici. Terapia profilactic cu inhibitor
de xantin oxidaz (allopurinol) este recomandat
pentru prevenirea recurenei.
ADULI CU BOAL CARDIAC CONGENITAL

z La copii, insuficiena cardiac este cel mai des
legat de situaiile cu debit cardiac crescut datorate unturilor intracardiace. Acestea sunt mai
puin frecvent observate la aduli. Leziuni complexe asociate cu cianoz secundar afectrii
perfuziei pulmonare pot face diagnosticul de
IC dificil. De aceea, msurarea peptidelor natriuretice trebuie inclus regulat la aceti pacieni.
Pacienii cu sindrom Eisenmenger ridic probleme speciale, ca insuficiena ventricular dreapt
asociat i reducerea presarcinii VS n timpul
efortului. Pacienii Fontan sunt incapabili de a
crete perfuzia pulmonar. Muli dintre aceti
pacieni beneficiaz de reducerea postsarcinii
chiar nainte ca simptome semnificative de IC s
fie manifeste clinic203,204.
VRSTNICII
z Majoritatea trialurilor clinice au inclus pacieni
mai tineri cu vrsta medie de ~61 ani i frecvent
70% din pacieni au fost brbai. Jumtate din
pacienii cu IC n populaie sunt >75 de ani, i numai n grupurile cu vrst mai tnr predomin
brbaii. IC cu FE prezervat este mai frecvent
la vrstnici i femei.
z IC la vrstnici este frecvent nediagnosticat,
deoarece simptomele principale de intoleran la

efort sunt deseori atribuite mbtrnirii, comorbiditilor coexistente, i statusului slab al sntii. Comorbiditile frecvente care pot avea impact asupra managementului includ insuficien
renal, diabet, accident vascular cerebral, disfuncie cognitiv i BPOC.
z Polifarmacia crete riscul interaciunilor adverse i al efectelor secundare care pot reduce
compliana. Alterarea proprietilor farmacocinetice i farmacodinamice ale medicamentelor
trebuie ntotdeauna luate n considerare. Alterarea funciei renale este o consecin natural
a mbtrnirii. De aceea, dozele de IECA, BRA,
spironolacton i digoxin pot necesita ajustare.
z Pentru pacienii vrstnici cu IC care sufer de
disfuncie cognitiv, programe de IC individuale
structurate multidisciplinar pot fi extrem de folositoare i pot mbunti aderena la tratament
i prevenirea spitalizrii.
z Contraindicaiile relative la proceduri diagnostice i intervenii, trebuie evaluate cu atenie i
cntrite mpotriva indicaiilor.
GLOSAR
ACC
ECA
IECA
SCA
FA
AHA
ICA
AAN
RA
BRA
RRA
SA
ATP
AV
AVP
b.i.d.
BNP
TA
b.p.m.
BUN
CABG
BCI
UTC
ICC
Clasa 1c
RMC
BPCO
PCPC
CR
PCR
CRT
CRT-D
Colegiul American de Cardiologie

enzima de conversie a angiotensinei
inhibitor al enzimei de conversie a angiotensinei
sindrom coronarian acut
fibrilaie atrial
Asociaia American a Inimii
insuficien cardiac acut
anticorpi antinucleari
regurgitare aortic
blocant al receptorilor de angiotensin
reducerea riscului absolut
stenoz aortic
adenozin trifosfat
atrioventricular
arginin vasopresin
de dou ori pe zi
peptid natriuretic tip B
tensiunea arterial
bti pe minut
ureea seric
by-pass aortocoronarian
boal coronarian ischemic
unitate terapie coronarian
insuficien cardiac cronic
clasificarea antiaritmicelor Vaughan Williams
rezonan magnetic cardiac
boal pulmonar cronic obstructiv
presiune continu pozitiv a cilor aeriene
eliberare prelungit
proteina C reactiv
terapie de resincronizare cardiac
terapie de resincronizare cardiac defibrilator

CRT-P
TC
DDD
CMD
dl
DZ
SESD
ECG
ED
FE
BEM
FiO2
FRG
h
IC
ICFEP
H-ISDN
HIV
IABP
ICD
ICU
INR
ISDN
i.v.
PVJ
BRS
VS
DAVS
FEVS
IM
mg
mmHg
mmol
RM
ms
ng/ml
VNPP
NNT
AINS
NTG
NT-proBNP
NYHA
o.d.
CAP
PCI
PDEI
PEEP
PET
pCO2
PCWP
pH
pg
p.o.
CMR
SCR
RRR
VD
S3
TAs
SPECT
STEMI
terapie de resincronizare cardiac- pacemaker

tomografie computerizat
stimulare cameral dual
cardiomiopatie dilatativ
decilitru
diabet zaharat
Societatea European pentru Studiul Diabetului
electrocardiogram
urgen
fracie de ejecie
biopsie endomiocardic
fraciunea de oxigen inspirat
rata filtrrii glomerulare
or
insuficien cardiac
insuficien cardiac cu fracie de ejecie prezervat
hidralazin i isosorbid dinitrat
virusul imunodeficienei umane
balon de contrapulsaie intraaortic
defibrilator cardiac implantabil
unitate de terapie intensiv
international normalized ratio
isosorbid dinitrat
intravenos
presiune venoas jugular
bloc de ramur stng
ventricul stng
dispozitiv de asistare a ventriculului stng
fracie de ejecie a ventriculului stng
infarct miocardic
miligrame
milimetri coloan mercur
milimoli
regurgitare mitral
milisecunde
nanograme per mililitru
ventilaie nonivaziv cu presiune pozitiv
numr necesar de tratat
antiinflamatorii nestroidiene
nitroglicerin
fragmentul N- terminal al peptidului natriuretic
tip B
New York Heart Association
o dat pe zi
cateter n artera pulmonar
intervenie coronarian percutan
inhibitor ai fosfodiesterazei
presiune pozitiv endexpiratorie
tomografie cu emisie de pozitroni
presiune parial a dioxidului de carbon
presiunea capilarului pulmonar
echilibru acido-bazic
picograme
oral
cardiomiopatie restrictiv
studiu clinic randomizat
reducerea riscului relativ
ventriculul drept
zgomot cardiac diastolic
tensiune arterial sistolic
tomografia cu emisie de un singur foton
infarct miocardic cu supradenivelarea segmentului

ST
SvO2
t.i.d.
TDI
ETE
RT
mol
V
AV
VE/VCO2
BCV
VO2
TV
VVI
saturaia mixt a oxigenului venos

de trei ori pe zi
Doppler tisular
ecocardiografie transesofagian
micromol
receptor de vasopresin
aritmie ventricular
ventilaie pe minut/ producia de dioxid de carbon
boal cardiac valvular
consum de oxigen
tahicardie ventricular
pacing cardiostimularea ventriculului drept
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Revista Romn de Cardiologie | Vol. XXIV, Nr.

Ghidul ESC pentru diagnosticul i tratamentul insuficienei

Ghidul Societii Europene de Cardiologie.

Tabelul 2: Nivele de eviden

Date obinute din trialuri clinice multiple randomizate sau metaanalize

Revista Romn de Cardiologie

Revista Romn de Cardiologie

Ghiduri de insuficien cardiac

Ghidul Societii Europene de Cardiologie.

Ghidul Societii Europene de Cardiologie.

practica clinic, ct i atunci cnd se desfoar studii

Dispnee sever n repaus

Tensiune arterial crescut

Termeni descriptivi n insuficiena cardiac

Revista Romn de Cardiologie

obinuit form de IC care duce la internarea n spital,

Tabelul 6. Clasificarea insuficienei cardiace dup anomaliile structurale

Clasificarea funcional NYHA

Stadiul D Boal structural cardiac avansat i

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Revista Romn de Cardiologie

Ghidul Societii Europene de Cardiologie.

tin n majoritatea trialurilor clinice. Cealalt descrie

Ghidul Societii Europene de Cardiologie.

ze de deteriorare funcional a inimii sunt lezarea sau

Revista Romn de Cardiologie

Simpome i semne de insuficien cardiac

*Vezi textul pentru detalii

O cardiomiopatie este o afectare miocardic n care

Stare de alert, status nutriional, greutate

Algoritm pentru diagnosticul insuficienei cardiace

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de simptome. Pacienii ar trebui titrai pn la dozele

Cauzele simptomelor n insuficiena cardiac

Simptomele i severitatea insuficienei cardiace

Ghidul Societii Europene de Cardiologie.

Diagnosticul insuficienei cardiace

+ = importan mic; ++ = importan intermediar; +++ = importan mare

Tabelul 12. Anomalii EKG obinuite n insuficiena cardiac

ncetinirea conducerii AV, conversie

Modificrile electrocardiografice sunt obinuite la

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Reconsider diagnosticul (dac netratat)

Presiune de umplere VS crescut

Insuficien cardiac stng confirmat

Presiune de umplere VS crescut

Insuficien cardiac stng confirmat

Ghidul Societii Europene de Cardiologie.

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iniierii, titrrii i etapelor de urmrire la pacienii care

t dovezi n favoarea folosirii lor pentru diagnosticarea,

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Cea mai practic msurtoare a funciei ventriculare

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i a pacienilor cu funcie sistolic prezervat este FEVS

Presiuni de umplere normale

Presiuni de umplere mari

Sunt trei tipuri de umplere anormal recunoscute

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2. La pacienii cu presiune atrial crescut (complian VS sczut, suprancrcare volemic,

Ghidul Societii Europene de Cardiologie.

legarea simptomelor de IC de anomaliile valvulare. La