CARDI

OLOGI
E
-SUBI
ECTEREZOLVATE-

Medi
ci
naGener
ala,
Anul
IV
Conf
.Dr
.Muset
escuRodi
ca

1
Reumat
ismul
art
icul
aracut
1.Di
agnost
icul
cli
nic
boalainfl
amator
iecareaparel
acopi isiadolescent
icaf enomennesupurati
v
i
ntar
ziat,l
a2-3saptamanidupaoi
nfect
iefar
ingi
anacust rept
ococ-hemol
i
ticgrup
A
- af
ect
eazacor
dul
,ar
ti
cul
ati
i
le,
SNC,
tesut
ulsubcut
anat
,pi
elea
Debutulcli
nicestebrusc,cufebramaresist
aregener
alaal
ter
ata,l
aceicuafect
are
art
icul
ara,SAUl ent
,insidi
os,l
aceicucardi
tausoar
a.Poatesafieati
picl
acopii
,cu
semnedei ri
tati
eperitoneal
a,apendi
cit
a.
Diagnost
iculsebazeazapeexi
stent
ainantecedent
eauneiinfect
iicustr
eptococ
beta-
hemol i
ti
cdegrupAsipr
ezentaa2cri
teri
imajoresauaunuicr
iter
iumajorsi2
cri
teri
iminore.
Cr
it
eri
i
lemaj
ore:
car
dit
a,pol
i
art
ri
ta,
cor
ee,
eri
tem mar
ginat
,nodul
isubcut
anat
i.
Cr
it
eriimi nore:febr
a,r
eact
ant
ide f
aza acut
a cr
escut
i,VSH,PCR,i
nter
valPR
pr
elungi
t,artr
algi
e.
Dov
ezi
l
eunei
inf
ect
iicust
rept
ococbet
a-hemol
i
ticsunt
:
- Cul
tur
ipozi
ti
vesaut
estr
api
dpent
ruant
igenest
rept
ococi
cepozi
ti
v
- Ti
tr
ucr
escutsaui
ncr
est
eredeant
icor
piant
ist
rept
ococi
ci

2.Cr
it
eri
i
leJones
Cr
it
eri
i
lemaj
ore:
car
dit
a,pol
i
art
ri
ta,
cor
ee,
eri
tem mar
ginat
,nodul
isubcut
anat
i.
Cr
it
eriimi nore:febr
a,r
eact
ant
ide f
aza acut
a cr
escut
i,VSH,PCR,i
nter
valPR
pr
elungi
t,artr
algi
e.
Cardit
aest
eceamaispeci
fi
camani
fest
are;
apar
ela50%di
npaci
ent
i,i
ndecur
sde3
saptamani
deladebut
.
a.Endocar
dit
a:

i
nter
eseazav
alv
ami
tr
alasi
cor
daj
elesal
e,v
alv
aaor
ti
ca.

cl
i
nic:sufl
urior
gani
ce de i
nsuf
ici
ent
aval
vul
ara,modi
fi
car
ea suf
lur
il
or
pr
eexi
stent
e.

1.Sufl
usist
oli
cder egur
git
aremi
tr
ala:pr
imulcar
eapar
e,est
elocal
i
zat
apexi
ancuir
adi
ereinaxil
a

2.Suf
lumezodi
astol
i
capexi
an aparerar
,est
ecar acteri
sti
cval
vul
i
tei
mit
ral
esi
confi
rmasemni
fi
cat
iaor
gani
caasufl
ului
sistoli
capexi
an

2
 3.Sufl
udiast
olicaor
ti
caspi
rat
iv,
det
onal
i
tat
einal
ta,
evi
dent
iazaapar
it
ia
uneii
nsufi
cient
eaort
ice

b.Mi
ocar
dit
a

- tahi
car
die,gal
opprotodi
astol
ic,cardi
omegalie,semnedei
nsuf
ici
ent
acar
diaca
cuhepatomegali
esit
urgescentajugul
arel
or.

c.Per
icar
dit
a

- Dur
erepr
ecor
dial
a,f
recat
uraper
icar
dica,
car
diomegal
i
e

- Di
agnost
ic:
prezent
aunei
lamef
inedel
i
chi
dinsacul
per
icar
dic

Ar
tri
ta
o Afectareaarti
cul
araest easi metri
casiimpli
caart
icul
ati
imari
:genunchi
,gl
ezna,
umar ,cot
.
o Cli
nic-semnel einfl
amat i
ei:eri
tem,tumefact
ie,
cal
dura,
durer
e
o Nudadef ormari
articul
areper manente
o Dureaza2- 3saptamani netr
atata
o Tratament :
aspir
ina,alt
eantireumatice

CoreeaSy denham af ectar

eneur ologicaceapar ela20% di npacient
isieste
caracteri
zatacli
nicpri
nmi scarii
nvoluntaresici
udate,i
ncoordonaremuscul
arasia
capului,labi
li
tat
eemot ionala,scri
sulsiv orbi
reasuntafect
ate.Simptomelepotsa
disparadupa1- 2sapt
amni ,far
atratament .Paci
enti
iprezi
ntariscdedezvol
tar
ea
unoraf ecti
unineur
opsihice,precum sindromuldepr
esiv.

Eri
temulmarginatesterar
,subfor
madeerit
em nonpr
uri
ginos,
vascul
ar,
cucent
rul
pal
id,r
otund.Lezi
uni
leaparpetr
unchisi
peext
remit
ati
.

Noduli
isubcutantat
i fer
mi ,nedur
erosi
,mobil
i,si
tuat
ilani
vel
ulart
icul
ati
i
lor
,in
regi
uneaoccipit
alasilanivel
ulprocesel
orspi
noase.Aparmaifr
ecv
entlaceicu
cardi
tasi
seremi tspont
an,f
arasalasesechel
e.

3.Di
agnost
icdi
fer
ent
ial
Car
dit
areumat
ismal
atr
ebui
edi
fer
ent
iat
ade:

pr
olapsul
dev
alv
ami
tr
ala

CMH

mi
xom at
ri
al

3
 mani
fest
ari
l
ecar
diacedi
nbol
i
ledecol
agen

mi
oper
icar
dit
esi
per
icar
dit
evi
ral
e

endocar
dit
einf
ect
ioase

Ar
tri
tadi
nRAAt
rebui
edi
fer
ent
iat
adeal
tear
tri
tepr
odusede:

Boliinfecti
oase:hepatit
av i
rala,reumat
ism secundar i
nfect
ios,ar
tri
ta
gonococica,endocar
dit
ainfect
ioasa

Bol
imet
abol
i
ce:
gut
a

Bol
idecol
agen:
LES,
pol
i
art
ri
tar
eumat
oida,
spondi
l
itaanchi
l
ozant
a

Bol
ii
munol
ogi
ce:
sar
coi
doza,
angi
oedem,
urt
icar
ie

Bol
ihemat
ologi
ce:
leucemi
iacut
e,si
clemi
e,boal
aHodgki
n.

Caract
eri
sti
ciRAA:car
act
erinf
lamator
,mi
grat
or;antecedent
erecur
ent
edef ar
ingit
a
st
reptococi
ca,modif
icar
idelabor
atorcar
eatest
anat urareumati
smalaainf
lamatii
l
or
ar
ti
culare.

4.Tr
atament
a.Ter
api
eant
ii
nfect
ioasaer
adi
car
eai
nfect
iei
str
ept
ococi
ce
- cur
ade10zi l
ecupeni
cil
i
na,2-
4MU/
zi,i
ntr
amuscul
ar(
sauer
it
romi
cinal
acei
al
ergi
cil
apeni
cil
i
na)

b.Ter
api
eant
ii
nfl
amat
ori
e,ant
ir
eumat
ismal
a

- Aspir
ina90-100mg/kgc/
zil
acopi
i
,4-
8g/
zil
aadul
t;amel
i
oreazasi
mpt
omat
ologi
a,
febr
asi dur
eril
ear
ti
cular
e
- Cort
icot
erapie:Pr
edni
son 1-
2mg/
kgc/
zi;l
a paci
ent
iicu i
mpl
i
car
e car
diaca
semnifi
cati
va
- Dur
atat er
apiei
:1 luna pent
ru at
aculusor,far
aimpli
care sau cu i
mpl
i
car
e
car
diacausoara(cuaspi
ri
na);
3lunipent
rucazur
il
esev
ere(cucort
icoi
zi
)

5.Pr
ofi
l
axi
e
- Recomandatacelorcar
eauavutunepi
soddocument
atdeRAAsicel
orcar
eau
afect
arecar
diacareumati
smal
a.

4
 - Profi
l
axi
a ant
imi
crobi
ana cont
inua est
e cea maibuna pr
otect
iei
mpot
ri
va
recur
ent
eiRAA
Per
ioada

- Peter
menlungsauchi artoat
aviat
alaceicucar
ditareumati
smal
a,l
acar
e
sev
eri
tat
eai
mpl
icar
iicar
diacecr
est
ecufi
ecar
eepi
sodrecurent

- 5anidelaul
ti
mulat
acpanal
a21deanil
apaci
ent
iicar
enuaucar
dit
alapr
imul
epi
sod.

Pr
ofi
l
axi
asef
acecu:
a)Peni
ci
li
naVperos:
200.
000UIde2or
i/zi

b)Benzat
inpeni
cil
i
na

c)Sul
fonami
de-pr
evi
ninf
ect
ia

d)Er
it
romi
ci
na-pent
ruceial
ergi
cil
apeni
cil
i
nasisul
fonami
de:250mgde2or
i/
zi

e)Vacci
nant
ist
rept
ococi
c

Endocar
dit
ainf
ect
ioasa
6.Et
iol
ogi
e
I
n75%di
ncazur
iest
edat
adest
rept
ococul
vir
idanssi
staf
il
ococ.

EIacut
a:st
afi
l
ococaur
iu,
str
ept
ococuspneumoni
ae

EIsubacut
a:st
rept
ococv
iri
dans,
staf
il
ococepi
der
midi
s

St
rept
ococulvi
ri
danssensi bi
llapeni
cil
i
nasigent
ami
cina;est
eubi
cui
tari
nfl
ora
or
ofar
ingi
anasigast
roi
ntest
inal
a

Str
eptococulpneumoni
ae deter
mina EIpe v
alv
ele aor
ti
ce siest
e sensi
bill
a
vancomici
na,r
ezist
entl
apeni
cil
i
nasi er
it
romi
ci
na

Enter
ocociipev al
vel
enati
ve,
prot
ezev
alv
ular
e;sensi
bil
il
apeni
cil
i
na,
vancomi
cina;
rezi
stent
ilacef
alospor
ine

Stafi
lococi
i:coagul
azo-
pozit
ivi(
S.aur
eus pr
oduce50% di
nEIl aceicupr oteze
valv
ulare)sicoagul
azo-
negati
vi(
S.epi
der
midi
s,l
aceicudi
spozi
ti
veint
racar
diace)

5
 Fungi
i:candi
dasiasper
gil
i
usf
recv
enti
nst
ari
l
eimunodepr
esi
vesil
aconsumat
ori
i
dedroguri
.

Sur
sabacter
iemi
ei:i
nfect
iicut
anat
e,cat
eterv
enosi
nfect
at,i
nfect
iipost
par
tum,
ost
eomi
eli
ta

7.Lezi
uni
car
diace
Ri
scul
deadezv
olt
aEIest
ecr
escuti
nur
mat
oar
elesi
tuat
ii
:
1.Paci
ent
ifar
aindi
cat
iedepr
ofi
l
axi
e
- Cardiopati
eischemica,far
aleziunival
vul
are
- Defectdeseptat ri
ali
nchisfaraanomalii
valv
ular
est
angi
- DSAost ium secundum i
naintesidupainchi
dere
- Bypassant eri
orsaustentint
racoronar
ian
2.Paci
ent
ilacar
esei
ndi
capr
ofi
l
axi
a
- Prot
ezevalv
ulare
- Boli
cardi
acecongenit
ale
- Boli
cardi
ovascul
aredobandi
te
- Prol
apsdev al
vamitr
alacuregur
git
aremi
tr
alasaui
ngr
osar
eval
vul
arasev
era
3.Paci
ent
icur
isccr
escutdeEI
,l
acar
epr
ofi
l
axi
aest
eobl
i
gat
ori
e
- Protezevalv
ulare
- AntecedentedeEI
- Bolicardi
acecongeni
tal
e
- Refacerechir
urgi
cal
aalezi
uni
l
ori
ntr
acar
diace

8.Cr
it
eri
idedi
agnost
icpozi
ti
v
Di
agnost
icul
EIsef
acedupacr
it
eri
i
leDuke.

Cr
it
eri
imaj
ore:

6
 1.hemocult
uripozi
ti
ve -mi
croor
gani
sme t
ipi
ce pent
ru EI
,in 2 hemocul
tur
i
separ
ate)

2.hemocult
uripozi
ti
vepersi
stent
ecumi cr
oor
gani
smespecif
iceEI:hemocul
tur
i
l
uatelaodistantade12or eSAUmaimul tehemocul
tur
iseparat
e,cupri
masi
ul
ti
mar ecol
tar
elacelput
in1or adi
stant
a

3.evident
ier
eaaf
ectar
iiendocar
diace:ecocardi
ogr
amapozi
ti
vapent
ruEI(
masa
i
ntracardi
acapev
alv
esaual test
ructur
i,abcese)
Cr
it
eri
imi
nor
e:

- si
tuat
iipredi
spozant
e:admi
nist
rar
eint
rav
enoasadedr
ogur
i,af
ect
iunicar
diace
pr
eexist
ente

- f
enomene v
ascul
are:embol
i
iar
ter
ial
e,i
nfar
ctpul
monarsept
ic,hemor
agi
e
i
ntr
acr
ani
ana

- f
enomenei
munol
ogi
ce:
glomer
ulonef
ri
ta,
fact
orr
eumat
oidpr
ezent
,nodul
iosl
er

- f
ebr
a

- dov
ezi
micr
obi
ologi
ce

- ecocar
diogr
ama

EIpoat
efi
def
ini
ta,
posi
bil
asaur
espi
nsa.

EIdef
ini
ta

- cr
iter
iicl
i
nice:2cr
it
eri
imaj
oreSAU1cr
it
eri
umaj
orsi3mi
nor
eSAU5cr
it
eri
i
minore

- pr
ezentadelezi
unipat
ologi
ce(veget
ati
isauabcesei
ntr
acar
diace)cuaspect
hi
stol
ogi
cconfi
rmatdeendocar
dit
aacti
va

EIposi
bil
a

- aspect
ecor
espunzat
oar
eunei
EIdarcar
eiesput
indi
ncadr
ulEIdef
ini
ta

EIr
espi
nsa

- di
agnost
ical
ter
nat
ivf
erm pent
rumani
fest
ari
l
edeendocar
dit
a

- rezol
var
eamani f
est
ari
l
ordeEIsiabsent
alezi
uni
l
orpat
ologi
cei
nmaiput
inde4
zil
edelainceper
eaant
ibi
oter
api
ei

7
 9.Compl
i
cat
ii
Car
diace:

I
nsuficientacardi
acaprodusadei
nsuf
ici
ent
elev
alv
ular
e
Peri
car di
ta
I
nfarctMi ocardi
c
Abcesesi r
upturi
miocardi
ce
Miocardite
Tul
bur arideconducere
RecurentealeEI
Ext
racar
diace
- Met astazesepti
ce
- Af ectarirenal
e
- Embol i
i
- Tul burarialeSNC
- Af ectarimusculare,schel
etal
e
- Fenomenei munologice

10. Tr
atament
Ter
api
acuant
ibi
oti
cesef
acepr
ecoce,
cudozemar
isi
peper
ioadal
unga.

a.EIst
rept
ococi
ca

-
peni
cil
i
naGi
npr
imel
e24or
e,admi
nist
rat
aint
rav
enos,
12-
20mi
lUI
,di
vi
zat
ain4-
6doze

-
vancomi
ci
na

-
ami
nogl
i
cozi
de

-
cef
tri
axona

b.EIst
afi
l
ococi
ca

-
oxaci
l
ina2gi
ntr
avenosl
a6or
e,t
impde4sapt
amani

-
vancomi
ci
nal
acei
aler
gici
lapeni
cil
i
na

-
ser
ecomandaasoci
ereacugent
ami
cina3-
5zi
l
e

c.EIcuent
erococi

-
tr
atamentcut
ri
met
opr
im sul
famet
oxaz
ol+chi
nol
one

8
 d.EIcuger
meni
gram negat
ivi

-
ant
ibi
oti
cbet
a-l
act
ami
c+gent
ami
cina,
cef
alospor
ine,
ampi
cil
i
na

e.EIcuf
ungi

-
amf
oter
ici
naB+i
nter
vent
iechi
rur
gical
a

Pent
ruEIcucul
tur
inegat
iveseadopt
aur
mat
oar
easchema:

- Moni
tor
izar
ecl
i
nicasi
eval
uar
eaef
icaci
tat
iit
erapeut
ice

- I
nter
vent
iechi
rur
gical
a

11. Pr
ofi
l
axi
e
- Paci entii
cuaf ectarecardiacareumat ismalanecesi t
aprof
il
axieantibiot
icape
termenscur tinaint edeoi nter
ventiechirurgicala
- Riscul estecr escutl apacienti
icupr otezev alvularesil
aceicuantecedent edeEI
- Cei careauRAAf aracarditanunecesi taprof i
laxieEI
- Antiobioticel
ef olosit
epent r
upr evenir
ear ecurent eiRAAsuntinadecvatepentru
EI
Paci
enticur isccr escutdeEI ,lacar epr ofi
laxiaest eobli
gat
orie:protezev alv
ular
e,
ant
ecedent edeEI ,bol icardiacecongenitale.
Pentr
upacient
iiexpusilar
iscurif
oart
emar ideEIsef
olosesc:Amoxaci
l
ina,Ampi
cil
i
na,
Cl
indami
cina,Ceft
riaxonai
nf unct
iedesi
tuati
e.

Val
vul
opat
ii
12. Di
agnost
iccl
i
nicst
enozami
tr
ala

Stenozamit
ral
ar epr
ezi
ntareducer
eaari
eiori
fi
ciul
uimi
tr 5cm2,r
alsub2. eal
i
zandun
obstacol
inumplereadi
astol
icaavent
ri
cul
ului
stang.

Si
mpt
omededebut
:
-
dispneepr
ogr
esi
vadeef
ort
,conseci
ntaast
azei
venoasepul
monar
e;
-
fat
igabi
l
itat
esi
ast
eni
edat
ori
tascader
iidebi
tul
uicar
diac,
-t
usesihemopt
izi
econsecut
ivr
uper
iiv
enul
elorpul
monar
edat
ori
tapr
esi
uni
ivenoase
crescut
e
-
dur
eri
tor
aci
ce
-
mar
ir
eaat
ri
ului
stangducel
adi
sfagi
epr
incompr
esi
unepeesof
ag
-
disf
oni
epr
incompr
esi
unepener
vul
lar
ingi
an

9
-
conv
ulsi
idat
ori
tascader
iidebi
tul
uicer
ebr
al
-
insuf
ici
ent
acar
diacadr
eapt
amani
fest
atapr
inedeme,
asci
ta
-
tr
omboembol
i
i

Examenobi
ect
iv:
1.Inspect
ie:faciesmi t
ral(eri
trozapometi
l
or)
,ci
anozaper
if
eri
ca,casexi
e,nani
sm,
edeme, ascit
a, t
urgescentajugul
arel
or
2.Pal
par
e:fr
eamatcatardi
ast
oli
c,v
ibr
ati
emi
tr
ala,
VDmar
it-
>pal
pabi
li
nepi
gast
ru,
pul
sat
iepar
ast
ernal
adreapt
a.
3.Auscul
tat
ia:
-r
it
mulDurozi
ezzgomot
ul1est
eaccent
uat
,ur
uit
uradi
ast
oli
ca,cl
acmentde
deschi
der
eami t
ral
ei
-
zgomot
ul1di
minuatv
alv
eremani
ate,
asoci
ereaSM cuI
M sauI
Ao
-zgomotul2 este accent
uat
,dedubl
atl
afocar
ulpul
monar
,conseci
ntaa
hiper
tensi
uni
ipul
monare
-
clacment
uldedeschidereami t
ral
eiest
eo v i
brat
iepr
odusadepuner
eai
n
t
ensiuneacor
daj
elori
ntimpul
deschi
der
iiv
alv
elor
-
urui
tur
adi
ast
oli
caest
eexpr
esi
aunui
fluxt
urbul
entpr
inor
if
ici
ulst
enozat
-suf
lur
i:pr
esist
oli
c,diast
oli
c par
ast
ernalst
ang (
de r
egur
git
are pul
monar
a),
sist
oli
cinf
ocarult
ri
cuspi
dian

13. Di
agnost
icpar
acl
i
nic
1.EKGnor
mal
ainf
ormel
eusoar
e.
Supr
asoli
cit
areat
ri
alastangaPmit
ral
,P>0.
12s,
dev
ier
eaxi
alast
anga
HVD
Tul
burar
iderit
m fi
bril
ati
eatr
ial
a
2.Radi
ogr
afi
acar
dio-
pul
monar
a
Lar
gir
eaat
ri
ului
stang
Cal
ci
fi
car
imi
tr
alesaudeAS
VSmi
c
Hemosi
der
oza,
cal
cif
icar
ipul
monar
e,i
nfar
ctpul
monar
Semnedehi
per
tensi
unev
eno-
capi
l
ara: edem al
veol
ar si i
nter
sti
ti
al,
r
evar
satpleur
al

10
 3.Ecocar
diogr
ama-pr
inci
pal
amet
odadedi
agnost
icsiev
aluar
eaconseci
ntel
or
SM
4.Fonocar
diogr
amapr
eci
zeazael
ement
eleauscul
tat
ori
ial
eSM
5.Expl
orar
eacur
adi
oizot
opi
car
dioangi
ogr
afi
a
-eval
uar
eadi
mensi
uni
nil
orcav
itat
il
or,debi
tsangv
in,f
ract
iedeej
ect
ie,pr
ezent
a
r
egur
gitar
il
or
6.Sci
nti
gramapul
monar
aI
nfar
ctepul
monar
e
7.Cor
onar
ogr
afi
apaci
entv
arst
niccuSM pr
eoper
ator

8.
Testdeef
ort
:ev
aluar
eagr
adi
ent
ului
sipr
esi
uni
idi
nar
ter
elepul
monar
e

14. Tr
atament
A.Et
apaasi
mpt
omat
ica
1.Pr
ofi
l
axi
aRAA
Peni
ci
li
naG,
Eri
tr
omi
cina
Secont
inuapanal
a40ani
saupanacandser
ezol
vachi
rur
gical
2.Pr
ofi
l
axi
aEI
Tr
atament
ulf
ocar
elori
nfect
ioase
Pr
otect
ieant
ibi
oti
cal
amanev
remedi
cal
esi
chi
rur
gical
e
3.Ev
itar
eaef
ort
uri
l
ormar
i
4.Sar
cinaest
econt
rai
ndi
cat
ainSM st
ransa
5.Tr
atar
eacor
ect
aaanemi
eisi
inf
ect
iei
B.Et
apasi
mpt
omat
ica
1.Dacas-ainstal
atinsuf
ici
entacar
diaca:r
estr
icti
elasaresief
ort,diur
eti
ce
de ansa,beta-bl
ocante sical
ciu bl
ocante pentr
u cont
rol
ulf r
ecventei
car
diace,
nitr
aticuacti
uneprel
ungit
apentruameliorar
eadi
spneei
2.Dacaaaparutfi
bri
lati
eatr
ial
asepoatefaceconv
ersi
elar
it
m si
nusal
;se
cont
rol
eazafr
ecventacar
diacacuant
iar
it
mice
3.Admini
str
aredeanti
coagul
ant
ein:SM cuf
ibr
il
ati
eat
rial
aparoxi
sti
casi
per
manenta,SM cut
rombozaconf
ir
matadeAS,SM l
apacient
ipest
e40

11
 deani
saucuacci
dent
etr
omboembol
i
ce,
SM pr
otezat
acuv
alv
amet
ali
ca.
C.Tr
atamentchi
rur
gical
Comi
sur
otomi
ami
tr
alaper
cut
anapaci
ent
ifar
acal
cif
icar
ival
vul
are;
Comi
sur
otomi
ami
tr
alachi
rur
gical
a
Val
vulopl
asti
ami t
ral
achirurgi
cal
acandambel evalv
esuntsupl
esiput
in
af
ect
ate,
faracal
cif
ieri
.Aceastametodapast
reazaanatomiav
alv
ei.
I
nlocui
reav
alv
eicupr
otezabi
ologi
casaumecani
ca

15. Di
agnost
iccl
i
nici
nsuf
ici
ent
ami
tr
ala
I
M secaracter
izeazapri
npierder
eaet ansei
tati
ivalv
eimitr
aler
esponsabi
l
adeun
r
efl
uxsi
stol
icalsangel
ui,
dinventr
icul
ulstanginatr
iulst
ang.

Tabl
oucl
i
nic

I
M usoar
asaumoder
ata:
asi
mpt
omat
ic

IM cr
oni
casever
a:di
spneeprogresi
vadeefort(
consecut
ivscaderi
idebi
tul
ui
cardi
ac)
,di
spneededecubi
t,or
topnee,papi
tat
ii(
odat
acui nst
alar
eafibr
il
ati
ei
atr
ial
e)

I
M acuta,secundaraEI
:rupt
uri
depil
i
er,decor
daje,
repr
ezent
atededi
spnee
par
oxisti
ca,edem pul
monaracut,
soccardi
ogen.

Examenobi
ect
iv

1.I
nspect
ie:
tur
gescent
ajugul
arel
or,
cianozaper
if
eri
ca,
socapexi
anv
izi
bil

2.Pal
par
e:ASpalpabi
li
nspati
ulI
IIpar
ast
ernal
stang,
zgomot
ul2pal
pabi
ll
afocar
ul
pul
monar,
freamatsi
stol
i
claapex

3.Auscul
tat
ie:

zgomot
ul1di
minuat

zgomot
ul2accent
uatl
afocar
ulpul
monar

zgomot
ul3pr
ezent,dat
ori
tacr
est
eri
ifl
uxul
uisangui
npr
inv
alv
ami
tr
alai
n
pri
mapart
eadiast
olei

scur
taur
uit
uradi
ast
oli
ca,
dat
ori
taumpl
eri
irapi
deaVScuunv
olum mar
e
desange

12
 sul
fuhol
osi
stoli
ci
njetdevapori
,cei
ncepei
medi
atdupazgomot
ul1si
i
radi
azai
naxilasauparast
ernal
stang.

16. Di
agnost
icpar
acl
i
nic
1.EKGnor
mal
ainI
M usoar
a
I
M sever
a:supr
asol
i
cit
aredeat
ri
ust
ang(
Plar
g,cr
est
at)
,hi
per
trof
iedeVS,
VD,
f
ibr
il
ati
eatr
ial
a
2.Radi
ogr
afi
ecar
dio-
pul
monar
a
I
M acut
a:at
ri
ust
angnor
mal
,mi
c;st
azapul
monar
a
I
M sev era:atr
iustangmaritdevol
um,ventr
iculst
angmar it
,ult
eri
ormar
ir
ea
ventri
culul
uidreptdator
it
asuprai
ncar
car
iisi
stoli
ce;cal
cif
icar
ideinelmi
tral
,
dil
atareaarter
eipulmonar
e.
3.Ecocar
diogr
afi
e
a.M-mode:marir
eaat r
iul
uist
ang,vent
ri
cul
uluidrept
,di
latar
eavent
ri
cul
ului
st
angpri
nincarcar
edev ol
um,miscar
eposteri
oaraavalv
eimit
ral
e
b.2D:veget
ati
i
,hipoki
nezi
e de sept
,hi
per
ecogeni
tat
e de pi
l
ier
i,v
alv
e
i
ngr
osatecumobil
i
tat
eredusa
c.Doppl
er:
apr
eci
azal
ungi
measi
ari
ajet
ului
regur
git
at
4.Fonocar
diogr
amaev
ident
iazasuf
lul
hol
osi
stol
i
c,zgomot
ul3pr
ezent
5.Dozar
eaBNPmar
kerpr
ecocedeev
olut
iespr
einsuf
ici
ent
acar
diaca
6.Cat
eter
ism siAngi
ogr
afi
e ut
il
e cand paci
ent
ulpr
ezi
ntar
isc de boal
a
cor
onari
ana
7.RMNmasoar
acuacur
atet
efl
uxul
regur
git
at

17. Tr
atament
1.I
M asi
mpt
omat
icanunecesi
tat
rat
ament
.Ser
ecomandapr
ofi
l
axi
aRAAsi
EI

2.I
M si
mpt
omat
ica:

-
regi
m hi
posodat

-
inhi
bit
ori
aienzi
mei
deconv
ersi
e:i
nregur
git
ari
mit
ral
easoci
atecudi
sfunt
ie

13
 deVS

-
instadi
uldei
nsufici
ent
acar
diacasepotadmi
nist
ra:
diur
eti
ce,
digi
tal
i
ce,
bet
a
-
blocant
e,ant
icoagul
ant
e

3.I
M acut
a:di
uret
ice,
nit
rat
i,agent
iinot
roppozi
ti
vi

Tr
atamentchi
rur
gical

- Reconstr
ucti
echir
urgi
calaaaparatul
uival
vularmitral
:i
nIM cual
ter
ari
val
vul
are
minore,
faracal
ci
ficar
i,cuconser
vareasauinlocui
reainel
ului
mit
ral

- Protezar
evalvul
aramit
ral
a,cuvalv
ebiol
ogicesaumecanice,
lapaci
ent
iicu
parametri
ihemodinami
cialt
erat
isihi
potensi
unear
ter
ial
amai put
insev
era.InI
M
severaserecomandaprot
ezaredeurgenta.

18. Et
iol
ogi
aval
vul
opat
ii
lormi
tr
ale
A.Et
iol
ogi
ast
enozei
mit
ral
e
- 99% cauzar
eumat
ismal
a
- al
teet
iol
ogi
i
1.Congeni
tal
a
-
rar
,izol
at
-SM cupil
i
erianor
mal
i(unsi
ngurpi
l
ier
),r
eal
i
zandaspectdev
alv
ai
nhamac
sauinpar
asuta
-
SM dobandi
ta,
asoci
atacudef
ectdeseptat
ri
al
2.Dobandi
ta
-
cal
ci
fi
car
idegener
ati
veal
einel
ului
mit
ral
,l
avar
stni
ci
-
col
agenoze di
nlupus er
it
emat
os si
stemi
c,st
enoze aor
ti
ce,pol
i
art
ri
ta
r
eumatoi
da
-
car
cinoi
d,mucopol
i
zahar
idoze,
miocar
dit
acucel
ulegi
gant
-
ami
l
oidoza:
foar
ter
ar

B.Et
iol
ogi
ainsuf
ici
ent
eimi
tr
ale
Cauzel
eIMi
nrapor
tcust
ruct
uri
l
eaf
ect
ate:
a.Foi
tel
eval
vul
are:
reumat
ism,
prol
aps,
EI,
col
agenoze,
cauzat
raumat
icaet
c

14
 b.Cor
daje(
rupturi
):i
schemie,r
eumat
ism,pr
olapsdev
alv
ami
tr
ala,si
ndr
om
Marf
an,osteogenezaimperf
ect
a
c.I
nel
ulmi
tr
al:
dil
atar
e,cal
cif
icar
isecundarHTA,
diabet
,CMH
d.Muschi
ipapi
l
ari
:i
schemi
e,di
l
atar
eaVS,
reumat
ism,
CMH,
per
icar
dit
e
I
M poat
efi
Congeni
tal
a:fenestr
aredeval
vamitr
ala,val
vamitr
alai
n par
asut
a,
def
ectdeseptatri
al,
anomal
i
ial
ear
ter
eicoronar
est
angi
Dobandi
ta:
1.I
schemi
ca:
anev
rism v
ent
ri
cul
ar
2.Noni
schemica:r
eumat
ismala(
35%),degener
ati
vasidi
str
oficai
diopat
ica,
tr
aumati
ca,CMH,di
spl
azi
i,
LES, ar
tri
tar
eumatoi
da,
IMfunct
ional
a(HTAcu
hi
pert
rof
iedeVS,CMD)

19. Di
agnost
iccl
i
nicst
enozaaor
ti
ca
St
enozaaort
icareprezintaunobst
acoli
nfat
avent
ri
cul
uluist
ang cedet
ermi
na
di
fi
cul
tat
eagoli
ri
iacestuia.

Reducer
eaor
if
ici
ului
aor
tcsub1cm2det
i ermi
naapar
it
iaur
mat
oar
elorsi
mpt
ome:

-di
spneedeef or
tprogresi
va,apar
edatori
tacr
esteri
ipr
esiuni
itelediast
oli
ceaVS
sistazeipul
monare.Ev ol
ueazacatr
edispneeparoxi
sti
canoct urna,ort
opneesi
edem pulmonaracut.

-
angi
napect
oral
aceapar
elaef
ortsi
cedeazai
nrepaussi
lani
tr
ogl
i
cer
ina

-
sincopaestedeter
minat
adescadereadebi
tul
uicar
diac,t
ulbur
ari
l
eder
it
m,
v
asodilat
ati
aper
if
eri
casiapar
edupaef
ort
.

-
moar
tesubi
ta

-
alt
esimptome:sanger
arigast
roi
ntest
inal
e,t
ulbur
aripasager
edev
eder
e,st
ari
f
ebri
le(
suspi
ci
unedeEI)

Examenobi
ect
iv
1.I
nspect
iesi
pal
par
e

-
pul
sint
arzi
at,
deampl
i
tudi
ner
edusa

-
tensi
unear
ter
ial
ascazut
a

15
 -
jugul
arenor
mal
esaudi
l
atat
e

-socapexi
ani
ntar
ziatsauv
igur
osi
nasoci
ereast
enozeiaor
ti
cecui
nsuf
ici
ent
a
aort
icasaumi
tr
ala
2.Auscul
tat
ie

-
zgomot1nor
mal
saudi
minuat

-
cli
cpr
otosi
stol
i
cdeej
ect
ie,
val
vul
ar

-
zgomot2aor
ti
c,di
minuat

-
gal
oppr
otodi
ast
oli
c(zgomot
ul3)

-
gal
oppr
esi
stol
i
c(zgomot
ul4)

-
suf
lusi
stol
i
ccr
escendo-
descr
escendoi
nfocar
ulaor
tei
,gr
ad3-
4.

-
suf
lusi
stol
i
cder
egur
git
aremi
tr
alal
aapex

-sufl
u si
stol
i
caor
ti
ccedi
minua cand sei
nst
aleaza i
nsuf
ici
ent
avent
ri
cul
ara
stanga

20. Di
agnost
icpar
acl
i
nic
1.EKG

Tulbur
arider
it
m extr
asi
stol
eat
ri
ale,
vent
ri
cul
are,
fibr
il
ati
eat
ri
ala,
tahi
cardi
event
ri
cul
ara

HVScusauf
arat
ulbur
ari
der
epol
ari
zar
e

BRScompl
etsaui
ncompl
et

BAVdegr
adedi
fer
it
e

Supr
asol
i
cit
areat
ri
ulst
angPmi
tr
al

2.Radi
ologi
c

SAsev
era

- Ar
cul
inf
eri
orst
angest
eal
ungi
t,bombat,
rot
unj
i
tcuuni
ndi
cecar
diot
oraci
c>
0.
5

- Ci
rcul
ati
avenoasapul
monar
aincar
cat
adacas-
ainst
alatI
VS

- Cal
cif
ier
ideinelsiv
alv
eaor
ti
ce,
dil
atat
iepost
stenot
icaaaor
tei
ascendent
esi
but
onaorti
cmi csor
at

16
 3.Ecocar
diogr
ama

Sef
olosest
epent
ru:

a.Ev
ident
ier
eaanat
omi
eiv
alv
ular
e

b.Det
ermi
nar
easev
eri
tat
iist
enozei

c.Ev
aluar
eaf
unct
iei
VS

d.I
dent
if
icar
eaal
toraf
ect
ari
val
vul
are

e.Ev
ident
ier
eai
ngr
osar
iiv
alv
eloraor
ti
cecur
educer
eami
scar
il
oracest
ora

4.Testdeef
ort

5.Cat
eter
ism car
diac

6.Cor
onar
ogr
afi
eut
il
aindet
ect
areaaf
ect
ari
icor
onar
iene

7.Exami
nareCTsi
RMNev
aluar
eaaor
tei
ascendent
e,cuant
if
icar
eacal
cif
icar
ii
val
vul
are

21. Tr
atament
- Paci
enti
isimptomat
ici necesi
taint
ervent
ie chi
rur
gical
aint
rucatni
ciot
erapi
e
medicament
oasanupoat
eamanai nt
ervent
ia.
- Pacient
iifaraindi
cati
eoperat
ori
epotfit
rataticudozemicidedi
git
ali
ce,di
uret
ice,
i
nhibit
oriaienzimeideconv
ersi
e.Bet
abl
ocanteletr
ebui
eev
itat
e.
- Lapaci
ent
iicuedem pul
monar ni
tr
opr
usi
atulpoat
efiut
il
izatsubmoni
tor
izar
e
hemodi
namica
- Sev
orut
il
izacupr
udent
aNi
tr
ogl
i
cer
ina,
Vasodi
l
atat
oar
elesi
Diur
eti
cel
e.
- Tr
atamentchi
rur
gical
val
vul
opl
ast
ieaor
ti
cacubal
on;
inl
ocui
rev
alv
ular
a.

22. Di
agnost
iccl
i
nici
nsuf
ici
ent
aaor
ti
ca
I
nsufici
entaaort
icaestedatadei nchider
eai
ncompl
etaavalv
eloraor
ti
ceindiast
olacu
i
ntoarcereainv ent
ri
cululstangauneicant i
tat
idi
nf l
uxulsangui
nsist
oli
c,ceeace
deter
mi nadi
lat
atiasihi
pert
rofiacavi
tati
i.
Insuf
ici
ent
aaorti
caacuta:di
spneesevera,edem pul
monaracut
,hi
pot
ensi
unear
ter
ial
a
sicol
apscardi
ovascul
arurgentacar
diovascul
ara
I
nsuf
icient
aaort
icacr
onica poatefibi
netol
erat
amul
tiani
,fi
i
ndasi
mpt
omat
ica,
pr
imelesimpt
omeapardeobi
ceidupa40ani

17
Debut
ulsepr
oducepr
insi
mpt
ome
a.Ati
pice:palpi
tat
ii
,tr
anspi
rat
ii
,dur
eripr
ecor
dial
e,pul
sat
iianor
mal
eper
ceput
ela
bazagatului
b.Ti
pice
Dispneedeefortpr
ogr
esi
vadat
ori
tast
azeipul
monar
e,di
spneepar
oxi
sti
ca
nocturnasi
ort
opnee
Angi
napectoral
alaef
ortapar
edat ori
tadebit
uluiscazutpr
incoronarei
n
ti
mpuldiastol
eisia cer
eri
icrescute de oxi
gen de catre un miocar
d
hi
per
trof
iat
Examenobi
ect
iv
Semneper
if
eri
cecl
asi
ce
- semnmussetpul
sat
ier
it
micaacapul
ui
- pul
sat
iaarter
eir
adi
alecu br
atulr
idi
cat
,cesesi
mtesil
ani
vel
ulmuscul
atur
ii
ant
ebr
atul
ui
- semnul
Mul
l
er
- semnulDur
ozi
ez (sufl
u sistol
ic audi
bill
a ni
vel
ulart
ereifemur
ale cand est
e
compri
mat
aproxi
mal si
diastoli
ccandestecompri
mat
adistal
)
- mi
scar
isi
stol
i
cesi
diast
oli
ceal
epupi
l
ei
Examencor
d
Car
diomegal
i
e
Tahi
car
die
Tul
bur
ari
der
it
m (f
ibr
il
ati
eat
ri
ala)
Zgomot
ul1di
minuat
Cl
i
cpr
otosi
stol
i
c
Zgomot
ul2poat
efi
nor
mal
,absent
,di
minuatsaudedubl
atpar
adoxal
Zgomot
ul3pr
ezent
Ur
uit
uramezodi
ast
oli
ca
Suf
lusi
stol
i
cinf
ocar
ulaor
ti
cdedebi
t

23. Di
agnost
icpar
acl
i
nic
EKG

18
-HVSdet
ipdi
ast
oli
c(i
ncar
car
edev
olum)
,di
l
atar
eAS,
tul
bur
ari
der
it
m si
deconducer
e.
Fonocadr
iogr
ama apar
e un suf
lu di
ast
oli
cimedi
atdupa component
a aor
ti
ca a
zgomotul
ui2.
Radi
ogr
afi
ecar
dio-
pul
monar
a
car
diomegal
i
e,di
l
atar
eaaor
tei
ascendent
e,cal
cif
ier
idebut
onaor
ti
c
di
l
atati
aanev r
ismal
aaaor
tei
,cal
cif
icar
ial
eper
eti
l
oraor
teiascendent
esi
ost
iumul
uicoronar
ian.
Ecocar
diogr
ama
Cr
it
eri
idedef
ini
real
eIA

Ar
iaor
if
ici
ului
regur
git 3cm2
at>0.
Vol
umul
regur
git
at>60ml
Fr
act
ieder
egur
git
are>50%
Ecograf
iatr
anst
oraci
casit
ransesof
agi
anaper
mitev
aluar
eaanat
omi
eiv
alv
eloraor
ti
ce
siaradaci
nii
aor
tei
.
-di
lat
areavent
ri
cul
uluist
ang,f
lut
terval
vul
armi
tr
al,i
nchi
der
eapr
ecoceav
alv
eimi
tr
ale
ant
eri
oare,
scader
eafract
iei
deeject
ie
Cat
eterism car
diacsiangiogr
afi
e:masoara presi
unea VS siev
alueaza sev
eri
tat
ea
i
nsufi
cientei
aort
ice,
funct
iei
vent
ri
cul
ului
stang.
RMN
Testdeef
ort
Angi
ogr
afi
esci
nti
graf
ica

24. Tr
atament
Insufi
cient
aaorti
cacr
oni
causoarasaumoderat
asiasi
mptomat
icanunecesi
ta
trat
ament cidoar supr
avegher
e anual
a a si
mpt
omatol
ogi
eisiparametr
il
or
ecocardiogr
afi
ci
.
I
nsuf
ici
ent
aaor
ti
cacr
oni
casev
erabenef
ici
azade:
-
prof
il
axi
aendocar
dit
eii
nfect
ioase
-
vasodi
alt
atoar
e(I
ECA)
-
cont
rol
ult
ulbur
ari
l
order
it
m cudi
git
ali
ce,
blocant
eal
ecanal
elordecal
ciu)
Nu se r
ecomanda t
erapi
a cu v
asodi
l
atat
oar
ela paci
ent
iicu t
ensi
une ar
ter
ial
a

19
 nor
mal
asi
vent
ri
cul
stangnedi
l
atat
.
Insuf
ici
entaaort
icaacutaest
eour gentamaj or
asii mpunet er
api
edesust i
ner
e
hemodinamica cu dopamina, dobutamina, ni
tropr
usiat de sodi
u, bal
on de
contr
apulsat
ieaort
ica,
panal
amoment uli
nter
venti
eichir
urgi
cal
e,car
etrebui
esafi
e
catmai pr
ecoce.
Tr
atamentchi
rur
gical
Seopereazaatuncicanddiamet
rult
eledi
ast
oli
calVSest
emaimar
ede55mm si
fr
act
iadeeject
iemai micade45%
Tipur
idei
nter
vent
ie:r
econst
ruct
iev
alv
ular
a,i
nlocui
rev
alv
ular
acupr
otezabi
ologi
ca
saumecani
ca.

. Et
iol
ogi
aval
vul
opat
ii
loraor
ti
ce
St
enozaAor
ti
ca:
-subval
vular
a poatefif i
xa (pr
ininelf
ibr
os sau di
afr
agm)sau di
nami
ca
(
car
diomiopati
ehi
pert
rof
icaobstr
ucti
va)
-supr
aval
vular
aestetot
deaunacongeni
tal
asubf or
mauneiaor
tehi
popl
azi
cesau
undiafr
agm supr
aval
vul
arsiseasoci
azacualt
elezi
uni
congeni
tal
e

-v
alv
ular
a,poat
efi
:
1.Congenit
ala:asoci
ata cu al
te anomal
ii
:stenoza pul
monar
a supr
aval
vul
ara,
coar
ctat
iedeaort
a,persi
stent
adecanalar
ter
ial
,vent
ri
culst
anghi
popl
azi
c
2.Dobandi
ta:
degener
ati
vasaur
eumat
ismal
a
I
nsuf
ici
ent
aAor
ti
ca
Sepoatepr
oducepr
inmodi
fi
car
ial
eval
vel
or,aor
teiascendent
esaual
ecel
ordoua
asoci
at.
1.Modi
fi
car
ial
eval
vel
or:75%di
ntot
alul
cazur
il
or;
est
edet
ermi
nat
ade:
RAA
Bicuspidi
eaor
ti
ca
EIpev alv
enor
malesauaf
ect
ateant
eri
or
2.Modi
fi
car
il
eaor
tei
din:

20
 Si
ndrom Marf
an
Di
secti
edeaorta
Tr
aumatism t
oraci
c
3.Modi
fi
car
il
eval
vel
orsi
aor
tei
apari
nspondi
l
itaanchi
l
ozant
a
Insuf
ici
ent
aaor t
icadegenerati
vaeceamaif recvent
af or
madeI
Ai
mpl
i
ca
l
ezi
unial
ev al
vel
orcaresuntsubti
risi
predi
spusel
apr ol
abare
RAA15%di
ncazur
il
edeI
A
Di
sect
iaAor
tei
det
ermi
naI
AAcut
a

Per
icar
dit
e
26. Et
iol
ogi
e
1. I
diopat
ica
2. Pr
odusadeor
gani
smepat
ogene
Vi
ral
aadenov
irosur
i,
HBV,
HIV,
vir
usgr
ipal
,vi
rusur
li
an
Bact
eri
anaSt
afi
l
ococ,
Str
ept
ococ,
Pneumococ
Mi
copl
asme
Fungi
Asper
gil
l
us,
Candi
da
Par
azi
tiToxopl
asma
3. Neopl
azi
ca
Metat
stati
ca sau pri
ni nvazi
e di
nveci
nat
ate -neopl
asme mamar
e,
pul
monar
e,l
eucemii
acute,melanom
Pr
imar
er
arr
abdomi
osar
com,
mezot
eli
om,
fibr
osar
com
4. Pr
odusapr
inmecani
smei
munol
ogi
ce
Bol
ireumat
oidesi
decol
agen:
RAA,
LES,
scl
eroder
mie,
art
ir
tar
eumat
oida.
Al
tel
e:Pol
i
art
eri
tanodoasa,
vascul
i
te
React
iimedi
cament
oase
6. Pr
odusapr
inagr
esi
uni
fizi
ce
Tr
aumat
ism t
oraci
cinchi
s
Pl
agi
penet
rant
ecusauf
aracor
pst
rai
n

21
 Perf
orati
ipr oduse de sonde,catet
ere,resuscit
are car
diopul
monar
a,
pocedur
idediagnosti
csauint
ervent
ional
e,i
nter
vent
iichi
rurgi
cal
e
Post
-i
radi
ere
7. Asoci
ataunorbol
idemet
abol
i
sm
i
nsuf
ici
ent
arenal
ainst
adi
ulur
emi
c
Gut
a
Hi
pot
ir
oidi
e
Per
icar
dit
acol
est
erol
i
ca
8. Pr odusapri
nmecani
smei
ncer
tesaunecunoscut
eincadr
ulunuispect
ru
l
argdebol
isisi
ndr
oame
Pancr
eat
it
aacut
a
React
iimedi
cament
oasef
aracomponent
aimuna
Pur
pur
atr
ombot
icat
romboci
topeni
ca
Azbest
oza
Ami
l
oidoza
Bet
a-t
alasemi
e

27. Di
agnost
ic
Debut
ult
ipi
c
Durer
etoraci
caanterioaramaii nt
ensaincli
nostat
ism,accent
uatade
miscar
il
erespi
rat
ori
i
,tuse,deglut
it
iesausughi
tcuinst
alar
epr ogr
esi
vaincatev
a
or
e
Dur
ereairadi
azainumar ulstang,ceaf
a,gat
.Speci
fi
caei
radi
ereape
mar
gineasuper
ioaraat
rapezul
uidarsiinmandi
bul
a.
Subf
ebr
il
it
ateasauf
ebr
amoder
ata-i
nsot
est
escdur
erea.
Tuseseaca
Odi
nof
agi
e,di
sfagi
e,sughi
t
Di
spneepoat
eli
psi
incel
emai
mul
tef
orme
Debut
uriat
ipi
cef
recv
entsubf
ormaunorst
arigr
ipal
e,mi
algi
i
,pal
pit
ati
isidur
eri
tor
aci
cedif
uze
Semnul
pat
ognomoni
ccl
i
nicf
recat
uraper
icar
dica(
in85%di
ncazur
i)

22
 Celmaibi neseaudepemar gi
nea st
anga a st
ernul
uicu membr
ana
st
etoscopul
uibi
neapasat
apet
orace
Examenepar
acl
i
nice
EKGev
olut
iei
n4st
adi
i
:
- St
adi
ul1:
supr
adeni
vel
areaST
- St
adi
ul2:
STr
evi
nel
ali
niai
zoel
ect
ri
ca,
Tdev
ineapl
ati
zatdi
fuz
- St
adi
ul3:
undeTnegat
ive,
STl
ali
niai
zoel
ect
ri
ca
- St
adi
ul4:
ECGnor
mal
,sauper
sist
ent
amodi
fi
car
il
ordi
fuzeal
eundei
T

28. Tabl
oucl
i
nic
Debut
ult
ipi
c
Durer
etoraci
caanterioaramaii nt
ensaincli
nostat
ism,accent
uatade
miscar
il
erespi
rat
ori
i
,tuse,deglut
it
iesausughi
tcuinst
alar
epr ogr
esi
vaincatev
a
or
e
Dur
ereairadi
azainumar ulstang,ceaf
a,gat
.Speci
fi
caei
radi
ereape
mar
gineasuper
ioaraat
rapezul
uidarsiinmandi
bul
a.
Subf
ebr
il
it
ateasauf
ebr
amoder
ata-i
nsot
est
escdur
erea.
Tuseseaca
Odi
nof
agi
e,di
sfagi
e,sughi
t
Di
spneepoat
eli
psi
incel
emai
mul
tef
orme
Debut
uriat
ipi
cef
recv
entsubf
ormaunorst
arigr
ipal
e,mi
algi
i
,pal
pit
ati
isidur
eri
tor
aci
cedif
uze
Semnul
pat
ognomoni
ccl
i
nicf
recat
uraper
icar
dica.
Apar
ecl asicin cel
et r
eimomentealemiscari
ivent
ri
cular
er api
depe
per
icar
d:si
stol
av ent
ri
cular
a,umpl
ereav
ent
ri
cul
ararapi
dasisi
stol
aatri
ala
Fr
ecat
uraper
icar
dicaseaudei
n85%di
ncazur
i
Celmaibi neseaudepemar gi
nea st
anga a st
ernul
uicu membr
ana
st
etoscopul
uibi
neapasat
apet
orace
Exi
stamanev
redepr
ovocar
e:pozi
ti
egenu-
pect
oral
a,r
idi
car
eamai
nil
or
I
nevoluti
eestetr
anzi
tor
ie,dispar
esireapar
epeparcursulcator
vazi
l
ein
f
unct
iedeevolut
iacant
it
ati
idel
ichidperi
car
dicsidepr
ocesuldevindecar
e

23
29. Di
agnost
icdi
fer
ent
ial
Di
agnost
icul
dif
erent
ial
sef
acecu
1.I
nfar
ctmi
ocar
dicacut
o Supr
adeni
vel
areaST
- Rel
ati
vampl a(
inperi
cardit
adepasest
erar5mm)
,ar
econcav
itat
eai
njos
sii
nderi
vat
ii
leI-I
IIar
easpectdiscor
dant
- I
nper
icar
dit
aaspect
uleconcor
dant
o Supr
adeni
vel
areaST
- Coexi
stacuundel
eTnegat
ive
- I
n peri
cardi
ta negat
ivar
ea undel
or T apar
e dupa r
eveni
rea l
ali
nia
i
zoel
ect
ricaasegmentul
uiST
o Subdeni
vel
areasegment
ului
PR
- Nuseobser
vadecatr
ari
nIMAat
ri
ali
nti
ns
- I
nper
icar
dit
ai
nder
ivat
ii
leDI
Isi
IIIcusupr
adeni
vel
arei
naVR
- Tul
bur
arideconducer
esir
it
m saual
ungi
reai
nter
val
uluiQTaparr
elat
iv
f
recv
ent
2.Si
ndr
om deRepol
ari
zar
ePr
ecoce
o Supr
adeni
vel
areaJ-
STapar
enumai
inder
ivat
ii
lepr
ecor
dial
e
o Rapor
tul
deampl
i
tudi
neST/
TinV6emer
eu<0.
24(
inper
icar
dit
e>0.
24)

30. Compl
i
cat
ii
Peri
cardi
tacronica:i
nfl
amati
eceper si
stapeste3lunisiseprezi
ntasubf or
made
peri
cardi
tainsotit
ader evar
satli
chi
dian,for
maadezi vasiformaconst r
ict
iva.I
n
ti
mp,pr ocesuli nfl
amator di
minua siintervi
ne ci
catri
zar
ea f i
brozarea si
cal
cif
icar
eapericardul
ui.
Tamponadacar di
aca r eprezi
ntafazadedecompensar eacompr esi
eicordul
ui
cauzatadeacumul areadel i
chidinpericard.Ini
tial
,li
chi
duldestindesinusuri
lesi
recesuri
l
eper i
cardi
ce,ult
eriorseintindfibrel
edecol agensicel eelasti
ceiarapoi
crestepresi
uneaperi
cardi
ca, consecuti
vcr est
erii
volumuluiper
icardi
c.
Per
icar
dit
aconst
ri
cti
vaaparecaurmareapr ocesuluidefi
brozar
eaper i
cardul
ui
car
eset r
ansf
ormaintr
-o
cuscar
igi
da.Aceastatransfor
maresepr oducelent
,in

24
 decur
sdeani
saumai
rar
,luni
.

31. Tr
atament
Mi
j
loace:
medi
cament
oase,
chi
rur
gical
e
Obi
ect
ive:
1)Ter
api
epat
ogeni
caant
ial
gicesi
ant
ii
nfl
amat
oar
e
Aspi
ri
na
I
bupr
ofen
Cor
ti
cost
eroi
zi
i
Predi
nisonsef olosescnumaiincazurider
ezi
stent
alaAINS,bol
ial
e
tesut
uluiconj
unct
iv,
pericar
dit
aur
emica,f
ormaaut
oreact
iva
Sepotadmi
nist
rai
ntr
aper
icar
dicpent
ruaev
itaef
ect
elesi
stemi
ce
Col
chi
ci
na-laceicuper
icar
dit
aacut
areci
div
ant
afi
einmonot
erapi
efi
ein
combi
nat
iecuAINSsauAIS
Opi
aceeant
ial
gicei
nfazaacut
a
2)Ter
api
aet
iol
ogi
caet
iol
ogi
eneopl
azi
ca
Admi
nist
rar
eint
raper
icar
dicadeant
ineopl
azi
ce
I
nducer
edel
i
ber
atadeader
ent
eper
icar
dice(
admi
nist
rar
edet
etr
aci
cli
na)
Tr
atament
echi
rur
gical
elocal
e
3)Ter
api
esi
mpt
omat
ica

32. Tamponadacar
diaca
repr
ezint
afaza de decompensar
e a compr
esi
eicor
dul
uicauzat
a de
acumul
areadel
i
chi
dinperi
card.
Trat
amentulconst
ain evacuarea de ur
gent
aal
i
chi
dul
uiper
icar
dic pr
in punct
ie
peri
car
dica,
per
icar
dot
omiepercutana.
Chir
urgi
cal
,sepoat efaceinci
zi
epericardicasubxi
foi
diana,ur
mat adet oracoscopi
ecu
event
ualabiopsi
eperi
cardi
casidrenaj.Semaipoat efaceofereast
rapleur o-
peri
car
dica
dedrenaji
ncazuril
eincareli
chi
dulser ef
acerapiddupapuncti
aper i
car
di ca.
I
n cazul peri
cardit
elor neopl
azi
ce se pot admi
nist
ra i
ntr
aper
icar
dic subst
ant
e
ant
ineopl
azi
ce,anti
bioti
c.

25
Puncti
aper
icar
dicasefacepri
nghidajfl
uoroscopi
c,cumonitor
izar
eEKG.Sepr
efer
a
el
iminar
eaamai put
inde1000mlpentr
uevit
areadil
atat
iei
car
diaceacut
e.

Hi
per
tensi
uneaar
ter
ial
a
33. Def
ini
ti
esi
clasi
fi
car
e
HTA reprezi
nta cr
ester
ea val
ori
l
orpr
esi
uni
iar
ter
ial
e pest
eval
ori
l
etensi
onal
e
consi
derat
enormale(<120/
80)
Cl
asi
fi
car
e:
HTApr
imar
a,i
diopat
icacauzai
nit
ial
asei
dent
if
icagr
eu(
95%)
HTAsecundar
asepoat
eident
if
icaocauzai
nit
ial
a,est
ecur
abi
l
a(5%di
n
cazur
i)
Cat
egor
ia PAS PAD
Opt
imal <120 <80
Nor
mal 120-
129 80-
89
I
nal
tNor
mal 130-
139 85-
89
HTAgr
ad1 140-
149 90-
99
HTAgr
ad2 160-
179 100-
109
HTAgr
ad3 >180 >110
HTAsi
stol
i
cai
zol
ata >140 <90

34. Examencl
i
nic
Pr
esupunemasurar
easiapreci
ereavalor
ilortensi
uni
iart
eri
ale,depi
star
eaaf
ect
ari
i
or
ganel
orti
nta,
acauzel
ordeHTAsi afactori
lorderi
sc.
Semneobi
ect
ive:
-
pulsulpoatefinormal,ri
tmi
c(ri
tm si
nusal
),arit
mic,tahi
car
dic,sl
ab(disfuncti
ade
VS)
-
TA>140/ 90;
pe24or e125/80,
acasa135/85.
-
cu v arst
a,TAS crest
e siTAD scade,cr escand astf
elpresi
unea pulsuluicar
e
repr
ezintaunfact
order i
scpent
ruboal
acoronarianasauAVC
Examenul
cli
nic:
-
cardi
omegal
ie

26
-socapexi andepl asatl ast anga
-palpareazgomot ului 4
-zgomot ul 1poatef inor mal
-zgomot ul 2esteaccent uatl afocarul aortei
-candsei nst al
eazai nsuf i
ci ent
acar diacaest epr ezentsi zgomotul 3
-suflur
i:sistoli
cder egur gitaremi t
rala,di astoli
cder egurgit
areaorticaparast
ernala
stanga, sufluri
lanivel ularterel
orrenal e,suf l
uripear ter
elecaroti
de,perif
eri
ce
-asi
met riedepul ssi tensi onala(disect i
edeaor ta)
-semnecar esuger eazaHTA secundar a:hi pert
ir
oidism,si ndr
om Cushi ng,rini
chi
poli
chist i
c,suflur
ipear t
er elerenale,suf l
udecoar ctat
iedeaor ta,tensi
unearteri
ala
redusal amembr elei nferi
oar efatadecel esuper ioare.

35. Expl
orar
ipar
acl
i
nice
Ev
aluar
eaaf
ect
ari
icar
diace
a.Radiografi
e cardiot
oraci
ca:cardi
omegal i
e,boal
a hiper
tensi
va avansat
a;
stazapulmonar ainstadi
uldeinsufi
cient
acardi
aca;di
lat
ati
eanevri
smalaa
aortei
toracice;
erozi
unisubcost
ale
b.El
ectr
ocardi
ograma:hi
per
trofi
edeVS,i schemi
emi ocar
dica,ar
it
mii
,tul
bur
ari
deconducer
e,blocder
amur astanga,
suprasol
i
cit
areaAS, ar
it
mii
-
indi
cel
eSokol
ow-
Lyon>38mm suger
eazaHVS
c.Ecocardi
ografi
et ranstoraci
ca:mar i
rea AS,VS,modi fi
carialef unct
iei
si
stol
ice in st adi
i av ansate de i nsuf
icient
a car
diaca, t
ulbur
ari de
contr
acti
li
tate,
modi f
icareafl
uxul
uivenospul monari
nAS.
Cr
it
eri
ipent
ruHVS:
-
per
etel
epost
eri
oral
VS>11mm
-
diamet
rut
eledi
ast
oli
cal
VS>57mm
-
septi
nter
vent
ri
cul
ar>11mm
-
crest
ereamasei
VS7
-
disf
unct
iedi
ast
oli
ca
d.Alt
eexpl or
ari
:RMN,coronarograf
ie,testdeefor
t,scint
igr
amamiocar
dica
(ut
il
izat
eincazur
ispeci
ale:
boalacoronari
ana,
suspi
ciunedeCMD)
Ev
aluar
eav
asel
orsangui
ne

27
 -sefaceut i
li
zandmet odaultrasonogr
afi
casideterminar
eapl
aci
ideat
erom la
nivel
ulcaroti
dei
-sedeterminasirapor
tulint
ima/mediecare,dacaest
emaimarede0.
9 lezi
uni
vascular
eimpor t
antedeterminatedehi
pertensi
une

Ev
aluar
eaaf
ect
ari
irenal
e
-ureesangui na
-acidur i
c
-creatininaser i
ca
-clearance-ul creat
ini
nei
-mi croalbumi nuri
esiprot
einur
ietotal
a
Laval
or ialecreatinineiseri
ce>1.5mg/ dlsauclearancealcr
eati
ninei<60-
70ml
/mi
n
i
nsufi
cientar enala pr ognosti
cnefavorabi
lpentr
upacientul
hiper
tensiv
.
Ev
aluar
eaaf
ect
ari
icer
ebr
ale
-
tomografi
ecomput er
izat
a
-
RMN
-
depi
steazaprecoceAVCi schemi
cesi
for
mel
emai
mici
,i
nfar
ctel
acunar
e.
Ev
aluar
eaaf
ect
ari
ici
rcul
atei
ret
ini
ene
-sefaceprinexamenulfunduluideochi ,i
nurmacar ui
aputem const
atal
eziuniprecum:
spasm arteri
olar(gr
adul1),stazav enoasasimodi fi
car
ipari
etal
earter
ial
e( gr
adul2),
hemor agi
isiexudateret
ini
ene(gradul3),edem papi
l
ar(gradul
4).
-
HTAnecompl
i
cat
a=gr
adul
1si
2
-
HTAcompl
i
cat
a=gr
aadul
3si
4.

36. Pr
inci
pii
ter
apeut
ice
Tr
atamentnon-
far
macol
ogi
c:
Presupunerenuntar
ealaf
umat,scadereaingr
eutate,r
educereaconsumuluideal
cool
,
exerci
ti
ulfi
zic,scader
eaapor
tul
uidesar e,crest
ereaaportuluidelegumesif r
uct
e,
reducer
eaconsumul ui
degr
asi
mi sat
urate.

28
Tr
atamentf
armacol
ogi
c:
Pr
inci
pii
l
eter
api
eiant
ihi
per
tensi
ve:
Est
eper
manenent
a
Se f
ace cu scopulati
ngeri
iti
ntel
ort
erapeut
ice 140/
85 l
a adul
ti
inon-
di
abeti
ci
,130/85ladi
abeti
ci
Elementulesenti
alalsuccesuluiter
apeuti
cin HTA est
er epr
ezent
atde
reducer
eari
sculuicar
diov
ascul
artot
alsicr
ester
eacal
i
tat
iiv
iet
ii
Esteindi
vi
dual
izat
ainf
unct
iedev
arst
a,sex,f
act
orider
isc,bol
iasoci
ate,
stadi
ulbol
ii
etc
Cl
asedemedi
cament
e
1.Di
uret
ice
t
iazi
dice:
- pr
efer
atei
nHTAusoar
e,moder
atesi
inmonot
erapi
e;
- i
ndi
cat
alav
arst
nici
,i
ninsuf
ici
ent
acar
diacacongest
iva,
HTAi
zol
atasi
stol
i
ca
- i
ndapami
da1.
5mg/
zi
deansa:
fur
osemi
d,t
orasemi
d,aci
det
acr
ini
c
- se f
olosesc in ur
gent
e hi
per
tensi
ve(
edem pul
monaracut
,cr
iza
hi
per
tensiva)
ant
ial
dost
eroni
ce:
spi
ronol
act
ona
- i
ndicateintoateformel
e de HTA darmaial
es i
n cel
e sev
ere cu HVS,
i
nsufici
ent
acardi
aca.
2.Bet
a-bl
ocant
e
-
nesel
ect
ive:
pindol
ol,
propr
anol
ol
-
sel
ect
ive:
met
opr
olol
,at
enol
ol,
bisopr
olol
-
depr
efer
atl
ati
ner
i,i
ninsuf
ici
ent
acar
diacacongest
iva,
insuf
ici
ent
arenal
a
-
cont
rai
ndi
cat
einast
m br
onsi
c,BAVgr
ad2,
3
3.Cal
ciu-
blocant
e
-
ver
apami
l
,di
l
tiazem (
cuel
i
ber
arepr
elungi
ta)
-
indi
cat
einHTAi
zol
atasi
stol
i
ca,
lav
arst
nici
,l
acei
cuAVC,
insar
cina

29
 -
cont
rai
ndi
cat
einbl
ocAVgr
ad2,
3,I
CC
4.I
nhi
bit
ori
aienzi
mei
deconv
ersi
eaangi
otensi
nei
- Cel
emai
uti
l
izat
eint
erapi
aant
ihi
per
tensi
va
- Scad mortal
i
tatea simor
bidi
tat
ea,i
mpi
edi
ca ev
olut
ia spr
einsuf
ici
ent
a
cardi
acasauboalar
enal
a
- Sunti
mparti
tein3cl
ase:cl
asaI(
capt
opr
il
),cl
asaI
I(per
indopr
il
,enal
apr
il
),
cl
asaI
II(
fosi
nopri
l
)
- Doze:
per
indopr
il4-
8mg/
zi

37. Fi
zi
opat
ologi
e
1.Af
ect
areacar
diaca
a.Hi
per
trof
iev
ent
ri
cul
arast
anga
-
fact
order
iscmaj
orl
apaci
ent
iicuhi
per
tensi
une
-pr
esupune hiper
trofi
a mi oci
tel
or,i
nter
stit
iul
ui si mat
ri
cei cel
ular
e,
consecut
ivcr
ester
iipostsar
cini
i
,sti
mul
ari
ifact
ori
lordecr
est
ereet
c
-
poat
efi
concent
ri
casauexcent
ri
ca
-i
nHTA sei
ntal
nest
efor
maconcent
ri
ca,dependent
adei
ncar
car
eade
presi
une
-
ini
ti
alHVSesteunmecanism deadaptar
edarul
ter
iorpoat
edet
ermi
na
i
schemiemi
ocar
dica,
ari
tmi
i
, moar
tesubi
ta,
IC
b.I
schemi
emi
ocar
dica
-seproducepri
ncrester
eapresiuni
itransmur
ale,compr
omi
ter
eaf
luxul
ui
coronar
iansi
progr
esiaater
oscl
erozei
-seexpri
mapri
nsindr
oamecor
onar
iene:cusupradeni
vel
aredeST(i
nfar
ct
miocardi
cacut)
,far
asupr
adeni
vel
aredeST( anginapector
alai
nst
abil
a),
angi
napector
alast
abil
a
c.Ar
it
mie
-
fi
bri
l
ati
eat
ri
ala
-
ari
tmi
eext
rasi
stol
i
cav
ent
ri
cul
ara
-
tahi
car
diev
ent
ri
cul
ara

30
 d.I
nsuf
ici
ent
acar
diacacongest
iva
-
ceamai
impor
tant
aconseci
ntaaHTApr
imar
a
-
90%di
npaci
ent
iicuI
Caui
nist
ori
cul
bol
i
iHTA
-HTAHVSal ter
area relaxar
iidi
ast
oli
ce sia umpl
eri
iVSdi
sfunct
ie
diast
oli
cadi
sfuncti
esistoli
caIC
e.Af
ect
arev
alv
ular
a
-
insuf
ici
ent
ami
tr
alasi
aor
ti
ca
f
. Supr
asol
i
cit
areat
ri
alast
anga
-
apar
einai
ntedeHVS,
dat
orandu-
secr
est
eri
ipr
esuni
itel
edi
ast
oli
ce
-
intimp duce l
a ari
tmi
iat
ri
ale,t
romboza at
ri
ala,embol
i
isi
stemi
ce,
i
nsuf
ici
ent
acardi
aca
2.Af
ect
areav
asel
ormar
i
-
anev
rism deaor
tacompl
i
catsaunecompl
i
cat
-
afect
areaci
rcul
ati
eicer
ebr
alecuAVC
-
ater
oscl
erozaper
if
eri
ca,
sindr
om dei
schemi
eper
if
eri
ca
3.Af
ect
arer
enal
anef
roangi
oscl
erozasi
insuf
ici
ent
arenal
acr
oni
ca
4.Afectar
e cognit
iva pi
erder
ea capaci
tat
iide concent
rar
e,t
ulbur
aride
personal
it
ate,
dementasenil
a

38. CauzeHTAsecundar
a
Bol
icar
diov
ascul
are
-
coar
ctat
iedeaor
ta
-
insuf
ici
ent
aaor
ti
ca
-
per
sist
ent
adecanal
atr
ial
-
BAVgr
adI
Iav
ansatsi
BAVgr
adI
II
Bol
irenal
eal
epar
enchi
mul
ui
-
glomer
ulonef
ri
teacut
esi
croni
ce
-
pol
i
chi
stozar
enal
a
-
ami
l
oidozar
enal
a
-
piel
onef
ri
tacr
oni
ca

31
 Bol
ivascul
arer
enal
e
-
inf
arct
ecor
ti
cal
erenal
e
-
stenozeal
ear
ter
elorr
enal
e
-
displ
azi
efi
bro-
muscul
araamedi
eiar
ter
ial
e
Bol
iendocr
ine
-
feocr
omoci
tom
-
sindr
omul
Cushi
ng
-
hiper
aldost
eroni
sm pr
imar
-
acr
omegal
i
e
-
hiper
ti
roi
dism,
hiper
par
ati
roi
dism
Al
tecauze
-
tumor
icer
ebr
ale
-
por
fi
ri
e
-
medi
cament
e:AI
NS,
cont
racept
iveor
ale,
est
rogeni
,cor
ti
coi
zi

Bol
icar
diacecongeni
tal
e
39. Def
ectdeseptat
ri
al
- Repr
ezi
ntaundefectdestr
uct
uralani
vel
ulsept
uluii
nter
atr
ialceper
mit
e
comuni
car
eadi
rect
aint
recel
e2atr
ii
.
Tabloucl inic
1.copi i:asi mpt omatic,diagnosticulsepunei nur madescoper ir
iiunuisuflu
cardiac
2.adul ti
:i ntol
er antal a efort( dispnee,f at
igabil
i
t at
e),palpi
tat
ii( f
lut
tersau
fi
bril
at i
eat riala),boaladenodsi nusal.Pacienti
ivarstni
cipotprezentasemne
deinsuf i
cient aventri
cul
ar adreapta.
Examenf izic
- Sochi per di
nami calVD,pal pabi lpemar gineast angaast er
nului,l
asf ar
sit
ul
expirului sausubxi f
oidi
ani ni
spi r
dpr ofund
- Trunchi ular t ereipulmonar e est e dil
atatsipoat e sipalpati n spati
ulII
inter
cost alstang
- Zgomot ul1est enormal

32
 - Dedubl arelar gaazgomot ului 2
- Suf l
usistolicdeej ectie, audi bili
nspat i
ul IIi
nt ercostalst ang
- Ur uituradi ast olicadei ntensitatemi ca,dat adecr est ereaf l
uxul uiprinv alv
a
tri
cuspida
Par aclinic
ECG:dev iati
eaxi aladr eapt a,BRDi ncompl et ;poat eapar eadev i
ati
eaxi alast angai n
DSAost ium primum.
Indef ecteledet ipsi nusv enosapar er it
mj ocnt ionalsauat ri
alinfer iorcuundeP
i
nv ersat ei nderivatiilei nferi
oar e.
Paci ent i
icuDSAauder egul a,r itm sinusalnor mali npr i
mel e3decadedev iatadar
ulteriorpotapar eaar itmi isifibr i
latiiatr
iale,tahicar diesupr avent r
icular a.
Radi ogr afiecor d-pul mon:car di
omegal ie,dat adedi l
atareacor dul uidr ept ,ar ter
e
pulmonar eproemi nent e, patt ernpul monarv ascul arper i
fericdet ipv ascul arizatiede
sunt
Ecocar diografi
et r
anst oracica:poat er elev at i
pulsidi mensi unea DSA,di r
ecti
a
sunt ului,uneori prezent adeanomal iial
er etur uluivenospul monar .
Cat eter i
sm pent ru adet er minamagni tudi neasidi r
ect iasunt ul ui;pr ezent asi
sev eritateahiper tensi unii pulmonar e.
Diagnost iculdiferent ialsef acecu:DSV,st enozapul monar a,PCAl acopi i,si ndrom
hiper kinetic, dialtatar ea i di opat ica a ar terei pul monar e, conexi une v enoasa
pulmonar aanor mal a.

40. Def
ectdeseptv
ent
ri
cul
ar
- Repr ezintaundef ectdest ructuralanivel
ulseptul
uiint
erventr
icul
arceper mit
e
comuni careali
beraintrecei doiventr
iculi
.
Cli
nicmaj ori
tat
eapaci enti
lorcuDSVmi c,r
est
rict
ivsuntasi
mpt omatici
Examenf izic
Sufl
u pansi stol
i
c de i nalt
af recv
enta,cu maxi ma intensit
atei n spati
ul3-4
i
ntercostalstang
DacaDSAemoder atrestr
icti
vf r
ecventdispneeaparutalav ar
staadultauneori
declansatadeapar i
tiafibr
il
atieiatri
ale
Seobser va:
Socapexi
andepl
asatl
ater
al
Suf
lulpansistol
i
c cu maxi
m de i
ntensi
tat
ein spat
iul3-
4int
ercost
al
par
aster
nalstang
Ur
uit
uradi
ast
oli
caapi
cal
acr
est
efl
uxul
sangui
ntr
ansmi
tr
al
Zgomot3pr
ezent

33
 Paci
enti
icu DSV nerest
ricti
v cu sindr
om Eisenmenger ci
anoza de cauza
cent
ral
asihipocr
ati
sm di
gi t
al.Tipi
csemnedeHTP:pal par
eVD,accentuarea
component
eiP2azgomot ului2,zgomot4datdeinsuf
ici
ent
aVD.
La auscul
tat
ie cl
i
c de ej
ect
ie pul
monar
,suf
lu di
ast
oli
c descr
escendo de
regur
git
arepul
monara
Par
acl
i
nic
EKG i
nfor
matiidespr
e mar
imea sunt
uluisigr
adulHTP.I
n def
ect
e mi
ci-
nesemni
fi
cat
iv.
Indef
ect
emoder at
e-semnedesuprasol
i
cit
areAS(Pcudurat
amar i
ta,i
nci
zat
),
semnedesuprasol
ici
tar
edev
olum aVS(qadanci
,Rinal
tecuTinal
teinV5V6).
Uneor
ipr
ezent
aFA.
Radi
ogr
afi
acar
dio-
pul
monar
a-magni
tudi
neasunt
ului
sigr
adul
HTP
Ecocar
diogr
afi
atr
anst
oraci
ca2Dsi
Doppl
er
- Tipul sidi
mensi uneaDSV
- Direct iasuntul ui
- Conseci ntelehemodi nami cealeDSV
- Exist entaleziunilorasoci ate
- Ident ifi
careaunei f
ormepar t
icul
aredeDSV
- Det ermi nareapr esiuniisistol
icepulmonare
Ecocardi
ogr afia t ransesofagi ana det ect
ia DSV mi
ci si moni
tor
izar
ea
i
ntraoper
at or i
eacor ecti
eichirurgicale
Ecocardiogr
afi
adecontrast
,cateteri
sm siangiograf
ie-local
i
zeazadef
ect
ulsi
deter
mi namarimeasunt
ului
sir
ezistentav
ascularapulmonar
a.

41. Per
sist
ent
adecanal
art
eri
al
Tabl
oul
cli
nic
Lapr
emat
uri
:
o Epi
soadedeapneesi
bradi
car
die
o Hepat
omegal
i
e
o I
mpul
svent
ri
cul
arst
anghi
per
dinami
c
o Suf
lusi
stol
i
csubcl
avi
cul
arsi
int
erscapul
ar
Lanou-
nascut
iil
ater
men,
copi
isi
adul
ti
PCAmoder
atpoat
epr
ezent
adi
spneesi
pal
pit
ati
idat
edear
it
mii
atr
ial
e

34
 Unsuf
lucont
inuu"demasi
nar
ie"audi
bil
inspat
iul
1-2i
nter
cost
alst
ang
Socul
apexi
anehi
per
dinami
c,depl
asatl
ater
al
Adult
iicuPCAlarg,
necorect
at-sufl
udeeject
iesi
stol
i
c,hi
poxemi
emaimul
tla
pi
cioaredecatl
amaini(
cianozadi
fer
ent
ial
a)
Par
acl
i
nic
1.Lapr
emat
uri
EKGpoat
efi
nor
mal
asaupoat
ear
ataHVS,
HVDsi
gradul
deHTP
Radi
ogr
afi
e cardi
opul
monar
a poat
e ev
ident
ia car
diomegal
i
e sici
rcul
ati
e
pul
monaracr
escuta
Ecocar
diogr
afi
a poat
evi
zual
i
za duct
ular
ter
ialsiest
imeaza di
mensi
unea
acest
utia.Ecograf
ia Doppl
er demonstr
eaza exi
stent
a sunt
uluisiper
mit
e
eval
uareacor
ectaapresi
unii
art
eri
alepul
monaremedii.
2.Lanou-
nascut
i,copi
isi
adul
ti
EKGr
efl
ect
adi
mensi
uneasi
gradul
sunt
ului
pri
nduct
Duct
ulmi
cnupr
oducemodi
fi
car
i
Duct
ulmoder
atpoat
edet
erminasemnedesuprasol
i
cit
aredev
loum aVS
cuundaPi
nci
zatasi
Qadanca,Ri
nalt
esiTascuti
tei
nV5,V6
Duct
ulmar
esemnedeHVD
RXcar
diopul
monar
- Ductmoderatcardiomegal
i
emoderatacudil
atareainimiist
angi
,buton
aor
ti
cproeminentsi
per
fuziepul
monaracr
escut
a.Laadult-calci
fi
ereaduct
ului
.
Ecocar
diogr
afi
atr
anst
oraci
ca evi
dent
iazapr
ezent
a,di
mensi
uni
l
esigr
adul
sunt
ului
Cat
eter
ismulsiangi
ogr
afi
aper
mitv
izual
i
zar
eaduct
ului

42. Coar
ctat
iedeaor
ta
-constai
ntr
-uninelcaundi af
ragm car
esei nti
ndeinlumenulaor
tei
,di
stalde
arter
asubcl
aviedreapt
a,l
aloculat
asari
iduct
ului
aort
ic.
-
cei
mai
mul
tiadul
tisuntasi
mpt
omat
ic
Examenul
fizi
c
-
presi
unea ar
ter
ial
a si
stol
i
ca est
e maimar
ela br
ate decatl
a pi
cioar
e,dar

35
 pr
esi
uneadi
ast
oli
caest
eegal
a
-
fr
eamatsi
stol
i
cini
nci
zur
asupr
ast
ernal
a
-
VSmar
it
-
cli
cdeej
ect
iesi
suf
lusi
stol
i
cdeej
ect
iemai
int
ensdeasupr
acoar
ctat
iei
-
zgomot
ul2accent
uat
Par
acl
i
nic
ECG:
hiper
trof
iaVS
Radi
ograf
ietor
acica:f
luxcolat
eralcrescut
,pr
inar
ter
elei
nter
cost
ale-
>inci
zur
i
al
etrei
miipost
eri
oarealecoast
elor3-
8
Ecocar
diogr
afic:se poatevizual
iza coar
ctat
ia.Exami
nar
ea Doppl
erper
mit
e
esti
mareagradului
presi
onal
transcoar
ctati
e.
RMN,
CTl
ocal
i
zar
easi
lungi
meacoar
ctat
iei
Frecventdi
agnosti
culepusl
aunexamenf i
zi
cder uti
nacandHTAsi stemicae
observatal
abr at
ecupulsfemuraldimi
nuatsauabsent .Casimptomeel ese
suprapunpest
ecelealehi
per
tensi
uni
i
:cef
alee,epi
staxi
s,amet
eli
,pal
pit
atii
.

43. Tet
ral
ogi
aFal
l
ot
-
secaracter
izeazapri
n:defectdeseptventr
icul
arti
poutl
et,aort
acalar
epesept
,
obst
ruct
ieat r
actul
uideiesi
realVD,hi
pertr
ofievent
ri
cul
aradreapta.
Cl
i
nic
-
cianozal
anast
eresaucudebuti
npr
imul
an
-cr
izehipoxi
cesubi
te,cutahipneesihiperpnee,ur
matedeinraut
ati
reaci
anozei
,
uneoricupier
der
ideconstienta,conv
ulsi
isauchiarmoar
te.Acestecri
zenuapar
l
aadul t
isauadol
escenti
.
-adul
ti
iprezi
ntadispneesil i
mitareatol
erant
eilaefor
t,compli
cati
ialeci
anozei
croni
ce(eri
tr
ocit
oza,hiper
viscozi
tate,
anomaliial
ehemostazei
,abcesecer
ebr
ale)
-
hipocr
ati
sm di
git
al

36
 -
component
apul
monar
aazgomot
ului
2est
einaudi
bil
a
-
suf
lusi
stol
i
cdeej
ect
ie,
pemar
gineast
angaast
ernul
ui
Par
acl
i
nic
ECG:devi
ati
e axi
ala dr
eapt
a,hi
per
trof
iev
ent
ri
cul
ara dr
eapt
a,supr
asol
i
cit
are
at
ri
aladr
eapt
a.
Radi
ogr
afi
ecar
diopul
monar
a:cor
ddedi
mensi
uni
nor
mal
edarcuf
ormadesabot
,
VDpr
oemi
nent
,ci
rcul
ati
epul
monar
adi
minuat
a.
Ecocar
diogr
afi
e: ut
il
a pent
ru di
agnost
ic, ev
aluar
ea anomal
i
il
or asoci
ate,
evaluar
ea sever
itat
iiobst
ructi
eii
ntractulde eject
ie alVD,mari
mea ar
ter
ei
pulmonarepri
ncipal
e,vi
zual
izar
eadef
ectelorsept
alevent
ri
cul
are.
Dupacorectiechi
rur
gical
asepoateeval
ua:stenozapulmonararezi
dual
a,DSV
rezi
dual
,funct
iasi
dimensiuneaVSsi
VD,gradulderegur
git
areaor
ti
ca.

44. Canal
atr
iov
ent
ri
cul
arcompl
et
Tabl
oucl
i
nic:
35%di
npaci
ent
iicucanal
atr
iov
ent
ri
cul
arcomunausi
ndr
om Down.
Car
diomegal
i
a
Suf
lusi
stol
i
cint
ract
uldeej
ect
ieal
VD
Suf
lul
pansi
stol
i
cdatder
egur
git
areaat
ri
ovent
ri
cul
ara
In cazulcanalul
uiat r
iovent
ri
cul
arneasoci
atcu si
ndr
om Down,tabl
oulcli
nic
depinde de pr ezenta si dimensi
uni
le DSA, DSV si compet
ent
a v al
vei
atr
ioventr
icul
arestangi.
si
mpt omedei
nsufi
cient
acardi
aca(di
spneedeef
ort
,fat
igabi
l
itat
e)sau
deHTP(
sincopal
aef
ort
,cianoza)
Laadul
tpal
pit
ati
i
lesuntdet
ermi
nat
edear
it
mii
Laex amenulf i
zi
c,canal
ulat
rioventi
rcularcomuncompletdet
erminaunzgomot
1scur t(
osi ngur
acomponent aatr
ioventri
cular
a)unsuf
ludi
astol
i
cdetermi
natde
fl
uxulcr escutprinvalv
ele atr
ioventr
icular
e sisemne de HTP si/sau sunt
dreapta/
stanga
Par
acl
i
nic
EKGblocAVgradIsidevi
ereaxial
astanga-inmaj
ori
tat
eacazur
il
or.Labat
rani
put
em
aveabl
ocAVcompletsi
/saufi
bri
lati
e/f
lut
terat
ri
al

37
Radiogr
afi
ecardi
opul
monar
acar
diomegal
i
ecupr
oemi
nent
aADsiVDcuaccent
uar
ea
desenul
uipul
monar
Ecocardiogr
afi
amet odadeel
ecti
esev
izual
i
zeazapr
ezent
asauabsent
aDSA,
DSV,
gradul
r egur
git
ari
iat
ri
ovent
ri
cul
are

45. St
enozaaor
ti
cacongeni
tal
a
Tabl
oucli
nic:i
ncazurisever
e,i
mpulsulcar
otidi
anest eintar
ziatsidi
mi nuat
,saunormal
l
apacienti
ivarst
nici
,componentaaort
icaazgomot ului2est ediminuatasiinaudi
bil
a,
est
eprezentzgomotul4,suf
lur
ugoscrescendo-descrescendocei r
adiazaspregat
Par
acl
i
nic
ECG:
hiper
trof
iev
ent
ri
cul
arast
anga
Radi
ogr
afi
ator
aci
caev
ident
iazaosi
l
uet
acar
diacanor
mal
a
Ecocardi
ografi
atranst
oraci
caev
alueazasev
eri
tat
east
enozeisiaf
unct
ieisi
stol
i
cea
vent
ricul
uluist
ang.
Ecocar
diogr
afi
a2Dof
erai
nfor
mat
iidespr
emor
fol
ogi
aval
vel
orsi
prezent
alezi
uni
l
or.
Ecocardi
ografi
a Doppl
erse uti
li
zeaza pentr
u det
ermi
nar
ea sev
eri
tat
iist
enozeisi
prezent
a/absentar
egur
git
ari
iaor
ti
ceascendente.
Cateter
ismulcar
diacsef
olosest
einscopuldet
erminar
iisev
eri
tat
iist
enozeiaor
ti
cedar
sipentr
uaev i
denti
aboal
acoronari
anaconcomi
tent
a.

46. St
enozapul
monar
acongeni
tal
a
Cl
i
nic
Dacast
enozaemoderatasausever
apotf ipal
pat
euni mpulsventi
rcul
ar
dr
eptpemargi
neastangaast
ernul
uisi
unfreamatinspat
iul
IIi
nter
cost
al st
ang
zgomotul1estenormali
arzgomotul2ededublatlar
gdarsemodi
fi
ca
nor
malcur
espir
ati
a.Component
asapulmonar
aediminuatasii
ntar
ziat
a
Unsufl
usist
olicaspru,crescendo-descr escendocar
ecr esteinintensi
tat
e
cuinspi
rul
,esteauzibi
lde-al ungulmar gini
ist angiasternului
.Dacav alv
ae
pl
iabi
l
a,uncli
cdeejecti
eprecedesuf lul
;cliculdiminuasaudispareininspir

38
 Pemasuracestenozadev i
nemaisev er
asuf
lulsist
oli
car
eintensi
tat
e
maximamaitar
ziuinsistol
asicliculdeej
ecti
eseapropiedezgomotul1si
event
ual
sesupr
apunevi
rtualpest
eel
Par
acl
i
nic
EKGI
ncazdeSPmoder
atasausev
eradev
iat
ieaxi
aladr
eapt
asi
HVD
Radi
ogr
afi
eTor
aci
cadi
l
atat
iapost
stenot
icaat
runchi
uluiar
ter
eipul
monar
esi
vascul
ari
zati
apulmonar
adiminuatasuntev
idente.Si
luet
acardiacaedeobiceide
marimenormala.Dacapaci
entular
eIVDsaur egurgi
tar
etri
cuspidi
anaaceast
ase
poatemari.
Ecocar
diogr
afi
a HVD simi
scar
eapar
adoxal
aasept
uluii
nter
vent
ri
cul
ari
n
t
impul
sist
olei
.Pr
inexami
nar
eDoppl
ersepoat
eapr
eci
asev
eri
tat
east
enozei
.

Bol
i
lemi
ocar
dul
ui
47. Cl
asi
fi
car
ecar
diomi
opat
ii
Cl
asi
fi
car
eaWHO
1. Cauzanecunoscut
a(pr
imar
a)
Di
l
atat
iva
Hi
per
trof
ica
Rest
ri
cti
va
Necl
asi
fi
cabi
l
e
2. Bol
ispeci
fi
ceal
emi
ocar
dul
ui
I
nfect
ioase
Met
abol
i
ce
Bol
isi
stemi
ce
Her
edof
ami
l
ial
e
Hi
per
sensi
bil
i
zar
e
Toxi
ce
Cl
asi
fi
careafunct
ional
apebazacar
act
eri
sti
cil
orf
izi
opat
ologi
cedomi
nant
e-se
i
mparti
n3t i
puri
CM di
l
atat
ive-ceamaif
recv
ent
afor
ma-di
l
ati
ati
event
ri
cul
ara,di
sfunct
ie

39
 cont
ract
il
asi
deseor
isi
mpt
omedeI
CC
CM hi
per
trof
ice-HVS inadecv
ata,cu f
unct
iecont
ract
il
apast
rat
asau
cr
escut
aoperi
oadainev
olut
ie
CM r
estri
cti
ve(inf
il
tr
ati
v-
restr
ict
ive)-car
acter
izat
eprinal
ter
areaumpleri
i
diast
oli
ce.In unel
e cazur
iprezint
a cicatr
ici(
fi
broza)la ni
vel
ulendocar
dului
ventr
icul
ar
Cardiomi
opati
il
especif
ice-af
ect
arial
emiocardul
uidarcar
esuntasoci
atecuo
boalacar
diacasausuntpar
teauneibol
isi
stemice
CM i
schemi
ca
CM v
alv
ular
a
CM i
nfl
amat
ori
e
CM met
abol
i
ca
CM di
nbol
isi
stemi
cegener
alecol
agenoze,bol
iinf
il
tr
ati
ve(
leucemi
e,
sar
coi
doza)
CM di
ndi
str
ofi
i
lemuscul
are
CM di
naf
ect
ari
neur
omuscul
are
CM t
oxi
ca(
alcool
,i
radi
ere,
cat
ecol
ami
ne)

48. Et
iopat
ogeni
eCMD
Pest
e50%di
ncazur
il
edeCMDnuauoet
iol
ogi
eident
if
icabi
l
a(CMDi
diopat
ica)
CMD este expr
esi
a comuna a dist
rugeri
imi ocardi
ce pr
int
r-
ov ari
etat
e de
mecani
smecitot
oxi
ce,
metabol
i
ce,imunoalergi
ce,famil
i
alesi
inf
ecti
oase.
1.
Fact
ori
igenet
ici
sif
ami
l
ial
i
o I
nci
dent
afami
l
ial
aaCMDest
esemni
fi
cat
iva(25-
30%di
ncazur
i)
o Cel
emai
mul
tecazur
ifami
l
ial
eaut
ransmi
ter
eaut
osomal
domi
nant
a
o CMD famil
i
aler ezul
ta di
n mut at
iila niv
elul genel
or ce codeaza
ci
toschel
etul
,membrananucl
eara,
prot
einel
econt
racti
le

o secar
act
eri
zeazapr
in di
l
atarevent
ri
cul
arasidi
sfunct
iei
ndecadel
e2si3
dev
iat
acuICpr
ogresi
vasi
ari
tmiivent
ri
cul
are.
2.
Fact
ori
vir
ali

40
 o ti
tr
ulmar e de anti
cor
piant
ivi
ral
i,secvent
e de ARN speci
fi
cvi
ral
e si
pr
otei
nev i
ral
elapaci
entii
cuCMD"idiopati
ca"
o Pri
nPCR sepotconf
ir
mapr
ezent
ader
est
uriv
iral
einmi
ocar
dulunor
paci
ent
icucar
diomi
opat
ie
3.
Fact
orul
imunol
ogi
c
- Numer
oaseanomal
iial
eimuni
tat
iiumor
alesicel
ular
eauf
osti
dent
if
icat
e
l
apaci
ent
iicuCMD

49. Di
agnost
icpozi
ti
vsi
dif
erent
ial
CMD
Di
agnosti
culpozi ti
vest e unulde excluder
e sise bazeaza pe st
abil
i
rea exi
stent
ei
di
l
atat
ieicardiace,asoci
atacuf unct
iesistol
icadiminuat
asiel
iminareaalt
orcauzede
di
l
atat
iecardiaca,insot
it
adei nsuf
ici
entacontract
il
a.
Manifestar
icli
nice:fat
igabil
i
tate,sl
abici
une,i
ntol
erantalaefor
t,cauzat
edescaderea
debit
uluicardi
ac,consecuti
vuneiinsuf
ici
entevent
ri
cularest
angi.Laasoci
ereadeboal
a
coronari
anasepoat emani f
estasipri
ndureret
oraci
ca.
Examenf
izi
c:
-
TAsi
stol
i
capoat
efi
nor
mal
asauscazut
a,pr
esi
uneapul
sul
uiest
escazut
a.
-di
stensi
avenel
orj
ugul
are,edemeper
if
eri
cesiasci
tai
ninsuf
ici
ent
acar
diaca
dreapta
-
hepat
omegal
i
e
-
socul
apexi
anest
edepl
asatl
ater
aldat
ori
tadi
l
atat
iei
VS
-zgomotul2 est
e nor
malsau dedubl
at,component
a pul
monar
a poat
efi
accent
uata
-
suf
lusi
stol
i
ccesedat
oreazai
nsuf
ici
ent
eimi
tr
ale
-
regur
git
aremi
tr
ala
Di
agnost
icul
dif
erent
ial
sef
acecu:
- Car
diopat
iicongeni
tal
e
- Val
vul
opat
iicast
igat
e
- Car
diopat
iei
schemi
ca
Dif
erenti
ereadecardi
opat
iisiv
alv
ulopati
isefaacepebazadat
elorcl
i
nicesiexpl
orar
il
or
paracl
ini
cenoninv
aziv
e,pr
ecum ecocardi
ografi
a.
Car
diopat
iai
schemi
caest
epr
ecedat
adei
nfar
ctemi
ocar
dicesaudur
eridenat
ura

41
angi
noasa.
Deosebi
reaCMD idi
opat
icedeCMD secundar
esebazeazapeanamneza,examenul
gener
alalbol
nav
ului
sial
teexpl
orar
icl
i
nice.

50. Tr
atamentCMD
Obi
ect
ive:
prev
eni
reasi
trat
areai
nsuf
ici
ent
eicar
diace,
ari
tmi
i
lor
,tr
omboembol
i
il
or.
CMDi diopat
icanuar
etr
atamentspeci
fi
ccibenef
ici
azadet
rat
ament
uli
nsuf
ici
ent
ei
car
diace.
Masur
il
esunt
:
-
nef
armacol
ogi
ce:
rest
ri
cti
onar
eaact
ivi
tat
iif
izi
ce,
modi
fi
car
eadi
etei
-
far
macol
ogi
ce:
1.
diur
eti
cecont
rol
ulr
etent
iei
hidr
osal
i
ne,
reducer
eadi
spneei
2.
vasodil
atat
oare IECA (
enalapri
l
,hi
dral
azi
na+ni
tr
ati
);cr
esct
oler
ant
alaef
ort
,
debi
tulcar
diacsif
racti
adeejecti
e
3.
medi
cat
iei
not
ropadi
git
ala:
lapaci
ent
iicuf
ibr
il
ati
eat
ri
ala
4.bet
a-bl
ocante:imbunat
atesccapaci
tat
eadeef
ort
,funct
iaVS,si
mpt
omat
ologi
a;
exemple:metoprol
ol,
carv
edilol
5.
ter
api
eant
iar
it
mica:
ami
odar
ona,
200mg/
zir
educear
it
mii
l
event
ri
cul
are
6.
ant
icoagul
ant
eor
ale,
pet
ermenl
ungl
apaci
ent
iicuf
ibr
il
ati
eat
ri
alasi
IC
7.
ter
api
eder
esi
ncr
oni
zar
e
8.
int
erv
enti
echir
urgical
acur
epar
areauneiv
alv
emi
tr
alenor
mal
acast
ruct
uradar
i
ncompetent
afunct
ional

51. Di
agnost
icpozi
ti
vsi
dif
erent
ial
CMH
CMHest eoboalacardiacagenetica,cutransmiter
eaut osomaldomi nanta.
Diagnost iculCMH est e usorde st abil
itcu aj utorulecocardiografiei2D car e
demonst reazaHVS.
Clinic:
-di
spnee,conseci nt
a a di sfunctieidiastoli
ce,i nsotita de cresterea presiuni
i
telediastoli
cedinVSsi ul
ter
iorapr esi
uniidi
nASsi venel epul
monar e
-angina pect or
ala:r
educerea rezer v
eicor onari
ene,spasm cor onarian,cresterea
necesar uluideO2 miocardi
c.

42
-pr
esincopa/si
ncopa,f
ati
gabi
l
itat
e:debi
tcar
diacneconcor
dantcuef
ort
ul,t
ulbur
ari
derit
m
Examenf izi
c:
-
socapexi
anput
erni
c,depl
asatl
ater
al
-
pul
sper
if
eri
cabr
upt
,ampl
u,dedur
atascur
ta
-
impul
sat
ri
alst
ang(
dil
atat
iaAS)
-
pul
svenosj
ugul
arampl
u
-sul
fusi
stol
iccrescendo-descrescendo,ceincepedeobi
ceidupazgomot
ul1sise
audeint
reapexsimar gi
neast angaast er
nul
ui

52. Tr
atamentCMH
-
Amel
i
orar
easi
mpt
omel
ordat
orat
einsuf
ici
ent
eicar
diac
-
gli
cozi
zidi
git
ali
ci:
ingener
alseev
ita,
mai
put
ini
ncazur
idef
ibr
il
ati
eat
ri
ala
-
diur
eti
cel
e:r
Reducsi
mpt
omel
edecongest
iepul
monar
a
-
blocanti
ibet
aadr energi
ci:auefect
ebenef i
ceasupradispneeideef
ort,cresc
t
olerantalaefor
t,scadf recvent
acardi
aca,reducischemia,potsaprevenina
moar t
easubi
tacardiacasireducmort
ali
tat
ea
-ant
agoni
stidecalci
u:verapamil,mair
arnif
edipi
nasidi l
ti
azem;scadischemia,
contr
acti
l
itat
eaVS,i mbunatatescumpler
eav ent
ricul
ara,cresccapaci
tateade
efor
t,ameli
oreazasi
mptomel e
I
nCMHser
ecomandaost
rat
egi
eagr
esi
vadement
iner
ear
it
mul
uisi
nusal
.
Exer
cit
iul
fizi
c
Peci
enti
iti
ner
itrebui
esa ev
itepr
act
icar
ea spor
tur
il
ordeper
for
mant
a
pent
ruareducemoar
teasubit
a
Tr
atament
ulchi
rur
gical
o Paci
ent
iicuCMHobst
ruct
iv
o Si
mpt
omat
ologi
esev
era
o Di
spneedeef
ortsi
dur
eri
tor
aci
ceNYHAI
IIsauI
V
o Ref
ract
ari
lat
rat
amentmedi
cal
o Inter
venti
a de electi
e est
e mi
otomi
e-mi
ect
omi
e sept
ala asoci
ata cu
pr
otezarevalv
ular
amitrala

43
53. Cl
asi
fi
car
eet
iol
ogi
caaCMR
1. Cauzemi
ocar
dice
Noni
nfi
l
trat
ive
-
Car
diomi
opat
iei
dipat
ica
-
Car
diomi
opat
ief
ami
l
ial
a
-
Car
diomi
opat
iedi
abet
ica
-
Pseudoxant
omael
ast
icum
-
Scl
eroder
mie
I
nfi
l
trat
ive
-
Ami
l
oidoza
-
Sar
coi
doza
Tezaur
ismoze
-
Hemocr
omat
oza
-
Boal
aFabr
y
-
Tul
bur
ari
dest
ocaj
alegl
i
cogenul
ui
2. Cauzeendomi
ocar
dice
Fi
brozaendomi
ocar
dica
Si
ndr
omul
hiper
eozi
nof
il
ic
Car
cinoi
d
Met
ast
aze
Radi
ati
i
Toxi
ci
tat
edupaant
raci
cli
ne

54. Di
agnost
icpozi
ti
vCMR
Cl
i
nicsi
hemodi
nami
cCMRsi
mul
eazaper
icar
dit
aconst
ri
cti
vacr
oni
ca
Hemodinamic scadereprecoceabr
uptasirapidaapresiuni
ivent
ri
cul
arel
a
debut
uldiast
olecuocrest
ererapi
dal
aplat
ouinprotodi
ast
ola
Tabl
oul
cli
nic

44
 I
ntol
erantalaefor
t frecvent
adatori
tai
ncapaci
tat
iipaci
ent
il
ordea- si
cr
est
edebitulcar
diacpr
intahi
cardi
efaraacompr
omiteumpler
eaventr
icul
ara
Sl
abi
ci
uneasi
dispneeaf
recv
entpr
ezent
e
Dur
ereatoraci
cal
aef
ortpoat
efisi
mpt
omuldomi
nanti
nunel
ecazur
i
dardeobi
ceil
ipsest
e
edemeper
if
eri
ce,
hepat
omegal
i
e,asci
ta
Examenul
fizi
c
Poat
eev
ident
iadi
stensi
evenoasaaj
ugul
arel
or
pr
ezent
azgomot
ului
3sau4sauaambel
or
Spr
edeosebi
redeper
icar
dit
aconst
ri
cti
va,i
mpul
sulapexul
uiest
epal
pabi
l
i
nCMR
Par
acl
i
nic
CT,
RMNpotaj
utal
adi
sti
nct
iai
ntr
eCMRsi
PC
Ecocar
diogr
afi
a i ngr
osareaper
etel
uiVSsiocr
est
ereamaseiVSl
a
paci
ent
iicuboalai
nfi
l
trat
ivacauzandCMR
Ecogr
afi
eDoppl
erpat
ter
ndeumpl
ereal
VSdi
fer
it

55. Et
iol
ogi
ami
ocar
dit
eloracut
e
1.Miocar
dit
einf
ect
ioase pr
oduse de agent
ivi
ral
i
,bact
eri
eni
,ri
cket
tsi
eni
,
pr
otozoar
e.
Agent
iet
iol
ogi
ci:
-
inf
ect
iibact
eri
ene:
str
ept
ococ,
staf
il
ococ,
pneumococ,
meni
ngococ
-
inf
ect
iif
ungi
ce:
asper
gil
oza,
candi
doza,
hist
opl
asmoza
-
inf
ect
iipar
azi
te:
toxopl
asmoza
-
inf
ect
iispi
rochet
ozi
ce:
lept
ospi
roza,
boal
aLy
me,
sif
il
is
-
inf
ect
iiv
iral
e:adenov
irusur
i,HI
V,ur
li
anet
c
2.Mi
ocar
dit
enei
nfect
ioase
A.Mi
ocar
dit
eapar utepri
nmecani sm i
mun
-al
ergeni
: col
chici
na,f
urosemid,peni
cil
i
na,tet
raci
cli
na
-al
l
oantigeni:r
eject
iedecordtranspl
antat

45
 -autoantigeni
:LES,scl erodermie,miasteniagravis,miocar
dit
acu
celulegigant,di
abetzahar at
B.Mi
ocar
ditet oxi
ce
-medi camente:amfetami ne,catecol
amine,cocaina,et
anol
-met alegrel
e:cupr
u,fier,plumb
-agent if
izi
ci:
socelectri
c, r
adiati
i
-di
ver se:muscatur
ideal bine,serpi
,pai
enjeni
,arseniuetc
56. Di
agnost
icpozi
ti
vmi
ocar
dit
eacut
e
Si
mpt
ome:
-afect
areacardi
acaest
easoci
atacusi
mpt
omenespeci
fi
cepr
ecum f
ati
gabi
l
itat
e,
dispnee,pal
pit
ati
i
-
dur
ereat
oraci
caest
eunsemnal
per
icar
dit
eiasoci
ate
-
inanumi
tecazuri
,mani
fest
ari
l
e(ECG,dur
ereat
oraci
ca)potsasi
mul
ezeun
i
nfar
ctmi
ocar
dicacut
.

Semne:
-
tahi
car
die,
inv
erspr
opor
ti
onal
acugr
adul
febr
ei
-
zgomot
ul1est
easur
zitdat
ori
tascader
iicapaci
tat
iidecont
ract
ieami
ocar
dul
ui
-
gal
oppr
otodi
ast
oli
c
-
unel
ecazur
ipr
ezi
ntaI
CC
-I
nIMAuni
ipaci
entipotaveasupradeni
vel
aredeST,
enzimedenecr
ozapozit
ive,
anomal
i
ideci
neti
capariet
ala,
arterecor
onarenor
mal
e,datedemi
ocardi
ta.
-
tahi
car
diev
ent
ri
cul
arar
efr
act
aral
atr
atament
,tor
sadav
arf
uri
l
or,
moar
tesubi
ta
-
microanev
risme v ent
ri
cular
e unice sau mul
ti
ple.Acest
ipaci
ent
ipr
ezi
nta
t
ahicar
dieventr
icul
aranesusti
nut
a,funct
iev
ent
ri
cul
aranormal
a.
Par
acl
i
nic
ECG:anomal
iiale segment
uluiST siundeiT,ar
it
miiat
ri
ale siv
ent
ri
cul
are,
tul
bur
ari
deconducere
Radi
ogr
afi
ecor
dpul
mon:
car
diomegal
i
e
Ecocardi
ogr
afi
a:di
sfuncti
eVS,
per
etii
ngr
osat
idat
ori
tai
nfl
amat
iei
,edem,
trombi
,
funct
iedi
astol
i
caalt
erata.

46
 Bi
opsi
eendomi
ocar
dica-pent
ruconf
ir
mar
eahi
stol
ogi
caadi
agnost
icul
ui

57. Tr
atamentmi
ocar
dit
eacut
e
Tr
atament
ulest
econt
rov
ersatsi
nespeci
fi
c.
Se recomanda li
mitar
ea act
ivi
tat
iifi
zi
ce,t
rat
area i
nsuf
ici
ent
eicar
diace,a
ar
it
mi i
lor
,ev
itar
easpasmul
uivascul
ar.
Lapaci
enti
icuICt erapiatrebui
esaincl
udadi
uret
icepentr
uascadeapresi
unea
deumplereventr
iculara,unI ECA pent
ruascadearezist
ent
avascul
arasiun
bet
abl
ocantdupast abil
izar
eacli
nica
Uni
ipacientipotnecesi
taadmini
str
areai
ntr
avenoasaaunorv
asodi
l
atat
oar
e
put
erni
ceinclusi
vni
tr
ogli
cer
ina.
Digoxi
nulseuti
li
zeazacuprudentasidoarindozescazut
e.Dacasi
mpt
omel
e
suntsever
esepoatei
ncludef
olosi
reaunoragent
iinot
roppozi
ti
vi
.
Ar
it
mii
l
eat
ri
alesi
vent
ri
cul
areant
iar
it
micesaui
mpl
ant
arededef
ibr
il
ator
.
I
ECA scad cerer
eadeO2,sint
ezadepr ot
eina,fi
broza,i
nfl
amatiaprecum si
l
ezi
uni
ledat
ori
taradi
cal
i
lorl
i
beri
iarpr
inbr
adi
kininadi
lataar
ter
elecor
onare.
Ter
apiaimunosupr
esi
va:nupoat efirecomandat
alapacient
iifar
aconfi
rmare
hi
stol
ogi
caami ocar
dit
ei,cidoarl
aceicarenuauraspunslat
erapi
estandar
da
i
nsufi
ci
entei
cardi
ace.

Tul
bur
ari
der
it
m si
conducer
e
58. I
mpact
ulcl
i
nical
ari
tmi
i
lor
I
mpor
tant
acl
i
nica:
- r
iscul
imedi
atdemoar
tesubi
tacar
diacaar
it
mica
- Af
ectar
ehemodinami
car
egi
onal
a/si
stemi
ca,dei
ntensi
tat
evar
iabi
l
acar
eaf
ect
eaza
st
areadesanat
ate
- Ari
tmii
lecar
diacesuntocauzaf
recv
ent
adedi
sconf
ortsisuf
eri
ntacar
eal
ter
eaza
cal
it
ateavi
eti
i
.
Cl
asedei
mpactcl
i
nic(
semnesi
simpt
omededi
sfunct
iehemodi
nami
ca)
Cl
asaIf
arasi
mpt
omesaucusi
mpt
omemi
nor
e(pal
pit
ati
i
,senzat
iedef
lut
urar
e
pr
ecor
dial
a);
impacthemodi
nami
cabsent
.
Cl
asaI
Isi
mpt
omesemni
fi
cat
ive(
amet
eli
,di
spnee,di
sconf
ortpr
ecor
dial
);i
mpact
hemodi
nami
cabsentsaumi
nor(
scadePAdarnusub90mmHg,
nici
inor
tost
ati
sm)

47
 Cl
asaI
IIsemnecl
i
nicesemni
fi
cat
ivededi
sfunct
ie;
impacthemodi
nami
cimpor
tant
:
- Acut
:general(ast
enie,fati
gabi
li
tat
e),cerebr
al( si
ncopa)
,car di
ac (i
nsuf
ici
ent
a
vent
ri
cul
arast
anga,
hipotensi
une,
durerest
enocardi
ca),r
enal(
oli
goanur
ie)
- Cr
oni
c:t
ahi
car
diomi
opat
ie
Cl
asaI
Vaf
ect
arecl
i
nicasev
era,
cucol
apsv
ascul
arper
if
eri
c,edem pul
monaracut
car
diogen,
soccar
diogen,
stopcar
dio-
respi
rat
or.

59. Mecani
smel
ear
it
mogenezei
1.Tul
bur
ari
deaut
omat
ism
a.Alterareaaut omatismuluinormal generataprin:
-cresterea acestuia:tahicardie si
nusala simpla sau inadecv
ata,toat
e
rit
mur il
e de scapar e( ri
tmur ipasive)
,unel er i
tmuriacti
ve,parasi
stol
i
e
atrial
asi ventri
culara
-deprimareaacest uia:bradi
cardiesinusala,opri
resi
nusala
b.aut
omat ism nor mal
c.par
asistoli
e
2.Activi
tatedecl ansataprinpost-depolar
izariprecocesautar
dive
3.Rei
ntr
aredefaza0,reint
rareanat
omi
ca,f
unct
ional
a,ani
zot
ropi
ca,spi
ral
a,l
a
i
ntamplar
e,r
efl
ect
are,defaza2.

60. Cl
asi
fi
car
iar
it
mii
1.Tahi
cardi
i supr
avent
ri
culare: pr
in mecani
sme care i
mpl
i
ca obl
i
gat
ori
u
st
ruct
uriaf
lat
edeasuprabif
urcati
eif
asci
cul
ului
His:
-
jonct
ional
independent
e(at
ri
ala)
-
dependent
e
-
atr
iov
ent
ri
cul
ar,
cur
eint
rar
epr
incai
accesor
iiat
ri
ovent
ri
cul
aret
ipKent
2.Tahicar
diiv
entr
icul
are:pr
inmecani
smeaf
lat
eexcl
usi
vdeasupr
abi
fur
cat
iei
fasci
cul
ului
His:
-
sust
inut
esaunesust
inut
e
-
monomor
fe,
pol
i
mor
fesaubi
dir
ect
ional
e
-
ischemi
ce,
medi
cament
oase(
toni
ce)saui
diopat
ice.

48
 3.Tahi
car
dii
regul
ate:
cucompl
exQRSi
ngustsaul
arg
4.Tahi
car
dii
ner
egul
ate:
fibr
il
ati
eat
ri
ala

61. Fi
bri
l
ati
eat
ri
aladef
ini
ti
e,et
iol
ogi
e
Defi
nit
ie:ar
it
miecesecaract
eri
zeazaECGpr
ininl
ocuir
eaundel
orPcuoscil
ati
ial
e
l
ini
eii
zoelect
ri
cecar
evar
iazaconti
nuucamor
fol
ogie,
ampli
tudi
ne,f
recv
ent
a,dur
ata
- Acti
vi
tat
eelectr
icaarter
ial
a:depolar
izar
ihaoti
ce,dezor
ganizat
e,f
recv
ent
acardi
aca
mare( 400-
600/min),ampl i
tudi
nea undelor at
ri
ale(0,05-0,
5 mV),nu pr
oduce
cont
racti
eatr
ial
aefici
enta
- Al
urav
ent
ri
cul
araest
ener
egul
atasi
rapi
da
- La paci
enti
icu si
ndr
om WPW,dat or
ita conducer
iipe cal
e accesori
e,alur
a
vent
ri
cul
araest
emaimareput
anddepasi300/min ri
scdefi
bri
lat
ievent
ri
cular
a
- Echi
val
ent
ulcl
i
nical
fibr
il
ati
eiat
ri
aleest
ear
it
miacompl
eta.
Et
iol
ogi
e:
1.Bol
icardi
acedef
ond:car
iopati
ehiper
tensi
va,
valv
ulopat
iereumati
ca,car
diopat
ie
i
schemica,CMD,CMH,v al
vul
are,non-r
eumati
ce,boala de nod si
nusal,al
te
car
diopat
ii
2.Factor
i pr
edi
spozant
i:insuf
ici
ent
a car
diaca,di
abet zahar
at,bol
i br
onho-
pulmonar
e,hi
per
ti
roi
dism

62. Fi
zi
opat
ologi
e,compl
i
cat
iif
ibr
il
ati
eat
ri
ala
- Pri
ncrest
ereafrecventeivent
ri
cularepeperi
oademaimar ideti
mpsepoat
einst
ala
ocardi
omiopati
et ahiari
tmicadil
atati
va insuf
ici
entacardi
acadesi
nest
atat
oare
saupri
nsuprapunerecuocar diopati
eorgani
capreexi
stent
a.
- Deteri
orar
ea hemodi
nami
ca poat
eficor
ect
atar
api
d pr
inr
educer
ea f
recv
ent
ei
ventr
icul
are
- Pier
dereafunct
ieidepompaaat r
iul
ui scader
eadebitul
uicardi
accu10- 30%
consecint
e hemodinamice sever
e,maial es daca umplerea v
ent
ri
culara este
dependenta de cont
ract
ia at
ri
ala(caz de st
enoza mitr
ala,HVS cu disfunct
ie
di
astoli
ca)
- Persistentafi
bri
l
at i
eiat
ri
aleducel aapari
ti
ademodi ficarist
ruct
ural
esifunct
ionale
al
et esutuluiat
rialcarefavorizeaza menti
nerea f
ibril
ati
eisiscad semnificat
iv
posibil
itat
eadereusitaaconversieil
ari
tm si
nusal

49
- Ri
scult
romboembol i
c:elementpatogeni
cal apar
it
iei
trombilorestestazasangeluii
n
at
ri
i,
mai al
esinatr
iulstangsiur
echiusastanga.I
ncont ext
ul f
ibr
il
ati
eiatri
ale,
factori
i
deri
scpentrutr
omboembol i
sm sunt:var
stamaimar ede75deani ,sexulfemi ni
n,
HTAsidisf
uncti
adeVS.
Compl
i
cat
ii
:
1.Ar
it
mice:r
emodel
areatr
ial
ael
ect
ri
casist
ruct
ural
a,ar
it
miiv
ent
ri
cul
arecur
isc
maredemoar
tesubi
ta
2.Hemodinamice: scader
ea debi
tului cardi
ac, CMD, hipot
ensi
une ar
ter
ial
a
or
tost
atica,
sincopa,
ICsauedem pulmonaracutcar
diogen
3.Tr
omboembol
i
ce:
sist
emi
cesaupul
monar
e(st
azaat
ri
ala)

63. Cl
asi
fi
car
eaf
ibr
il
ati
eiat
ri
ale
1.Fi
bril
ati
eatri
alaparoxi
sti
ca:episodari
tmic,cudebutdemaiput i
nde48ore,
documentatsausimptomati
c;inpeste60%dincazuriseconvert
est
espont
anl
a
ri
tm si
nusal
,i
ndecursde48deor e.Nunecesi
taneapar
atant
icoagul
are.
2.Fibr
il
ati
eat ri
alapersi
stent
a:episodari
tmiccar
edureazamaimultde7zil
e,l
a
care nu s-af acutcar di
over
sie sau est
e de v
echime nepr
eci
zat
a.Nu se
convertest
espont anlar i
tm si
nusalsipoatefif
ormaculminant
aaf i
bri
l
ati
ei
atri
aleparoxi
sti
cerecurent
e.
3.Fibr
il
atieatr
ialapermanent a,cecupri
ndefi
bri
l
ati
eat r
ial
apersist
entamaimul tde
1ansaucar enuaput utf iconver
ti
tal
arit
m sinusalsaurit
mulsi nusalnus-a
mentinut.Cupridesif i
bri
latiaatr
ial
apefonddebol icauzaleseverelacarenu
esteindicat
aconv er
sia.

64. Rest
abi
l
irear
it
mul
uisi
nusal
inf
ibr
il
ati
aat
ri
ala
- Avant
ajehemodi
nami
ce:amel
i
orar
easi
mpt
omel
or,pr
event
iat
romboembol
i
smul
ui
si
stemic
- Sepoat
efacepr
inconv
ersi
eel
ect
ri
ca(
car
diov
ersi
e)saucumedi
cament
e
Cardi
over
siaseindi
cadeur gentai
ncazdef i
bri
lat
ieatr
ialacualt
erarehemodinamica
major
a,precedat
adeoper i
oadadei ncar
carecumedi camenteanti
ar i
tmicecar
esa
cr
eascaratadesuccesaconversi
eisi
mentinereault
eri
oaraarit
muluisinusal
- Argument
epro:i
mpactcli
nicsever,sindr
om WPW,al
urav
ent
ri
cul
ara>180/
min,
tr
omboembol
i
sm recur
ent
,inadapt
abil
i
tatehemodi
nami
ca
- Ar
gument
econt
ra:at
ri
isauur
echi
useocupat
e,boal
aacut
aindependent
adeFA,
bol
i

50
 gener
alesev
ere,
bol
ii
nvazi
vesaui
nst
adi
iter
minal
e,et
il
ism cr
oni
c.
Medicati
eutil
i
zatapentruconversiafi
bri
lat
ieiat
ri
ale:dof
etil
i
d(oral
),f
lecainid(or
alsau
i
ntr
av enos)
,propaf
enona,amiodarona,i
buti
li
d,pr
ocainamida,di
goxi
na,sotalol
.

65. Cont
rol
ulf
recv
ent
eiv
ent
ri
cul
arei
nfi
bri
l
ati
aat
ri
ala
Rat
iuni
l
eopt
imi
zar
iial
uri
ivent
ri
cul
are:
-ameli
orar
ea simptomatologi
ei:diminuarea pal
pit
ati
i
lor
,reducer
ea di
spneei
,
asigur
areaconfor
tuluit
erapeuti
c,scader
ear i
scul
uidehipot
ensi
unemaialesin
ort
ostati
sm,scadereari
sculuidesi
ncopa
-r
educer
earisculuideevol
uti
espr
einsufi
ci
entacardi
aca,
saudeagravar
eaIC,cu
sau far
at ahicardi
omiopati
e di
l
atat
iva,pri
n crest
erea f
ract
ieide ej
ect
iea
vent
ri
culul
uistang
-
reducer
ear
iscul
uidear
it
mii
vent
ri
cul
aremal
i
gnecar
epotducel
amoar
tesubi
ta
-
reducer
ear
iscul
uidesuf
eri
ntacor
onar
iana(
incazulf
ibr
il
ati
eiat
ri
alecual
ura
r
apida)
-
scadereaper
ioadei
despi
tal
i
zar
e:al
urav
ent
ri
cul
araopt
imai
nrepaus60-
80bpm,
l
aefort90-
115bpm.
Medi
cament
e:
-
uti
l
izat
epentr
uopt i
mizareaaluri
ivent
ri
cul
arei
nsituat
iicarenecesi
taunef
ectr
api
d
(
admini
str
atei
ntr
avenos):
dilt
iazem,esmol
ol,
metopr
olol
,verapami
l,di
goxi
n
-
pet
ermenl
ung:
digoxi
n,v
erapami
l
,ami
odar
ona,
dil
ti
azem
Ablat
ianodul
uiat
ri
o-vent
ri
cularsauaunorcaiaccesor
iisefol
osest
ecametodaatunci
candter
apiacumedicamenteesteinsuf
ici
ent
asauareefect
esecundar
esemnif
icat
ive.
I
mplantar
eaunuicar diost
imul
atorpermanentsepoat
efacelaceicufi
bri
l
atieat
ri
alacu
al
uravent
ricular
alentacarenecesi
taadmini
str
aredemedicament
edromotropnegati
ve,
dat
ori
taboliidefond.

66. Pr
event
iat
romboembol
i
smul
ui
- Esteimport
ant
adeoarecefi
bri
l
ati
aatr
ialaest
ecelmaii mportantf
act
order
isc
pentr
ueveni
mentel
etr
omboemboli
cesi
stemi
ce,mai
alescerebr
ale.
- Infi
bri
lat
iaat
ri
alacuri
scmic(
var
stasub65ani
,far
afact
orider
isc)sepoat
e
admini
str
aaspi
ri
na325mg/
zi

51
- I
nfi
bril
ati
aatr
ial
acuriscint
ermediar(v
arst
acupri
nsaint
re65si75ani
,far
afact
ori
der
isc)
,sepotadmi
nistr
aanticoagul
anteor
alecut
int
aINR2-3;
aspi
ri
na325mg/zi
- InFAcur i
scmar e(varsta>75ani,cufact
orideriscpr
ecum ant
ecedent
edeAVC,
embolism si
stemic,ICC,disf
unct
ie si
stol
ica a VS,HTA,DZ)se admi ni
str
eaza
ant
icoagul
anteoral
ecuI NRti
ntade2-3.

67. Fl
utt
erat
ri
aldef
ini
ti
e,ECG
Defi
nit
ie:aparepri
nmecani sm demacr orei
ntr
areint
r-uncircui
tat r
ialsiseprezi
nta
peECgcaoact i
vit
ateat
rial
aregulatasinonomorfa,f
aralini
eizoelectri
cacelputi
nin
unadinderivat
ii
,cufr
ecventai
nj urde300compl exeatri
alepemi nut(capm).
1.Flutt
eratr
ialtipic:ci
rcuitcarei
ncludepereteleli
beralatri
uluidrept
,de-alungul
crist
eiter
mi nale,obligator
iuist
mul ,ca zona deconducer el enta siperet
ele
septuluii
nteratri
al.Activar
eaacestuitr
aiecti st
mo-dependenti nsensant eri
or
producefl
utterat r
ial
tipi
ccomunsi i
nsensor arproducefl
utt
erat r
ialt
ipi
crar.
2.Fl
utterat
ri
alat
ipi
c:or
iceal
teci
rcui
teder
eint
rar
eindi
ver
sezoneat
ri
alecar
enu
i
ncludist
mul.
ECG:
Fl
utt
erti
piccomun:undeat
ri
alecumorf
ologi
ede
dint
idef
ier
ast
rau
,numi
teundeF,
i
ndervi
ati
il
eII,
II
I,
aVF,fr
ecv
enta240-
320capm
Fl
utt
erati
pic:osci
l
ati
ial
eli
nieii
zoel
ect
ri
ce,
cudi
ver
seal
temor
fol
ogi
i
,fr
ecv
ent
a300-
360capm.
I
npract
icaci
rca5% dincazur
il
edeFLAsepr
ezi
ntacuconducer
eatr
iovent
ricul
ara
1:
1(AV=300bpm) ,80-
85% cuBAV2:1(
AV=150bpm) ,rest
ulde10-15% cualte
gr
adesiti
pur
ideBAV.

68. Tr
atament
ulf
lut
ter
ului
atr
ial
1.Ter
api
ari
tmul
uicar
diac:
- Rei
nst
aur
areasi
ment
iner
ear
it
mul
uisi
nusal
,sauopt
imi
zar
eaf
recv
ent
eiv
ent
ri
cul
are
- Conversi
alarit
m si
nusalsepoat
ef acepri
ncardi
over
siecuener
giir
epetat
emi ci
,
car
et r
ebuieapli
cat
aurgenti
nf l
utt
erulat
ri
alcuconducer
e1:1sielect
ivintoate
cel
elal
tecazur
i
- Menti
nerea ult
eri
oar
a a r it
mul
ui si
nusal
: medi
cament
os (
ami
odar
ona, al
te
ant
iar
it
mi cedecl
asaI
IIcuef
ici
ent
amaiscazut
a)
- Ter
api
aact
ual
apent
rupr
event
iar
eci
div
elorsebazeazapeabl
ati
epecat
etercu

52
 cur
ent
ider
adi
ofr
ecv
ent
aazonei
deconducer
elent
a
- I
n cazuriin carenu sepoater estaur
ar it
mulsi nusal,sepoateopt i
miza al
ura
v
entri
culara pri
n admini
str
are de medi camente dr omotr
op negat
ive,sau prin
i
mplantaredepacemakerincondit
ii
leuneibradi
cardiisever
e.
2.Pr
ofi
l
axi
aacci
dent
elort
romboembol
i
ce

69. Cl
asi
fi
car
etahi
car
dii
supr
avent
ri
cul
are
Tahicardi
il
esupraventr
icul
aresunttahi
cardiiproduseprinmecanismecar eincl
ud
str
ucturiafl
atedeasuprabif
urcati
eif
asci
coluluiHis.Suntt
ahi
cardiregul
atecareau
compl exQRSingust(<120ms) .
Cl
asif
icarei
nfunct
iedest
ruct
uri
l
eimpl
i
cat
einmecani
smel
edeapar
it
iesiment
iner
ea
ar
it
miilor
:
1.Tahi
cardi
ijonct
ionaldependente:pri
nr eint
rar
ei nt
ranodala,atri
ovent
ri
cul
ara,
j
oncti
onal
aectopica,
jonct
ional
areci
procatapermanenta,sauidi
o-nodal
a.
2.Tahi
car
dii
jonct
ional
independent
e(at
ri
ale)
:
-
tahi
car
diesi
nusal
a
-
tahi
car
diei
nadecv
ata
-
tahi
car
dieat
ri
alacur
eint
rar
esi
noat
ri
ala,
int
rat
ri
ala,
atr
ioj
onct
ional
a
-
tahi
car
dii
aut
omat
ice
-
tahi
car
dieat
ri
alanon-
rei
ntr
ant
a,non-
aut
omat
ica(
post
-depol
ari
zar
etar
div
a)
-
fl
utt
erat
ri
al

70. Abor
dar
eat
ahi
car
dii
l
orcucompl
exQRSi
ngust(
nor
mal
)
I
ncr
iza:
-
masaj
desi
nuscar
oti
dian/
alt
emanev
rev
agal
e(manev
raVal
sal
va)
-
adenozi
na6-
9mgsauATP10-
20mgi
ntr
avenosi
nbol
us
-
ver
apami
l5mgi
ntr
avenosi
ndecur
sde1mi
nut
-
elect
rost
imul
areov
erdr
ivi
ng
-
car
diov
ersi
e(i
mpactcl
i
nicdecl
asaI
II
-I
V)
Def
ond:

53
 -prof
il
act
ic:ant
iar
it
mice de cl
asa I
a,I
c,I
Isau I
II
,cu excl
uder
ea f
act
ori
l
or
preci
pit
anti
-cur
ati
v:abl
ati
eacircui
tul
uiderei
ntr
are(
mair
ardeoar
ecenecesi
taapar
atur
a
sofi
sti
cat
asiesteoexpl
orar
einv
azi
va)
-
dispozi
ti
vant
iar
it
mic

71. Tahicar
diev
ent
ri
cul
aranesust
inut
a,sust
inut
a,t
orsada
v
arf
uri
l
or
Tahi
cardi
eventr
icul
ara=ar
it
miecu3saumaimult
ebat
aisuccesi
vecuor
igi
nei
n
vent
ri
culsif
recv
entacardi
acamaimar
ede100bpm.
Tahicardi
ev ent
ricul
aranesust
inut
a=ar i
tmiecu3saumaimul t
ebataisuccesiv
e
ce se opr esc spontan i
n 30 de secunde.Poat
ef imonomor fa(o singur
a
morfologieQRS)saupol i
morf
a( morfol
ogiaQRSestevar
iaabi
la,cul
ungimede
ci
cluintre600si 180ms).
Tahi
cardi
ev entri
cul
arasusti
nutacompl exeQRSl ar
gi,cudurat
amaimar ede
30sec,car
et r
ebuieoprit
adatori
tacompr omiter
iici
rculat
iei
chi
ar<30sec.Poate
fimonomorfa:mor f
ologi
eQRSst abi
la,saupoli
mor fa:morfol
ogieQRSvar
iabi
la,
mult
if
orma,cul ungi
meaci cl
uluii
ntre600-180ms.
Torsada v ar
fur
il
or:tahicardie ventr
iculara asociat
a cu i nterv
al QT lung,
caracterizat
a pe ECG prinr asucir
ea var f
uluicomplexuluiQRS i njur
ulliniei
i
zoelect r
ice,i
nti
mpularit
mi ei.Poateapareat i
picdupaosecv entadecicl
uri
lung
-scurt
-lungsaudupaosecv ent
adecupl arenormal-scurt(vari
antadecupl aj
scurt)
.

72. Abor
dar
eat
ahi
car
dii
l
orcucompl
exQRSl
arg
I
ncr
iza:
-
lov
itur
apr
ecor
dial
a(t
hump)
,al
urav
ent
ri
cul
ara<180/
min
-
li
docai
na100mgi
ntr
avenosi
nbol
us(
repet
atdemaxi
m 2or
i)
-
elect
rost
imul
areov
erdr
ivi
ng
-
car
diov
ersi
e(l
aimpactcl
i
nicdecl
asaI
IIsauI
V)
Tr
atamentdef
ond:
-
prof
il
act
ic:ant
iar
it
micedecl
asaI
a,I
c(i
nabsent
aHVSsicar
diopat
iei
schemi
ca)
,

54
 I
I(l
acei
cucar
diopat
iei
schemi
ca)
,II
I.
-
cur
ati
v:abl
ati
eaci
rcui
tul
uider
eint
rar
e
-
def
ibr
il
atorcar
diov
ert
eri
mpl
ant
abi
l
.

73. Bl
ocur
isi
no-
atr
ial
ecl
asi
fi
car
e,descr
ier
e
Defi
nit
ie:alt
erar
ialetr
ansmi t
eri
iimpulsul
uiel
ect
ricf
ormataut
omatincelul
ele
Pacemakeral enodul
uisinusal,
laatr
iuldr
eptpri
nint
ermedi
ulcel
ulel
orperi
nodal
e
numitecelul
eT( tr
anzi
tional
e)

BSAgr
ad1
Nuar
eni
ciunf
eldeconseci
ntaasupr
ari
tmul
uiundel
orP

Evaluareatimpuluideconducer
esino-
atr
ial
asefacei
ndir
ectpri
nanali
zadurat
ei
pauzelordedupabat ai
l
eprematur
eatri
alesaupri
nstudi
ulel
ectr
ofi
zi
ologi
cal
functi
ei nodul
uisinusal

BSA1ecompl
etasi
mpt
omat
icsi
nuar
eni
ciunf
eldesemni
fi
cat
iecl
i
nica

BSAgr
ad2
Cazul
1

o TraseeleEKG pr
ezint
abataisi
nusal
egrupatei
nper
ioadedesi
stemat
izar
ein
cadrulcaror
aint
erv
alulPPscadeprogr
esiv

o posbi
l
itat
edeper
iodi
cit
atedet
ipWenckebach

Cazul
2

o Ceamai
frecv
ent
afor
madeBSA2

o Apar
it
iaunorpauzei
nact
ivi
tat
easi
nusal
a(absent
aint
ermi
tent
aaundel
orP)

o BSA2cuconducer
eti
p2:
1cont
inuapeEKGar
easpectdebr
adi
car
diesi
nusal
a
cufr
ecv
ent
asub40bpm

o Patognomoni cpent
ruaceastafor
maestesalt
ul f
recvent
eiundelorPl
a
aproximativdublulval
ori
ii
nit
ial
einur
maunui efortusorri
dicareai
n
ort
ost at
ism saudupaadmi nist
rar
eai
ntr
avenoasaa1mgat ropinatoat
educ
l
adi sparit
iatemporaraablocul
ui

Cazul
3

o undel
ePaparcupauzemar
idart
otmul
ti
pli
exact
iai
cicl
ului
sinusal
debaza(
3x,

55
 4x)

BSA gr
ad3
Absent
acompl
etaat
ransmi
ter
iii
mpul
sul
uisi
nusal
laat
ri
i(absent
aundel
orP
si
nusal
e)

Acti
vit
ateaatr
ial
apoat
efiguvernat
adeal
tcent
rudot
atcuaut
omat
ism saupoat
e
l
ipsicompletri
tmulf
ii
ndjocti
onal

Toat
egradel
edeBSApotf
icomponent
eal
eunorsi
ndr
oamecompl
exeboal
adenod
si
nusal
siboal
abi
nodal
a.

74. Bl
ocur
iat
ri
o-v
ent
ri
cul
arecl
asi
fi
car
e,descr
ier
e
BAV=i ncet
ini
reasauopri
reatr
ansmiter
iinor
mal
eai mpulsur
il
orsupr
avent
ri
cul
arel
a
vent
ri
culipr
instr
uctur
ianatomo-
fi
zi
ologiceal
esi
stemului
deconducere.
Clasi
fi
car
ea se bazeaza pe r
elat
ia matemat
ica di
ntr
e numar
ulde unde at
ri
ale
condusel
aventr
iculsicel
deundebl ocat
e.
BAVgradul1:numar
ult
otaldeundeat
ri
alecondusel
avent
ri
cul(
nAcond)est
eegalcu
numar
ultotal
deundeat
ri
ale(N)
.nAbl
oc=0
BAVgr
adul
2:nAcond<N,
nAbl
oc>0;
1.
ti
pMobi
tz:
nAcond>nAbl
oc:
-
Mobi
tz1:
cual
ungi
reapr
ogr
esi
vadePR
-
Mobi
tz2:
far
aal
ungi
reant
ecedent
adePR
2.
ti
p2:
1,i
ncar
enAcond=nAbl
oc
3.
avansat
,incar
enAcond<nAbl
oc
BAVgradul3:nAcond=0,nAbloc=N.Tablouclinic:sincopaAdams-St
okes,convul
sii
,
rel
axar
esfinct
eri
ana.Pul
snormaldarrar.Si
mptomat ologi
esaracadarpoateaveasi
fenomenedeICC.Laauscul
tat
ieser
emarcasi
stoleleinecou,
zgomotuldetun
.

75. Cauzedebl
ocat
ri
o-v
ent
ri
cul
ar
1.Fi
brozasi
/sauscl
erozasi
stemul
uideconducer
e(pr
imar
a,secundar
a)
2.Car
diopat
iei
schemi
ca(
inf
arctmi
ocar
dicacut
)
3.Cr
est
ereamar
cat
aat
onusul
uiv
agal
4.Admini
strar
edemedi camentedromotr
op negat
ive:di
git
ali
ce,ant
agoni
steal
e
canal
elordecal
ci
u,bet
ablocant
eadr
energi
ce,ami
odarona

56
 5.Val
vul
opat
ii(
mai
alescel
eaor
ti
cecucal
cif
ier
edei
nel
aor
ti
c)
6.Bol
icongeni
tal
e:BAVf
ami
l
ial
,BAVdi
ncadr
ulal
torcar
diopat
iicongeni
tal
e
7.Cauzediver
se:cardi
omiopat
iepri
mara,secundara,mi
ocardi
teacute,int
erventi
i
chi
rur
gical
epeorif
ici
ulaor
ti
ce,hi
per
potasemie,
traumat
isme,neopl
azii
infi
l
trati
ve.

76. Bl
ocur
iint
rav
ent
ri
cul
areECG
1.BLOCUL FASCI
CULAR ANTERO-
SUPERI
OR
AxQRSi
npl
anf
ront
aldev
iatl
ast
anga-30panal
a-75

Undeqasoci
atecuundeRr
elat
ivampl
einDI,
aVL,
V5,
V6

UndeSi
nDI
I,
II
Isi
frecv
ent
eV5V6

Dur
ataQRS<0.
12sec

2.BLOCUL FASCI
CULAR POSTERO-
INFERI
OR
AxQRSinplanf
ront
aldevi
atl
adr
eapt
a+90panal
a160i
nabsent
aal
torcauze
dedev
iat
ieaxi
aladr
eapt
asauacr
it
eri
i
lorEKGdeHVD

Dur
ataQRS<0.
12sec

UndeTnegat
ivesi
asi
met
ri
cei
nII
,I
IIsi
aVF

3.BLOCURI
LEDERAMURA STANGA
Absent
aundei
qinDI
,aVL,
siV5V6

Dur
ataQRS>0.
12s

Mor
fol
ogi
eQRSsubf
ormal
i
ter
eiM

AxQRSi
npl
anf
ront
alnor
mal
sauusordev
iatl
ast
anga

Bl
oci
ncompl
etacel
easi
cri
ter
iidarcompl
exul
QRSar
edur
ata<0.
12s

4.BLOCURI
LEDERAMURA DREAPTA
Dur
ataQRS>0.
12s

Morofol
ogi
eQRSdeti
prsR'
sauQri
nV1si
undeSl
argi
(>0.
4s)dardeampl
i
tudi
ne
r
elat
ivmicai
nDI,
DII
,V5siV6

AxQRSf
ront
alnor
mal

Bl
oci
ncompl
etcompl
exul
QRSar
edur
ata<0.
12s,
undeSmai
put
inl
argi
,

57
 mor
fol
ogi
aQRSdi
nV1det
ipr
Sr'

Si
ncopa
77. Def
ini
ti
ehi
pot
ensi
unesi
sincopa
Sincopar
eprezintapier
der
eatr
anzit
ori
eastar
iideconst
ientasiatonusul
uipostural
,di
n
carepacient
uli sirevi
nespont
an,completsirapid.Duratasincopeivasovagalenu
depasest
eder egula20desecunde.
Hi
potensi
uneaar
ter
ial
arepr
ezi
ntascader
eat
ensi
uni
iar
ter
ial
esubv
aloar
eade90/
60
mm Hg.

78. Cauzel
ehi
pot
ensi
uni
i
Cauzahipot
ensi
uni
inuesteint
otdeaunacunoscut
a.Hi
pot
ensi
uneapost
ural
apoat
efi
asoci
atacuurmat
oarel
econdi
ti
i
Sarcina
Hipotiroidism, hipert
iroi
dism
Supradozaj ulmedi cament el
orant
ihi
pert
ensi
ve
Insufi
cient acar diaca
Arit
mi il
ecar di
ace
Vasodi latatie
Afectiuni hepatice
Hemor agiile
Hipo-sauHi pertermia
Septicemi a
Deshidr atareasev er
a
Socul anaf il
actic
Cauzeextracar diace:tumor i,deshi
drat
are,bol
iinst
adi
uter
minal
,obst
ruct
iial
efl
uxul
ui
sangui
n.

79. Cl
asi
fi
car
easi
ncopel
or
1.Si
ncopaneur
ogenar
efl
exa

Si
ncopav
asov
agal
a

Si
ncopacar
oti
diana(
sindr
omul
desi
nuscar
oti
dianhi
per
sensi
bil
)

Si
ncopasi
tuat
ional
a:hemor
agi
iacut
e,dupast
ranutsaut
use,
dupami
cti
une,

58
 post
prandi
al,
dupar
idi
car
edegr
eut
ati

2.Si
ncopaor
tost
ati
ca

I
nsuf
ici
ent
aaut
onomadi
n:

- Si
ndroamedei
nsuf
ici
ent
aaut
onomapr
imar
a:at
rof
iesi
stemi
camul
ti
pla,
boal
a
Par
kinson

- Si
ndr
oamedei
nsuf
ici
ent
aaut
onomasecundar
a:neur
opat
iedi
abet
ica,
ami
l
oida

Medi
cament
e,al
cool

Depl
eti
evol
emi
ca:
hemor
agi
e,deshi
drat
are,
boal
aAddi
son

3.Ar
it
mii
car
diace

Boal
adenodsi
nusal

Bl
ocur
il
eAVgr
ad2si
3

Tahi
car
diepar
oxi
sti
casupr
avent
ri
cul
arasi
vent
ri
cul
ara

Af
ect
iuni
congent
it
ale

4.Cauzast
ruct
ural
acar
diacasaucar
diopul
monar
a

HTP

I
nfar
ct/i
schemi
emi
ocar
dicaacut
a

Val
vul
opat
ii

CMH

Embol
i
epul
monar
a

Di
sect
iedeaor
ta

Tamponadacar
diaca

5.Cauzacer
ebr
o-v
ascul
ara

St
enozadear
ter
asubcl
avi
e

80. Ev
aluar
eapaci
ent
il
orcusi
ncopa

59
1.Si
ncopav
asov
agal
a-exi
staf
act
ori
preci
pit
ant
isi
simpt
omepr
odr
omal
eti
pice.

i
nor
tost
ati
sm pr
elungi
tinspat
iical
de,
agl
omer
ate,
emot
ii
,dur
erei
ntensa

apar
eov
enodi
l
atat
ier
efl
exacuscader
eapr
esar
cini
isi
adebi
tul
uicar
diac

scadet
onusul
simpat
ici
nper
if
eri
e

cr
est
etonusul
vagal
vasodi
l
atat
iesi
bradi
car
die

2.Si
ncopacar
oti
diana

Apar
elar
oti
reacapul
ui,
bar
bier
it

St
imul
area si
nusul
uicar
oti
dian pr
oduce o hi
per
toni
evagal
a v
asodi
l
atat
ie,
br
adi
cardi
e,BAV

Pent
ruobi
ect
ivar
emasaj
ulsi
nusul
uicar
oti
dian

3.Si
ncopasi
tuat
ional
a

Apar
edupami
cti
une,
def
ecar
e,degl
uti
ti
e,t
use

Scadet
onusul
Simpat
ic

Cr
est
etonusul
Vagal
vasodi
l
atat
iesi
bradi
car
die

4.Si
ncopaor
tost
ati
ca

Scadepr esar
cina Scadedebi t
ulcardi
ac NU seact i
v eazabaror
ecept
ori
i
arter
ial
i(mecanismulsimpat
ic de compensar
e NU i
nter
vine) NU se f ace
vasoconstr
ict
ie ar
ter
ial
a sivenoasa Hipot
ensi
une ar
terial
a or
tost
ati
ca
Sincopa

5.Si
ncopadecauzai
schemi
ca

Modi
fi
car
iischemi
cepeEKG

i
nfar
ctmi
ocar
dicacuti
nfer
ior
,tul
bur
ari
mal
i
gneder
it
mvent
ri
cul
ar

6.Si
ncopadecauzaar
it
mica

-I
nblocuriat
ri
ovent
ri
cul
aredegradIIsauII
I,br
aadi
car
diesi
nusal
a<40/
min,
tahi
car
die
par
oxist
icasupr
avent
ri
cul
ara,
malfuncti
edepacemaker.

60
 Ev
aluar
easepoat
efacepr
in:

Ti
l
t-t
est

Sef
acei
ncazdesi
ncopaneexpl
i
cat
a

Paci
ent
ulest
emoni
tor
izatEKGsi
TA

Test
ulseopr
est
edacaapar
esi
ncopasaudupacesepar
cur
get
apel
e

Moni
tor
izar
eaHol
tersef
ace24h

Examenul
ecocar
diogr
afi
c

TestulECGdeef ort
:incazulsincopeiceapar
eint
impulef
ort
uluisaul
apaci
ent
ii
suspectat
idecar
diopati
eischemica.

Massaj
ulsi
nusul
uicar
oti
dian

81. Tr
atament
ulsi
ncopei
1.Tr
atament
uli
nSi
ncopaVasov
agal
a

a.Educar
eapaci
ent
ului
siexpl
i
car
eapr
ognost
icul
uibeni
gnal
afect
iuni
i

b.Evi
tar
ea sit
uat
ii
lor pr
edi
spozant
e: ortost
ati
sm prel
ungi
t, evi
tar
ea spat
ii
lor
agl
omerat
esical
de,l
adebutpaci
entul
trebui
esatr
eacai
ncli
nostat
ism

c.Apor
thi
dri
csi
desar
ecr
escut

d.Vasoconst
ri
ctoar
e-
adr
ener
giceMi
dodr
ina,
Eti
l
efr
ina

e.I
nsincopesevere,f
recvent
e,cuci
rcumstanteder i
sccr
escut,seindi
capaci
ng
(
car
diosti
mul
are)lapaci
enti
icuf
ormacardioi
nhi
bit
ori
edesincopavasov
agal
a

2.Tr
atament
uli
nSi
ncopaCar
oti
diana

a.Ev
itar
easi
tuat
ii
lorpr
edi
spozant
e

b.Paci
ng(
car
diost
imul
are)l
apaci
ent
iicuf
ormecar
dioi
nhi
bit
oar
esaumi
xte

c.Pr
edomina v
asodi
l
atat
ia Vasoconst
ri
ctoar
e -
adr
ener
gice Mi
dodr
ina,
Et
il
efr
ina

3.Tr
atament
uli
nSi
ncopaSi
tuat
ional
a

61
 a.l
afel
capent
rusi
ncopav
asov
agal
a

4.Tr
atament
uli
nSi
ncopaOr
tost
ati
ca

Evi
tar
easituat
ii
lorpr
edispozante:schimbaribr
ust
edepozi
ti
e,medi
ucut
emper
atur
a
cr
escuta,
efortf
izici
ntens,consumul dealcool

Apor
thi
dri
csi
desar
ecr
escut

Mesemi
cisi
frecv
ent
ecucont
inutr
edusdecar
bohi
drat
i

Exer
cit
iif
izi
cepent
rui
ntar
ir
eamuscul
atur
iiabdomi
nal
e

5.Tr
atament
uli
nSi
ncopadeCauzaAr
it
mica

a.Boal
adenodsi
nusal

o Car
diost
imul
areper
manent
a

o Tr
atamentmedi
cament
osadecv
atal
tahi
ari
tmi
i
lorasoci
ate

b.Tahi
car
dii
supr
avent
ri
cul
are

o Tr
atamentmedi
cament
ossaui
nter
vent
ional

o Abl
ati
afocar
elorar
it
mogenesauacai
iaccesor
ii

c.BAVdegr
adi
nal
t

o Car
diost
imul
areper
manent
avent
ri
cul
arasaubi
camer
ala

d.Tahi
car
dii
vent
ri
cul
are

o Tr
atamentmedi
cament
os

oI
mpl
ant
arededef
ri
bri
l
atorcar
diov
ert
er

Angi
napect
oral
ast
abi
l
a
82.Cl
asi
fi
car
easoci
etat
iicanadi
ene
Definit
ie:anginapectoral
ast abi
l
aest econsecintauneisuferi
nteacute,subacute,
cronice a mi ocar
duluideter mi
nata de reducerea marcataaf l
uxuluisanguin
coronar i
ansisecaracteri
zeazaprindurer
esaudi sconfor
ttoraci
ccudi v
erseir
adieri
i
numar ,spate,mandi
bula,epi
gastri
csaubrate,aparut
acuocazi aunuiefor
tfi
zicsau

62
st
resemot
ional
,cal
mat
ader
epaussauni
tr
ogl
i
cer
ina.
CLASI
FICARE:
Cl
asaIangi naestedeclansat
adeefort
urifi
zi
cedeosebi
tdemar
isaupr
elungi
te,
cedepasesccumultgraduldeantr
enamentfi
zi
cindi
vi
dual.
Clasa I
I angina est
e decl
ansat
a de ef
ort
urif
izi
ce cu put
in maimar
idecat
acti
vi
tat
eazi
lni
cauzuala.
ClasaII
Ianginaestedecl
ansat
adeef
ort
uri
l
efi
zi
ceal
eact
ivi
tat
iizi
l
niceobi
snui
te
(nualevi
eti
iderel
ati
e).
Cl
asaIVanginaestedecl
ansat
adecel
emaimi
cief
ort
uri(
incl
usi
vdecel
eal
evi
eti
i
derel
ati
e)saui
nrepaus.

83.Et
iol
ogi
asi
fizi
opat
ologi
e
Eti
ologie est
e domi nat
a de at er
oscler
oza (95-
98%),rest
ulde 2- 5% sunt
reprezent
atedestenozaaorti
ca,CMH sauCMD,embol i
icor
onari
ene,anomali
iale
arterel
orcor
onar
e,vascul
it
e/ar
teri
tecoronari
ene.
Fi
ziopatol
ogiear elabazascadereapasageraafurnizari
ideO2cat r
emi ocardfi
e
di
ncauzacr ester
iinevoi
idinti
mpulefortul
uifi
zicsauechi val
entel
ordeefort:st
ari
emotionale,str
es,postpr
andial
,febr
a,expuner
elafrig,hiper
tir
oidi
sm,fiedincauza
uneireduceriacut
edecal i
bruvascul
arcoronar
ianpri
nspasm.
Durereaapar
ecaur mareairi
tar
iimecanor
ecept
ori
l
orsichemor
ecept
ori
l
ordel
a
ni
velulmi
ocardul
uihi
pov
ascul
ari
zat.
Fizi
opatologiaestedomi nat
adecr est
ereanecesarul
uideO2l anivelmiocardic,i
n
ti
mpulef ortul
uif
izi
csaupef ondulexcesuluidecat
ecolaminesir
educer
eaact iv
itat
ii
vagaleconsecut i
vf r
igul
ui,stresul
ui,emot i
il
ornegati
veinconditi
i
leunuit eri
tori
u
vascularr est
ri
cti
onatde st enozel
e arterel
orepicar
dice.Emotii
l
e negative pot
producespasm cor onari
anfaraconsum mar edeO2.
t
rombii
ntr
acoronar
iei-
>eliber
areincir
cul
ati
easerot
ini
nel
orsitr
omboxanul
uiA2-
>
v
asoconst
ri
cti
e->scadereanivel
ului
deO2->angi
napector
ala.

84.Fact
ori
ider
iscai
car
diopat
iei
ischemi
ce
Fact
oriideri
scsuntreprezent
atideHTA,di
sli
pidemie,DZ,sedent
ari
sm,obezi
tat
esi
fumatul,
fact
ori
ceafecteazainsensnegat
ivprognosti
culbol
navil
or.

63
85.Di
agnost
icul
cli
nicpozi
ti
val
angi
nei
pect
oral
est
abi
l
e
1.ANAMNEZASII
STORI
CATENTALDURERI
IPECTORALE
-local
i
zare:preponderentinr egi
unea anteri
oar
aat
oracel
ui,r
etr
ost
ernal
,rar
epi
gast
ri
c,mandibul
a,inter
scapul
over
tebr
al,brat
e.
-car
act
eruldureri
i
:const
ri
cti
esubformadegheara,strangul
aresausubf ormade
pr
esi
une,greut
ate,ar
sur
a.Semneasoci
atedur
eri
i
:dispnee,fat
igabi
l
itat
e,anxi
etat
e.
-durat
aepi sodul
uidurer
os:nudepasest
e10mi nute,uneorimaiput
insiaparein
cont
extulunuiefor
tfi
zi
csauechival
entdeef
ort(
stres,st
ariemoti
onal
e,expuner
ela
fr
ig,
febraetc)
Admini
str
area de ni
trogl
icer
ina subl
i
ngualsau sub f
orma de prepar
ate or
ale
det
erminadispar
it
iar
apidaadureri
isaudi
minuar
easasemnif
icat
iva.
Asociereadurer
iicuef
ortfi
zi
c,st
resemoti
onal
,mesecopioasesauapari
ti
aeila
pri
mel e ore al
e di
minet
ii
,suntcondi
ti
icare pl
edeaza pent
ru car
act
erulsau
coronarian.
2.EXAMENULFI ZICur marest edepi stareadeHTA,CMH,v al
vulopatii
,xant el
asme
(l
aceicudi sli
pidemie),diminuar easauabsent apul suluilani
vel
ulmembr elorpel
v i
ne
(asociereauneiar teri
opatiiat eroscleroti
ce).La auscul t
ati
apaci entuluii ntimpul
dureriise poat e depista suflu sistolic de insuf i
cienta mit
ral
ai schemi ca,pr i
n
afectareamuschi ul
uipapilar,det ectareagalopuluipr oto-saupresistol
ic( zgomot el
e
3si4)semnaldi sfuncti
eiVS,r alurilabazelepul monare.Dimi nuareadur eri
ila
masaj ulcar ot
idiancr estepr obabi l
i
tateacaaceast asaf i
edecauzacor onari
ana.
Dedubl areazgomot ul
ui2est eoconseci ntaaasi ncr oni
smuluisaual ungi ri
iduratei
decont racti
eaVS.
3.TESTEDELABORATORaucascopdepi
star
eaf
act
ori
l
order
iscat
eroscl
erot
ici
si
cauzel
eischemi
ei.
Marker
idenecr
ozami
ocar
dica negat
ivi
,facdi
fer
ent
acusi
ndr
omulcor
onar
ian
acut
.
Li
pidogramacomplet
asist atusgl
icemicajeun,r
ezi
stent
al ai
nsuli
naCr eat
ini
na
seri
ca eval
uareafunct
ieirenal
e( HTA,DZ,boal
arenovascul
ara,avandimpact
negati
v)
Mar
ker
iii
nfl
amat
ori
pr
otei
naCr
eact
iva.

86.Di
agnost
icul
par
acl
i
nical
angi
nei
pect
oral
est
abi
l
e
64
1.Radi
ografi
etoraci
ca sefacelapaci enti
icuanginapect
oral
acar
easoci
aza
valvul
opati
i
,bol
ipulmonar
ecr
onice,
insuf
icient
acar
diaca.
2.Electrocardiogr
amader epaus normalalapeste50% dinpacient
i.Potexista
semnedenecr ozavecheexprimatepri
nundeq.I nt
impuldurer
iipaci
enti
icuECG
anter i
or nor malpr ezi
nta modifi
car
ipr ecum:subdeni
velar
ea segment uluiST,
i
nv ersarea undel orT,nor mali
zar
ea segmentul
uiST anteri
orsubdenivelat,sau
supr adenivelaretr
anzi
tor
ieST.
3.
Elect
rocar
diogr
amadeef
ortpozi
ti
vacandSTest
esupr
a-sausubdeni
vel
atpest
e
1mm.
4.
Test
uldeef
ortsi
ecocar
diogr
afi
adest
res
5.Sci
nti
grafi
edest
res v
aloar
epr
edi
cti
vasuper
ioar
a;l
i
mit
atadecost
,ir
adi
ere,
accesi
bil
itat
e
6.
Testulf
armacol
ogicdestresalt
ernati
valapaci
ent
iicar
enupotef
ect
uat
est
ulde
ef
ort
;seadminist
reazadobutami
naintr
avenos.
7.
Rezonant
amagnet
icadest
resmet
odacedepasest
ecal
i
tat
ivecocar
diogr
afi
ade
st
res.
8.
Moni
tor
izar
eHol
terut
il
ainf
ormesi
l
ent
ioasedeangi
na.
9.
Ecogr
afi
eint
racor
onar
ianaev
aluar
eadi
amet
rul
uiv
asul
ui,compozi
ti
apl
aci
ide
at
erom.
10.Ar
ter
iograf
iecoronar
ianaofer
acelemaii mportant
einf
ormati
idespr
eanat
omi
a
vasel
orcoronare,
graduldest
enoza;cuant
if
icaprognosti
cul
boli
i
.

87.El
ement
edepr
ognost
ical
eangi
nei
pect
oral
est
abi
l
e
Prognost
iculdepi
nde de cal
cul
area r
iscul
uiboli
i
,de opt i
uni
leter
apeut
ice al
e
tr
atamentului
medi
camentossaudeproceduri
leder
evascul
ari
zar
e.
El
ementel
epr
edi
cti
veal
eri
scul
uisuntdat
ede:ev
olut
iaECGsiv
alor
il
epr
obel
orde
l
abor
ator.
Paci
entiicuanginader epaussimodi f
icar
ipeECG,cuantecedent
edeinfar
ct
miocardi
c,BCRS,hipert
rof
iev ent
ri
cul
ara st
anga (
HVS)
,bl
oc AV de gr
ad mar
e,
fi
bri
lat
ieatr
ial
a,auunri
scmar e.
Asocierea DZ,HTA,a f umatul
uisiv al
oricrescute ale col
esteroluluiseri
csunt
elemente de pr ognostic negativ. Varst
a,ant ecedente de i nfarct miocar
dic,
simptomeledei nsufi
cientacardiaca,severi
tat
eaangi neisiraspunsull atrat
ament
reprezi
ntadeasemenea, elementedepr ognosti
cnegativ.

65
Prezent
aboli
iater
oscler
oti
ceper
if
eri
ce,caroti
dienesau amembr
elori
nfer
ioar
e
denotaunr
isccr
escutpentr
uev
eni
menteult
erioar
enefavor
abi
l
e.

88.For
mecl
i
niceal
eangi
nei
pect
oral
est
abi
l
e
A.I
SCHEMI
ASI
LENTI
OASA
- ar elabazasemnecl inicedecardi
opati
eischemica, i
nabsentadureri
i
- citokineleinflamator
iiaurolinest
ompareasenzat i
eidedurere
- exi st
a3t ipuri:
pr i
mav ari
ant apacientulnuexprimadurere,i
ndiferentdegraduldeext ensi
eal
boli
i
a doua v arianta pacientiasi
mptomaticicu semne de boal a coronari
ana
evol
utiva
at rei
av ariantapacientiipotpr
ezent
adisconforttoraci
csauischemi e.

B.SI
NDROMULX(
APCUARTERECORONARENORMALE)
Semainumestesiangi
namicr
ov ascul
ara(f
luxulcor
onar
iannusepoat
eadapt
a
nev
oil
orcr
escut
edeO2alemi
ocardului
,i
nefor
t).
C.ANGI
NAVASOSPASTI
CA.ANGI
NAPRI
NZMETAL
Durer
epr ecordi
aladecauzai schemicaami ocar
dul
uiceapareinr epaussieste
asoci
ata uneisupradeni
velar
it r
anzi
tori
ia ECG,care poat
e ev
olua spreinf
arct
miocardi
c,tahi
ari
tmi
ivent
ricul
areseveresichi
armoar
tesubit
acar
diaca.
Pat
ogeni
e:arel a baza vasospasmulpr
in hi
per
react
ivi
tat
ea cel
ulel
ormuscul
are
net
edesidi
sfunct
iaendoteli
ala.
D.I
NSUFI
CIENTACARDI
ACAI
SCHEMI
CA
Senumestegeneri
ccardi
omiopati
eischemi
ca.I
nti
mppoat
egener
aanev
rism deVS
sii
nsuf
ici
ent
ami t
ral
aischemica.
E.I
NSUFI
CIENTAMI
TRALAI
SCHEMI
CA
- Poatedebut
acuedem pul
monaracutcar
diogensaui
nsuf
ici
ent
avent
ri
cul
ara
st
anga
F.ANEVRI
SM VENTRI
CULARSTANG
- Si
tuatf
recv
entl
ani
vel
ant
erol
ater
al,
langaapex

66
89.Tr
atament
ulmedi
cament
os
Medi
cat
iahi
pol
i
pemi
ant
a:
- Stat
ine (si
nvastat
ina):scad col
est
erol
ulser
ict
otal
,scad LDL;au ef
ect
e
ant
ii
nfl
amatoaresianti
tromboti
ce.
- Fi
brat
ii(
gemf
ibr
ozi
lsi
fenof
ibr
at)
:seadmi
nist
reazaconcomi
tentcust
ati
nel
e
- Rasi
nisi
aci
dni
cot
ini
c:i
ncombi
nat
iecust
ati
nel
e
Nit
ratiior
gani
cicuacti
unerapi
da( nit
rogl
i
cer
ina)seadmi
nist
reazai
nti
mpulcr
izei
anginoase.Auefect
evasodi
lat
atoare.
Nit
rat
iicuact
iunelungareducf
recv
ent
a,sev
eri
tat
easidur
atacr
izel
orangi
noase,
potcr
estetol
erant
alaefor
t.
Blocantel
e canalel
orde Ca2+ -pr
oduc v
asodi
l
atati
e;suntanti
angi
noase pr
in
scadereacontracti
eimi
ocardi
ce,af
recv
ent
eicar
diace,r
educer
eavasospasmul
ui
arter
ial
.
Betabl ocantel
e pr event
iaepi
soadel
ordeangi nasii schemiemiocar
dica,pri
n
reducereaconsumul uideO2,afr
ecvent
eicar
diace,cont
racti
li
tat
iimi
ocar
duluidarsi
apresiuniiar
teri
ale.
Inhibi
tori
ienzi
meideconversi
er educi
ncidentainf
arctul
uimiocar
dic,pr
esi
unea
arteri
ala,
previ
ndi
sfunct
iar
enal
a,r
educmorti
l
itateasir
isculdeAVC.

90.Tr
atament
ulder
evascul
ari
zar
e
By-passaortocor
onari
ani ndicat
ii
:st
enozapest
e50%at runchi
uluiart
ereicor
onare
stangi,stenoze semnifi
cati
ve ale cel
or 3 art
ere epi
cardi
ce maj ore,stenoza
semnificat
iva a cel
or2 ar tere cor
onar
e pri
ncipal
e,st
enoza sev era pe art
era
descendentaanteri
oara.
Angi
oplasti
ecor onari
anapercut
anat r
anscutanat
ar ecomandatadoarpacienti
l
or
si
mptomat ici
;cresteniv
elulcal
it
ati
iv i
eti
i
,reducei ncidentacri
zelorangi
noase,a
di
spneei,numaruluidezi
ledespit
ali
zaresicr
estecapacitateadeefort
.

I
nfar
ctul
miocar
dicacutcusupr
adeni
vel
aredeST
91.Cl
asi
fi
car
eIMA
67
1.Cl
asi
fi
car
eaf
izi
opat
ologi
ca

Dupav echimeanecrozei
, f
ii
ndconsi
der
atai
nev
olut
iesub6or
edel
adebut
Acutininterv
alul6orepanala7zil
e
Incur sdev i
ndecare728dezi le
Vi
ndecatpest e29zile
2.Cl
asif
icareaelectr
ocardi
ografi
ca

I
M ant
eri
or,
ext
ins

o Local
izati
nsegmentulIal
art
erei
descendent
eant
eri
oar
epr
oxi
mal
de
emergentapr
imeisept
ale

o Supr
adeni
vel
aredeSTi
nder
ivat
ii
leV1-
V6,
D1,
aVL

o Bl
occompl
etder
amur
ast
anga

I
M ant
eri
or

o Local
izati
nsegmentul
IIal
art
erei
descendent
eant
eri
oar
epr
oxi
mal
de
emergentapr
imeidi
agonal
e

o Supr
adeni
vel
aredeSTi
nder
ivat
ii
leV1-
V6,
D1,
aVL

I
M ant
erosept
alsauant
erol
ater
aldi
stal

o Local
izati
nsegmentulI
IsauI
IIal
art
erei
descendent
eant
eri
oar
e,di
stal
de
emergentapr
imeisept
ale

o STsupr
adeni
vel
ati
nV1-
V4sauD1,
aVL,
V5-
V6

I
Minf
eri
ormi
c

o Ocl
uzi
edi
stal
apear
ter
acor
onar
adr
eapt
asauci
rcumf
lexa

o Supr
adeni
vel
areSTi
nD2,
D3,
aVF

I
Minf
erol
ater
al

o Ocl
uzi
epr
oxi
mal
apear
ter
acor
onar
adr
eapt
asauci
rcumf
lexa

o Supr
adeni
vel
areSTi
nD2,
D3,
aVF,
V5-
V6

I
Minf
eri
orsi
dev
ent
ri
cul
drept

o Supr
adeni
vel
areSTi
nD2,
D3,
aVF,
V1-
V4

68
 I
Minf
ero-
post
eri
or

o Supr
adeni
vel
areSTi
nD2,
D3,
aVFcur
apor
tR>Si
nV1

o Ev
ent
ual
subdeni
vel
areSTV1-
V3

92.Def
ini
ti
esi
eti
opat
ogeni
eIMA
Defi
nit
ie:
supradeni
vel
areaelect
rocardi
ogr
afi
capersist
entapest
e20deminute,laun
paci
entcusimptomet i
picedeanginapect
oral
asicrester
easimetr
icaamarkeri
l
orde
necr
ozami ocar
dicapeste2.5or
i v
aloar
eanormal
a, cuapari
ti
aundeiQdenecrozacu
evol
uti
enormalaelect
rocardi
ografi
ca.

Et
iopat
ogeni
e

Ater
oscl
eroza95%-ocl
uziauneiart
erecoronar
ienedecal
i
brui
mpor
tant
necr
ozair
ev er
sibi
l
aat
eri
tor
iul
uideser
vitdeacelvas

5%:

1.Anomali
icongeni
tal
ecoronar
iene:
inser
ti
aanor
mal
aaar
ter
eicor
onar
est
angi
,
anev
rism al
art
erel
orcor
onare

2.I
nfl
amat
ii

3.Cauzeembol
ice:endocar
dit
ainf
ect
ioasa,
mixom car
diac,
prol
apsdev
alv
a
mit
ral
a,emboli
eparadoxal
a

4.Cauzehemat
ologi
ce:
pol
i
cit
emi
aver
a,coagul
arei
ntr
avascul
aradi
semi
nat
a

5.Bol
ial
earter
elorcor
onar
e:arter
itei
nfl
amatori
i(spondi
li
ta,LES),
traumatisme
al
eart
erel
orcoronar
e,amil
oidoza,i
ngust
arealumenuluicoronar
(disect
iede
aor
ta,
spasm).

93.Di
agnost
iccl
i
nicpozi
ti
vIMA
Semnecl i
ncesisimptomedei schemiemiocardica:dureret
oraci
capeste20minut
e,
retr
oster
nal
a v i
olent
a;di
spnee;amet el
i
;fati
gabi l
i
tate;si
ncopa;ral
uripul
monar
ede
staza;
galoppr
esistol
i
csauprot
osistol
i
cdeVS; bradicardi
esautahi
cardi
e

-
Presi
uneaar
ter
ial
a

Nor
mal
asaucr
escut
amoder
at

69
 Hi
pot
ensi
une

Soccar
diogen

-
Frecat
uraper
icar
dica

-
Subf
ebr
il
it
atel
a8or
edel
adebut
;dur
eaza4-
5zi
l
e

-
Frecv
ent
arespi
rat
ori
e

1.Nor
mal
aI
M necompl
i
cat

2.Cr
escut
a20-
25pef
ondul
anxi
etat
ii

3.Cr
escut
a>40EPACpost
inf
arct

-
Moar
tesubi
tacar
diacapr
inf
ibr
il
ati
event
ri
cul
ara

Di
agnost
icul
cli
nicpozi
ti
v

Semnecl
i
nicedei
schemi
emi
ocar
dica

Cr
est
ereaMar
ker
il
ordeNecr
ozaTr
oponi
naTsi
I,Mi
ogl
obi
na

Di
agnost
icul
elect
rocar
diogr
afi
c:

1.I
M supr
aacut

- UndeTsupr
aacut
edeampl
i
tudi
nemar
e,ascut
it
e

2.I
M acut

- Supradeni
vel
areaST>1mm cuconvexi
tat
easuper
ioar
aincel
put
in2der
ivat
ii
consecuti
ve,
poateper
sist
apanal
a14zi l
e

- Per
sist
ent
apest
e4sapt
amani
aSTanev
rism dev
ent
ri
cul
stang

- Qdenecr
ozaapar
erapi
dinpr
imel
eor
e,ar
eodur
ata>40ms

3.I
Mvechi

- Qdenecr
oza

70
 - STr
evi
nel
anor
mal
(except
andi
nanev
rismul
dev
ent
ri
cul
)

- Tnegat
iva,
nor
mal
asaui
zoel
ect
ri
ca

94.Di
agnost
icpar
acl
i
nicI
MA
1.Ecocar diografi
a
Decel eazat ulburaril
edeki neticaconsecut i
veischemiei saunecr ozei
Cal cif
icarisaudi sfunctiivalvular e
Nupoat ediferenti
aunI M noudeunul v
echi
Ut i
lainev aluareaf unctieidiast oli
ce,mar imeaatriul
uistang, presi
unea
telediastoli
caaVS, presiuneav enoasacapi lar
a
Excl udecauzel enon-cor onarienededur ereprodusedeper i
cardit
e,miocardit
e,
embol iepulmonar a
Ecogr af i
adecont r
astaf osti nlocui
tadeecogr afi
atisularaDoppl erpentr
u
vizualizareaef ici
entaamar giniiendocar dul
ui,ki
netici
isi aprecier
eagr adul
uide
per fuzieacor onarelorint erit
or iuldeinfarct

2.Ecocar diogr af
iat r
ansesof agi ana
- Poat edecel a: lezi
uni leat er oscler ot i
ce,anomal ii
dear terecor onare,
rezervadeflux
coronar i
an
3.Ecocar diogr af
iai ntravascul ar a
Eval uar eadi rectaapl acilorat eroscl erotice
Fluxul cor onar ianpr e-si post sist olicsi r
ezervadef l
ux
4.Ecocar diogr af
iaasoci at ast resul ui fizicsaut estul
uiladobut ami na
Det ecteazai schemi a, per i
necr oza, vi
abil
itat
eami ocardului hi
bernant,ci
catr
ici
l
e
post infarct
5.Testul deef ortel ectrocar diogr afic
I ndicatl apaci entiicur iscmi cdei nfarctmi ocardi
c
6.RMNev alueaza:
o St ar eami crocirculat i
ei cor onar iene
o Vi abi li
tateat erit
or iului pr ei
nf arct
o Fact ordepr ognost i
ci ndependentdemar i
meai nfarctului
7.Sci
ntigr afiacar diacadeper fuzi e
Ev alueazadef ectul deper f uziepost infarct

95.Di
agnost
icdi
fer
ent
ial
IMA
1.Angi
nai
nst
abi
l
a

71
 Dur er eadi ferapr indur ata, i
nt ensi tate
Crest er eamar ker il
ordenecr ozaI MA
Supr adeni velaredeST
2.Disect iadeaor ta
Lipsapul suluilani velulmembr elor
suf l
uder egur gitareaor tica
Dur er esf asietoar edecat ev aor e( disect i
edeaor ta)
Ir
adi azapost erior
Hipoi rigar e
3.Per icar dit aacut a
Supr adeni velareSTi nt oateder ivat i
i
le
Frecat ur aasoci atasi car acter ulpleur it
icsi postur al
aldurer
iiaj
utal
adiagnost
icul
difer ent ial
4.Embol iapul monar a
Dispnee
Dur er epl euriti
casaudet ipcost ocondr al
Hemopt i
zie
5.Pneumot orax
Dispneepar oxisticabr usci nst alata
Dur er epl euriti
ca
Abol i
r eamur mur ului vezicular
Hiper sonor it
atepear i
apul monar a
6.Ulcerduodenal perforat
Dur er eepi gast ri
casaut oracicai radi atapost eri
or
Hemat emeza
Mel ena
7.Col eci st i
taacut asi esof agitader eflux-poat ecr eaconfuzi
edacadurereanueste
l
ocal izat ai nepi gastrusauhi pocondr uldrept
8.Pancr eat i
taacut a
Dur er ei nt ensa, prelungi t
a, subst er nala,epigastrica
Hiper trigliceri
demi e
Crest er eaenzi mel orpancr eat ice
9.Hiper tensi uneaPul monar a
Dur er epl euretica
Dispneebr usci nstalata
Tahi car die
Tahi pnee
SemnedeI CDr eapta

72
10.
Tulbur
ari
ledepanica
Int
epaturasauapasarenespeci
fi
caret
rost
ernal
a
Dureazapeste30mi n
Nemodi f
icatdepozi
ti
e
Li
psescelementel
eparacli
nicedei
nfar
ct

96.Di
agnost
icdi
fer
ent
ial
int
reI
MAsi
per
icar
dit
aacut
a
Per
icardit
aacut aasoci
azasupr adeni
velar
eaconcor dant
aasegment ul
uiSTi ntoat
e
der
ivat
iil
e,subdeni
vel
areasirarsupradeniv
elar
eadesegmentPR.Fr ecat
uraasoci
atasi
car
acterulpl
euri
ti
csipostur
alaldureri
iajut
aladiagnosti
culdi
fer
ent
ial
.
Cli
nic peri
cardit
a acuta se r
emarca pri
n durer
et oraci
ca accentuata de miscaril
e
respir
ator
ii
,tuse,deglut
it
ie,sughi
t,cuinstal
areprogr esi
vapepar cursulcator
v aor e,
i
radierespeci
ficapemar gineasuperi
oar
aamuschi uluitr
apez,inmandi bul
asit orace
posteri
or.
I
MA:dur eret or
aci
cacedur eazamaimul
tde20demi nut
e,vi
olent
a,r
etr
ost
ernal
,cao
apasare,constr
ict
ie,cui
radier
espr
eumerisibr
ate.I
MAinfer
iordurer
eepigast
ri
ca,
arsur
i,i
ndigesti
e.

97.Compl
i
cat
ii
lear
it
miceal
eIMA
Compl
i
cat
ii
lear
it
micecupot
ent
ial
let
al

1.Fi
bri
l
ati
avent
ri
cul
ara

o Cr
est
emor t
ali
tat
eai
ntr
aspi
tal
i
ceascapr
opor
ti
onal
cugr
avi
tat
eaaf
ect
ari
i
mi
ocardi
ce

o -
blocant
eler
educi
ndi
cent
a

2.Opr
ir
eacar
diaca

o Apar
einpr
imel
eor
eal
eunui
inf
arctmi
ocar
dicpr
inFV

o Necesi
tamasur
ider
esusci
tar
esi
def
ibr
il
arer
api
da

3.Ri
tmur
il
eect
opi
cev
ent
ri
cul
are

o depol
ari
zar
epr
emat
urav
ent
ri
cul
ara

o Scur
teper
ioadedeext
rasi
stol
event
ri
cul
are

o nunecesi
tat
rat
ament
,darpotgener
aFV

73
4.Tahi
car
diav
ent
ri
cul
aranesust
inut
a

o <30sec

o Ri
tmi
diov
ent
ri
cul
araccel
erat

o Nunecesi
tat
rat
amentpr
ofi
l
act
ic

5.Tahi
car
diav
ent
ri
cul
arasust
inut
a

o Poat
egener
aFV

o Necesi
tacar
diov
ersi
e

oI
ncazr
efr
act
ar,
seadmi
nist
reazai
ntr
avenosAmi
odar
ona,
Lidocai
na,
Sot
alol

6.Bl
occompl
etAt
ri
o-v
ent
ri
cul
ar(
BAVI
II
)necesi
tacar
diost
imul
are

7.Tahi
car
diav
ent
ri
cul
arapol
i
mor
fat
orsadav
arf
uri
l
or

o Necesi
tat
rat
amentmedi
cament
oscu-
blocant
ele,
Sot
alol
,Ami
odar
ona,
Li
docai
na

Compl
i
cat
ii
lear
it
micenonl
etal
e

Ar
it
mii
l
esupr
avent
ri
cul
are

Fi
bri
l
ati
eAt
ri
ala

Ant
icoagul
ant
,ant
iar
it
mic,
ami
odar
ona

Cont
rol
ulf
recv
ent
eipr
incr
est
ereal
anev
oiea-
blocant
elor

Br
adi
car
diasi
nusal
a

Apar
edupaunI
MAi
nfer
ior
,ladebutsaut
rat
ament
ului
cuOpi
acee

Necesi
taAt
ropi
na

Car
diost
imul
aret
empor
ara

Bl
ocur
il
eAt
ri
o-vent
ri
cul
are

-I
MAi nf
eri
or:
evol
ueazat
ranzi
tor
iucuunr
it
m descapar
e,QRSi
ngust
,mor
tal
i
tat
e
r
edusa

-I
MAant
eri
or:
prognost
icnef
avor
abi
l

74
 - Bloccompl
etder
amur ast
anga,
nouapar
ut,
denot
anecr
ozami
ocar
dicai
nti
nsa,
sufer
int
adepompa,
riscdeapar
it
ieBAVI
II

98.Compl
i
cat
ii
lemecani
ceal
eIMA
1.Rupt
uraacut
adeper
etel
iberv
ent
ri
cul
ardet
ermi
na:

Col
apscar
diov
ascul
ar

Di
soci
ati
eel
ect
romecani
ca

Nur
aspundel
amanev
rel
eder
esusci
tar
e

Supr
avi
etui
reaest
eposi
bil
adoarl
apaci
ent
iicar
eaj
ungl
aoper
ati
e

2.Rupt
urasubacut
adeper
etel
iberv
ent
ri
cul
ar

Sef
ormeazaunt
rombocl
uzi
vsauader
ent
e i
nter
vent
iechi
rur
gical
a

Acut
izarea se manifesta pr
in dur
eri precor
dial
e, supradeni
vel
are de ST,
hi
potensiunesaucol
aps,det
eri
orar
ehemodinamicaiminent
a

Ecocar
diogr
afi
aconf
ir
mapr
ezent
atamponadei
car
diace

3.Rupt
urasept
uluii
nter
vent
ri
cul
ar

Det
eri
oar
ebr
uscahemodi
nami
ca

Suf
luhol
osi
stol
i
c

Cr
est
ereasat
urat
iei
deoxi
genav
ent
ri
cul
ului
drept

Per
fuzi
acuni
tr
ogl
i
cer
inar
ecomandat
ainl
i
psadesoccar
diogen

4.I
nsuf
ici
ent
ami
tr
alaacut
aischemi
ca

Aparein pri
mele7 ziledeladebutulIM pr
in di
l
atar
eai
nel
uluiv
alv
eimi
tr
ale
consecut
ivdi
sfunct
iei
vent
ri
cul
ului
stang

Di
sfunct
iamuschi
ului
papi
l
arpost
eri
orconsecut
ivunui
inf
arcti
nfer
ior

Suf
lusi
stol
i
csl
ab

Congest
iepul
monar
a

75
 Ecogr
afi
aar
atagr
adul
regur
git
ari
imi
tr
ale

Ruptur
ademuschipapi
l
arnecesi
tai
nter
vent
iechi
rur
gical
acuanul
opl
ast
iesau
prot
ezarev
alv
ular
a

99.Compl
i
cat
ii
lehemodi
nami
ceal
eIMA
-cauzat edet ahiar i
t mi i
,rupt urimecanicesaual ter
ar eami ocardi
capr i
mara
1.Insuficient a car diaca i nf unctie de congestia pulmonar a siprezenta galopul
ui
v
ent r
icul arst ang:
Gradul If ar ar aluri saugal op
Gradul IIcur aluri pulmonar esubj umatateaambi lorplamani saugalopprezent
Gradul IIIcuEdem Pul monarAcutCar diogen
Gradul IVcuSocCar diogen
Pacientii pr ezint a: t ahicar di
e, dispnee, tahipnee, fat i
gabil
it
ate, hi
potensiune cu
bradicardie, venodi latat i
esi presiunevenoasacent ralanormal a
2.Infarctul dev ent ricul dr ept
Asoci atcuI Mi nf eri
or
Crest epr esiuneav enoasacent r
ala
Reducer eapr esi unii ti
sularesausoc
Hipot ensi unesi br adi cardie
3.Socul car diogen
I ndexcar diacsub1, 8l /min/m2
Presi uneav enoasacapi l
ara>20mmH2O
Per fuziet isul aradr amat i
credusa
Oligur i
e
Hipoper fuzi ecer ebr ala
Edem pul monaracut
Hipot ensi unear teriala
Tahi car die
Vasoconst ri
ct ieper i
ferica

100.Compl
i
cat
iit
ardi
veal
eIMA
1.Ar
it
mii
l
event
ri
cul
aret
ardi
ve

Aparla72deor epost i
nfar
ct
t ahi
cardi
eventri
cularasifi
bri
l
at i
avent r
icular
ar iscdemoartesubi
ta
ischemi amiocardi
caact i
vasiinsufici
entacardiacacauzeetiol
ogi
cefr
ecv
ent
e
necesi
tandcorectarearapi
dasi revasculari
zareami ocar
dul
ui
pri
maopt i
uneterapeuticasocul electri
cextern

76
2.Pericarditaacut apost i
nf arct
Dur ereascut it
aasoci atacupost urasi respi ratia
Fr ecaturiper i
car dice
Apar einformel et ransmur aledenecr ozami ocardica
Tr atamentAspi rinai ndozemar i,AI NS
3.Trombozai ntrav ent ricul arasi embol ismul sist emi c
Aparasoci at ecui nfar ctmasi val per etelui ant er
ior
Necesi t
at r
at amentdeur gent acuant i
coagul anthepar i
nanefract
ionata
4.Trombozav enoasapr of undasi t
rombembol ismul pulmonar
Apar elapaci ent ii i
mobi lizaticumul tipliifact orider i
scasociati
obezi t
ate,
Insuf i
cientacar di aca, accidentv ascul arcer ebr al,IMA
Tr atamentant icoagul ant eor ale,hepar i
naf r
actionata
5.Angi napect oralapost i
nf arctsaur einfarct i
zar ea
Apar edupat rombof ibr i
nol i
zasauangi oplast iepr i
mara
Necesi t
acor onar ogr afiedeur gent acur ev ascul arizar
eami ocar
dica
6.Anev ri
smul Vent ricul ului Stang
Apar econsecut i
vnecr ozei miocar dului
Tul burarideki net icar egi onal aper et event ri
cularsubti
reconsecutivexpansi
uni
i
acest uia
Apar einocl uziaunei arterei mpor tant e
Fr actiadeej ect ieser educesemni fi
cat iv
Umpl ereav ent ricul arasi volumul telediast oliccr esc
Si mpt omat ologi edeI nsuf icientaCar diaca
101.Tr
atamentf
ibr
inol
i
tici
nIMA
-redeschidear teraocl uzionatasi pri
nrestaurareafl
uxuluicoronari
anreducemar
imea
i
nf ar
ctului,amel ioreazaf unctiaventri
culul
uistang,r
educemor tal
it
atea.
-seiniti
azai npr i
mel e12or e,cubenef i
ciumaxi minpr i
mele2or e
St reptokinaza
Ceamai iefti
na
Mul teef ect eadv erse:hemor agii
,hipot
ensiune,reacti
ial
ergice
Act ivatoruldepl asmi nogent isul
ar
Ret eplaza
Tenect eplazar educer atadeacci dentehemor agice
Contraindicatiiabsol ute
o Acci dentev ascul ar
ecer ebrale
o Hemor agi igast ro-i
ntesti
nale
o Disect i
edeaor t
a
o Or i
cei ntervent iechirurgi
calasaut raumatism recent

77
 o Neopl azii
Contraindicatiirelative
o Acci dentev ascul ar
ei schemicetranzi
tor
iir
ecent
e
o Tr atamentcr oni cant i
coagulant
o Ul cergast roduodenal act
iv
o Endocar ditai nfecti
oasa
o Manev reder esusci tareprel
ungit
a
oI nsuf i
cientahepat i
ca
Anti
coagul ant easoci atef i
brinoli
zei
Hepar i
na
Hepar i
naf ract i
onat a
Anti
agr egant eplachet are
-aspi
rina
-cl
opidogr el
-asociatecupr otect orgast ri
comepr azol

102.Tr
atamenti
npr
imel
e24or
eal
eIMA

Obi
ect
ive

Rest
aur
areaper
fuz
iei
miocar
dice

r
edeschi
der
eaar
ter
eiocl
uzi
onat
er
est
aur
areaf
luxul
uicor
onar
ian

Reducemar
imeai
nfar
ctul
ui

Amel
i
oreazaf
unct
iaVS

Reducesemni
fi
cat
ivmor
tal
i
tat
easi
mor
bidi
tat
ea

Masur
igener
alei
nfazaacut
a

Ment
iner
eaunei
li
nii
venoasesi
gur
e

Hi
drat
arecor
ect
a<2000ml

Rest
ri
cti
esal
i
na

Oxi
genot
erapi
e

Moni
tor
izar
eaf
unct
ii
lorv
ital
e

Li
mit
areaact
ivi
tat
iif
izi
ce

78
 o Repausabsol
ut12or
einl
i
psacompl
i
cat
ii
lor

o Rel
uar
eat
rept
ataami
scar
il
or

Sedar
easicombat
ereaanxi
etat
ii

Ment
iner
eaunui
cli
matr
elaxatambi
ent
al

Di
minuar
eael
i
ber
ari
icat
ecol
ami
nel
or

Ant
ial
gici
mpunedi
spar
it
iadur
eri
i

Der
ivat
imorfi
nici
-mial
gin2-
4mg;ni
tr
ogl
i
cer
inai
v10mg/
kg/
minutcument
iner
ea
TAsist
oli
cepeste100mmHg.

Aspir
inasiclopi
dogr
elseadmi
nist
reazai
mpr
eunacupr
otect
orgast
ri
c;auef
ect
e
ant
iagregant
e.

Betablocantel
e: intravenos, metopr
olol 5mg/
fiol
a pent
ru ment
iner
ea al
uri
i
ventr
icular
esi pr
esiunii
ar t
eri
ale.

I
ECAl
acei
cuI
Csaucuf
ract
iedeej
ect
iesub40%

103.Tr
atamenti
nvazi
vinI
MA.I
ndi
cat
iisi
cont
rai
ndi
cat
ii
1.Angi
opl
ast
ia

Presupune deschi
der
ea art
ereicor
onar
eramase i
nchi
sa dupa admi
nist
rar
ea
tr
atamentul
uitrombof
ibr
inol
i
tic

Ri
scdesanger
arescazut

Ser
ecomandal
apaci
ent
iicul
ezi
uni
mul
ti
vascul
are

Presupuneadmi ni
strar
eaunuiagentl
i
ticant
eri
orpr
ocedur
ii
:tr
ombof
ibr
inol
i
tic,
anti
agregantpl
achetar

Cont
raindi
cati
i
leabsolut
esuntr epr
ezentat
edeabsent
aunorst
enozecor
onar
iene
semnif
icat
ive,
lezi
unipetrunchi
ular
terei
coronar
est
angi.

2.By
-passulAor
to-
cor
onar
ian

I
ndi
cat
iil
i
mit
atei
nfazaacut
aaSTEMI
:

79
 o Dupaesecul
Angi
opl
ast
iei
Per
cut
ane

o Soccar
diogen

o Per
sist
ent
asi
mpt
omel
orpostangi
opl
ast
ie

o Rupt
urademi
ocar
d

o Regur
git
areMi
tr
alaI
schemi
caAcut
a

o Def
ect
ulsept
alv
ent
ri
cul
ar

104.Tr
atamentf
armacol
ogi
cinI
MAdupa24or
e
1.-
blocant
e

Met
opr
olol
,Car
vedi
l
ol,
Bisopr
alol
,Nebi
vol
ol

I
ndi
cat
ii

o Ment
iner
eaal
uri
ivent
ri
cul
aresi
TA

o Reducer
eaconsumul
uideO2

o Reducer
eai
ndexul
uicar
diac

o Ant
iar
it
mic

o Reducer
eaef
ect
elorcat
ecol
ami
nel
orci
rcul
ant
e

Cont
rai
ndi
cat
ii

o Ast
m,BPOC

o BAV

o hTA

o Br
adi
car
diesi
nusal
a

oI
nsuf
ici
ent
acar
diacasev
era

2.I
nhi
bit
ori
ienzi
mei
deconv
ersi
e

Enal
apr
il
,Per
indopr
il
,Rami
pri
l
,Zof
enopr
il

I
ndi
cat
ii

oI
nsuf
ici
ent
aCar
diacasauFr
act
iedeEj
ect
ie<40%

80
 oI
nfar
ctMi
ocar
dicAcut

o Nef
ropat
iigl
omer
ular
e

o HTA

Cont
rai
ndi
cat
ii

o React
iial
ergi
ce

o Sar
cina

o St
enozedear
ter
erenal
e

o St
enozaAor
ti
ca

o Boal
aCr
oni
cadeRi
nichi

3.Ant
agoni
sti
irecept
ori
l
ordeAngi
otensi
na

Losar
tan

I
ndi
cat
iincazul
int
oler
ant
eil
aIECA

4.Ant
agoni
sti
iCanal
elordeCa

Ver
apami
l

Di
l
tiazem

Recomandati
ncondi
ti
il
eli
psei
decont
rol
al:

o Angi
na

o Tahi
ari
tmi
i

o Fi
bri
l
ati
isauf
lut
terat
ri
al

o HTA

o CMH

5.Ni
tr
ati
ior
gani
ci

Ni
tr
ogl
i
cer
ina,
isosor
bidmono-si
dini
tr
at

81
 I
ndi
cat
ii

o Dur
eri
per
sist
ent
e>48h

oI
nsuf
ici
ent
avent
ri
cul
araper
sist
ent
a>48h

105.Pr
event
iesecundar
apostI
MA.Regi
migi
eno-
diet
eti
c
1.Renunt
areal
afumat

Reducer
iscul
rei
nfar
cti
zar
iicupest
e30%

Ef
ect
elet
utunul
ui:
prot
rombot
ic,
vasoconst
ri
ctor

2.Al
iment
ati
a

Var
iat
a

Ni
vel
cal
ori
creduscont
rol
ulI
MC(
<25)

Cr
ester
eacont
inut
ului
def
ruct
e,l
egume,
cer
eal
e,f
ibr
e,pest
e,ul
eidepest
e,car
ne
sl
aba

Apor
tli
pidi
cscazutsub30%cupr
edomi
nant
acel
ormono-si
pol
i
nesat
urat
e

3.Gr
adulact
ivi
tat
iif
izi
ce

Est
edi
minuatdi
ncauzadi
spneei
,fat
igabi
l
itat
iisi
dur
eri
l
orpr
ecor
dial
e

Act
ivi
tat
eaf
izi
cat
rebui
ecr
escut
ainl
i
mit
atol
erant
ei

Mi
nim 30demi
nut
ezi
l
nic,
5zi
l
epesapt
amanar
isccar
diov
ascul
arr
eduscu26%

Benefi
ciulef
ortul
uifi
zi
cser efl
ect
ai n:
crest
ereacir
uclat
ieicol
ateral
e,r
educer
ea
progr
esieiat
eroscl
erozeicoronar
iene,r
educereast
atusuluipr
otromboti
c,
ameli
orareafuncti
eiendotel
ial
e

4.Apor
tredusdeal
coolmaxi
m 20-
30g/
zi

5.Cont
rol
ulTensi
uni
iar
ter
ial
e

<130/
80mmHg

Ladi
abet
ici
:<125/
75mmHg,
<6.
5%Hbgl
i
cat
a,<140gl
i
cemi
a

82
 106.Pr
event
iesecundar
at
rat
amentf
armacol
ogi
c
Aspi rina:
-ar ei ndicat i
edecl asaI75- 162mg
-poat ef ii nlocuitacuant icoagul ant eor alelapaci entiicupr otezemet al
i
ce,trombi
i
nt racav i
tari saufract iedeej ect i
er edusa
Clopi dogr el:
-indozede75mgpet ermennel imi t
atl aceicustenturiintracor onar i
ene
-impr eunacuacenocumar ol est erecomandatl acei cuint ol
er antal aaspir
ina.
Ant icoagul anteleor ale:
-acenocumar olsauwar farinar educmor t
ali
tat
ea,ri
scul der einfar cti
zaresiAVC
-recomandat elapaci ent i
i cuFA, ri
sct romboembol ic,embol icerebr al
i.
Bet abl ocant ele:
-reducmor t
alit
ateasi r
atadei nfarctizare
-car v edilol,bisoprolol ,met opr olol
Ant agoni stelecanal ului decal ciu:
-v er apami lsidi lti
azem suntcont rai
ndicateinf azaacut adarr educmor tal
it
ateasi
reinfar ctizareaul terior.
IECA:
-scadmor talit
ateal apaci ent iipost infarctmiocardiccuf ract i
adeej ecti
esub40%,cu
semnedei nsuf i
cient acar diaca, ser ecomandal atot iat
er osclerot i
ciiposti
nfarct
.
Ant ialdost eronicepr ecum spi ronol actonasuntr ecomandat el apaci ent
iicudisfunct
ie
sistol i
cadeVS, fr
act iedeej ect iescazut a,I
C,DZ.
Cont rolul valori
lorlipidelorser i
ce:
-at orv astat i
na80mg, simv astat ina
-fibrat iiprecum f enof ibrat, gemf ibrozilcrescHDL, scadt rigl
iceridele,reducLDL

107.Tr
atamentant
it
rombot
icsi
ant
icoagul
anti
nIMA
Trombofi
bri
nol
izar
edeschideart
eraocluzionatasipri
nr est
aurareafl
uxului
cor
onari
an
reducemari
meainf
arctul
ui,amel
ioreazafuncti
av entr
iculul
uist
ang, r
educemort
ali
tat
ea.
St r
ept
oki
naza
Ceamai i
eft
ina
Multeef
ecteadv er
se:hemoragii,
hipotensi
une, r
eacti
ialer
gice

83
 Act ivat
oruldepl asmi nogentisul
ar
Tenect eplazar educer atadeaccidentehemor agice
Contraindi
catiiabsol ute:AVC, hemoragiigastr
o-i
ntesti
nal
e,neopl
azi
i.
Contraindi
catiirelative:t
ratamentcronicanticoagulant
,ul
cergast
roduodenal
act
iv,
endocar di
tainf
ect i
oasa
Anti
coagul anteasoci atefibri
noli
zei
Hepar i
na
Hepar i
naf ractionata
Anti
agr egantepl achet are
-aspi
r i
na
-cl
opidogr el
-asociatecupr ot ectorgast r
icomepr azol

Angi
na pect or
ala inst
abi
la. I
nfar
ct mi
ocar
dic f
ara
supr
adeni
vel
aredeST(
API/NSTEMI
)

108.
Eti
opat
ogeni
esi
ndr
om cor
onar
ianf
arasupr
adeni
vel
arede
ST
Defi
nit
ie:r
eprezintaunt er
mencompl excarecupr
indeangi
napect
oral
ainst
abi
l
asi
i
nfar
ctulmiocardicacutf
arasupr
adeni
vel
aredeST

Ambel
esuntpr
odusedeat
eroscl
eroza98%

ECG:

o Subdeni
vel
areST

o UndaTnegat
iva

o Cr
est
ereamar
ker
il
ordenecr
oza

Fi
zi
opat
ologi
a.Et
iopat
ogeni
a

- Ruper
easauer
odar
eauneipl
acide cut
rombocl
uzi
vsiuneor
icuv
ase

84
 colateralesaut rombocl uzi
vsubt otal peoplacaat eroscler ot
icapr eexi
stent
a.
- Altecause i mpl i
cat romboembol i
sm di stalmicrov ascul arcut rombf ormat
peopl acasauf or matdi ner oziuneapl acii
- Trombembol ism cor onar i
arndi ntr
-osur sanelegatadepl acadeat erom
- Angi naPr i
nzmet alobst ructiapr i
nspasm sauv asoconst rict
ieaunuiv as
coronar i
anepi cardicsauami crocirculati
ei
- Obst ructi
emecani capr ogresiv aasi mptomat i
cai nangi nai nstabilaclasi
ca
sausecundar adecauz aextr i
nsecacor onari
ana(febr a,tahicardi
e) ;
- Sindr omulcoronar ianacutf arasupr adenivel
aredesegmentSTsei nstal
eaza
pef ondulcrest eri
inev oiideoxi genacor dului f ebr a,ti
reotoxicozasau
tahicardie.
Fact
ori
iderisc: HTA,disli
pidemi e,DZ, sedent arismul,obezit
atea, fumat ul

109.Cl
asi
fi
car
eaangi
nei
pect
oral
einst
abi
l
e
Cl
asi
fi
car
eaBr
aunwal
dinf
unct
iedei
stor
icsiev
olut
iacl
ini
ca

I
.Angi
nacudebutr
ecentde1-
3luni
sauangi
naaccel
erat
a;f
araangi
nader
epaus

I
I.Angi
nade1l
una,
inr
epaus,
darnusub48deor
eAngi
nasubacut
a

I
II
.Angi
nai
nul
ti
mel
e48deor
e,i
nrepausAngi
naacut
a

Dupaci
rcumst
ant
eleCl
i
nicedeapar
it
ie

A.Cauzeext
racar
diaceAngi
naPect
oral
aInst
abi
l
aSecundar
a

B.I
nabsent
aunorcauzeext
racar
diaceAngi
naPect
oral
aInst
abi
l
aPr
imar
a

C.I
ndecur
sde2sapt
amani
dupaunI
nfar
ctMi
ocar
dic

I
nfunct
iedet
rat
ament
uladmi
nist
rat

1.Far
atr
atamentAnt
iangi
nossauCor
onar
otr
op

2.Subt
rat
amentst
andar
dpent
ruAngi
naPect
oral
aSt
abi
l
a

3.Subt
rat
amentant
iangi
nosmaxi
mal

85
 110.Diagnost
iculdi
fer
enti
alaldur
eri
itor
aci
cedi
nsi
ndr
omul
coronar
ianfar
asupradeni
vel
aredeST
Se poatef ace cu cauze gast ro-esof agiene,i nt
ratoraci
ce ( pneumoni e,pleurezi
e,
pneumot or ax),durereamuscul oschel etica,zonazost er,tromboembol ism pulmonar,
cauzeneur opsihi
atrice(hiperventi
latie, panica),mi ocardit
a, pericardit
aacut a,di
secti
e
de aor t
a.Exi sta bol icar di
ov ascul are ca st enoza aor ti
ca sau car di
omiopati
a
hipert
rofi
cacar epotev oluacusi mpt omet ipiceangi noasef arapr ezent auneiboli
ateroscl
erot i
cecor onari
ene.Cel emaii mpor tant ecauzesecundar edecar di
opati
e
i
schemi capef ondulcr esteri
inecesar uluideoxi gensuntr epr ezentatedeanemi i
severe,hiper ti
roi
dism, sangerarigast rointesti
nal e,acut i
zarea uneibol iobstr
uctiv
e
pulmonar e,v alor
icr escutealpr esiuni iar t
eriale,fist
ulaar teri
ov enoasal apacienti
i
dial
izati
cr onic.

111.Di
agnost
iccl
i
nicsi
ndr
om cor
onar
ian
1.Di
agnost
icul
pozi
ti
v

Dur
ereacucar
act
erecor
onar
iene

Modi
fi
car
iEKG

Cr
est
ereaMar
ker
il
ordeNecr
oza

Pest
e1.
5xAngi
naI
nst
abi
l
a

Pest
e2.
5xI
nfar
ctMi
ocar
dicf
arasupr
adeni
vel
aredesegmentST

Af
ect
areaEcocar
diogr
afi
caaki
net
ici
imi
ocar
dul
ui

2.Si
mpt
omat
ologi
a

Dureretor
acicacedepasest
e20min,iradi
azai
nbr
ate,mandi
bul
a,epi
gast
ri
csi
cedeazaputi
nsaudel
oclanitr
ogl
i
cer
ina

Di
spnee

Fat
igabi
l
itat
e

For
mesi
l
ent
ioase:
diabet
ici
,var
stni
ci
,femei

3.Semnel
edegr
avi
tat
eal
eangi
nei
pect
oral
inst
abi
l
ecur
iscmar
easoci
aza:

Cr
izedur
eroasepr
elungi
te>20mi
n

86
 EPACdecauzai
schemi
ca

Angi
nai
nrepauscuSubdeni
vel
areST>1mm

Regur
git
areMi
tr
alanouapar
utasauagr
avat
a

Gal
opPr
otodi
ast
oli
cdeVent
ri
cul
Stang

Hi
pot
ensi
unear
ter
ial
a

4.Ri
sci
nter
medi
ar

Cr
izedur
eroasepr
elungi
te>20mi
n

Raspunsf
avor
abi
ll
aNi
tr
ogl
i
cer
ina

Angi
nacudebutr
ecentsub2sapt
amani

UndeQpat
ologi
cesauSubdeni
vel
areST>1mm

5.Ri
scmi
c

Debutal
dur
eri
ipest
e2sapt
amani

Angi
nacupr
agr
idi
catdeef
ort

EKGnor
mal

112.Di
agnost
icECGal
sindr
omul
uicor
onar
ian
1.ST

Subdeni
vel
are>1,
5mm i
ncel
put
in2der
ivat
ii

Supr
adeni
vel
are0.
5-1mm r
ari
nti
mpul
unui
epi
sodedur
erosi
nrepaus

Persi
stentaSupradeni
velar
iiSTincelputi
ndouaderi
vat
iianuntaIM,intimpce
subdenivel
areaesteti
picapent
ruangi
nainstabi
l
asauI
Mfrasupradeni
vel
are.

Al
ungi
re

2.T

I
schemi
c

87
 Undenegat
ivesi
simet
ri
ce

3.Q

Pat
ologi
c

Tr
anzi
tor
iu

4.QRS

Al
ungi
re>100ms

Aspectbif
azicQRsauRSsiev entuali
nci
zur
ial
epor
ti
uni
idescendent
eQRSi
n
der
ivat
iist
andar
daparasoci
atei
nIM

Bl
ocFasci
cul
arAnt
erosuper
ior

Bl
ocAt
ri
o-v
ent
ri
cul
ar

Bl
ocCompl
etdeRamur
aSt
angasauDr
eapt
anecr
oza

Bl
ocAt
ri
ovent
ri
cul
ar

5.U

I
schemi
cnegat
iv

V4,
V6

Lezi
uneaar
ter
eicor
onar
edescendent
eant
eri
oar
a

l
aunpacientcuI
Minat
ac-semni
fi
caaf
ect
aresi
stol
i
caaVSsir
educer
eaf
ract
iei
deej
ect
ie.

113.Rol
ulmar
ker
il
ordenecr
ozami
ocar
dica
1.Tr
oponi
naTsi
I

Ext
rem desensi
bil
asi
speci
fi
canecr
ozei
miocar
dice

El
i
ber
arepr
ecocepozi
ti
var
edupa2-
4hest
eat
ri
bui
tael
ement
elorci
tosol
i
ce

El
i
ber
aret
ardi
vapozi
ti
var
edupa8-
12hest
eat
ri
bui
tael
ement
elorst
ruct
ural
e

Mar
imeai
nfar
ctul
uiest
edi
rectpr
opor
ti
onal
acuni
vel
ult
roponi
nel
or

88
 Al
tecauzedecrest
ere:neopl
azii
,curecit
ost
ati
ce,t
ahi
ari
tmiisev
ere,per
icar
dit
e,
i
nsuf
ici
ent
arespi
rat
ori
e,hepat
ica,
renal
a,emboli
epul
monara

2.Mi
ogl
obi
na

Speci
fi
cit
atesl
aba

Pozi
ti
var
e pr
imel
e 2-
4 h de l
a debut
ulsi
mpt
omel
or,de pr
efer
atasoci
ata
tr
oponi
nei

Per
sist
a24h

3.Cr
eat
in-
kinaza-
MB

Pr
imul
mar
kerdenecr
ozaut
il
izat

Cr
est
einaf
ect
iuni
miocar
dicesi
alemuschul
atur
iischel
eti
ce

I
eft
inasi
usordeef
ect
uat

Pozi
ti
var
epr
imel
e6-
12hdel
adebut
ulsi
mpt
omel
or

Negat
ivar
ebr
uscadupa36h

4.I
nter
leuki
na6

I
nfl
ameazapl
aci
l
edeat
erom

Cr
est
est
atusul
prot
rombot
ic

Accel
ereazacascadai
nfl
amat
ori
einI
MA

5.Neopt
eri
na

Indi
cat
oralcr
est
eri
iact
ivi
tat
iicel
ulel
ori
muni
tar
econsecut
ivl
ezi
uni
l
orpl
aci
l
orde
ater
om

Poat
eant
ici
pacu100dezi
l
eunNSTEMI

6.Al
bumi
na

I
ndusadei
schemi
e

Pr
ecedemi
ogl
obi
na

89
 114.Ev
olut
ie,
compl
i
cat
iial
esi
ndr
omul
uicor
onar
ian
Monit
ori
zar
eaHol
terpoat
edet
ect
acazur
idei
schemi
e-l
ezi
uninedet
ect
atedeEKG
uzual

Ev
olut
ianat
ural
aaAngi
neiPect
oral
eInst
abi
leest
ecat
re

STEMI

NSTEMI

Moar
tesubi
tacar
diaca

RarI
nsuf
ici
ent
aCar
diacaI
schemi
ca

Ri
scmar
e:

Var
stni
ci
i

Di
abet
ici
icucel
put
inunI
M sauAVCi
nant
ecedent
e

Val
oribi
ochimicecr
escut
ealeenzi
mel
ormi
ocar
dice,al
atur
idev
alor
icr
escut
e
l
acreati
ninasauHBgli
cat
a.

Devi
ati
ipersi
stent
e peEKG,BRS complet
,semnedei
nsuf
ici
ent
a car
diac,
hi
potensi
une,
arit
miiv
ent
ri
cul
aresev
ere.

115.Tr
atamentcuant
iagr
egant
epl
achet
are
1.Aspi
ri
na

o Totipaci
ent
iicuSTEMIsauNSTEMIpetermennel
i
mit
at75-
160mg/
zi(
doza
minima),
lapaci
enti
il
acarenus-
amontatst
ent
.

o Paci
ent
iicuSt
entMet
ali
cmi
nim 1l
una160-
325 t
ermennel
i
mit
atdoza
mini
ma

o Paci
ent
iicuSt
entAcoper
it3-
6luni
160-
325 t
ermennel
i
mit
atdozami
nima

2.Ti
enopi
ri
dine

o Clopidogrelsedaasoci
atcuAspir
inapeter
menneli
mit
at.75mg/zi
,1an.La
pacienti
ilacaresedecideint
erv
ent i
einv
azi
va asoci
ereadeclopidogr
ell
a

90
 aspi
ri
naesteobli
gat
ori
e inai
nteaint
erv
entieisisement
inenel
i
mit
atdupa
i
nter
vent
iei
nspeci
all
aceil
acares-amontatstent
.

o Ticl
opidi
na pentr
uceicui ntoler
antalaAspiri
na250mgx2/zi
,ptprevent
ia
secundaraaIM siaav c,putandav eaefecteadv
ersepr
ecum neut
ropeni
a,
purpur
atromboci
topeni
ca,tul
burari
digest
ive.

o Di
pir
idamol
cont
rai
ndi
cat
.

116.Tr
atamentcuant
it
rombot
icesi
ant
icoagul
ant
e
1.
Ant
it
rombot
ice

-t
ir
ofi
ban,
abci
xi
mab

-r
ecomandat
elapaci
enti
icuri
sctrombot
icmar
esaul
asi
mpt
omat
ici
il
acar
e
anti
agr
egant
elen-
audatrezul
tat

-cel
emai
buner
ezul
tat
eauf
ostobt
inut
einasoci
erecut
rombof
ibr
inol
i
tice.

-ant
it
rombi
nel
edi
rect
escadi
nci
dent
aangi
nei
post
inf
arct
,darcr
escr
iscul
desanger
are

2.
Ant
icoagul
ant
e

r
ecomandat
eint
oat
esi
ndr
oamel
ecor
onar
iene

seasoci
azacut
rat
ament
ulant
ipl
achet
arsi
ant
it
rombot
ic

i
ndicati
i-scadecu58%ri
sculdemoar
teasubit
a,rei
nfarct
izare,ameli
oreaza
anginapector
alar
efr
act
ara,
scader
ataspi
tal
izari
ipentr
ucar diopat
ie
i
schemi ca

cont
rai
ndi
cat
iicr
esccompl
i
cat
ii
lehemor
agi
ce

hepar
inel
ecumol
ecul
afr
act
ionat
asuntmai
efi
cient
ecacel
enef
ract
ionat
e

ant i
coagul
ant
eoral
eacenocumarol
,warf
ari
na,
recomandatei
nfracti
ede
ejecti
esub40%,anevr
ism v
ent
ri
cul
ar,
cardi
omegali
e,f
ibr
il
ati
esif
lutt
eratr
ial
,
tulburar
ideri
tm.

91
 117.Tr
atamentcuni
tr
ati
inAPI
/NSTEMI
Ni
tr
ati
organi
ci-medi
cat
ieant
ii
schemi
caangi
noasa

Nit
rogl
i
cerinar epr
ezentant
uldebaza,r
ecomandatl
apaci
ent
iisi
mpt
omat
ici
,cu
dur
ereprecordi
aladerepaussaul
aefort

Efectv enodil
atat
or r educe presarcina vent
ri
cul
ara reduce consumulde
oxigen mi ocardi
c si sarci
na per et
ilor in ti
mpul sist
olei amel i
oreaza
contracti
l
itat
ea i ndozemar iser educepost sar
cina cr est
er andament ul
miocardicsicapacit
ateadeeff
ort

Cor
onarodi
lat
ati
aesteprezent
aatatl
anivel
ulart
erel
orepi
car
dicenor
mal
e,catsi
l
aceleater
oscl
erot
icesaulacel
edecal
ibr
umi c

Ef
ectv
asodi
l
atat
oref
ectant
ii
schemi
c

Reducedur
ereapr
ecor
dial
ader
epaussauef
ort

Sepoat
eadmi
nist
rai
ntr
avenossausubl
i
ngual

Dispari
ti
asimptomelordeischemi
eref
ractar
apermit
eut
il
izareapr
eparat
elororal
e
precum isosor
biddini
tr
atdozede40mg- 80mg/zi
,mononit
rat20mg-240mg/ zii
n
functi
edet i
pulpr
eparat
ului
.

118.Tr
atamenthi
pol
i
pemi
anti
nAPI
/NSTEMI
-Reducer eav aloril
orseri
ceal eLDLi nitialsub100apoi sub70mg/ dl
-Statinelemedi catiadeel ect i
e
-Dietahi pocal ori
ca, hi
polipidica
Cont i
nutdegr asi mi saturat
edemax im 7%dintot
alulcal
ori
il
or
Col esterolulali
ment ar<200mg/ zi
Cr estereaapor tului ali
mentardef i
brela10-
25gr /
zi
Cr estereast er
olilorla2gr /zi
Cr estereef ort
ului fi
zic
Descur ajareasedent ar
ismul ui
I MC<25
Tratament ul hiper tr
igli
ceri
demi eicufibrati, VitaminaPP( Ni
acin)
Tratament ul i
gi eno-dieteti
cpr esupunesi r enunt ar
ealafumat:reduceri
scul
reinfarcti
zar i
i cupest e30%; met odeleutilizat epelangapsihoterapi
esuntpl
ast
uri
ide
nicotina
Aliment ati
a:

92
 Var iata
Ni vel calor icreduscont rolulIMC( <25)
Cr ester eacont inut ului def ructe,legume, cereale,fi
bre,pest e,uleidepeste,
carnesl aba
Apor tlipidi cscazutsub30%cupr edomi nantacel ormono-si poli
nesatur
ate
Gradulactiv
itati
i fi
zice
Est edi mi nuatdi ncauzadi spneei, fati
gabili
tatii
si dureri
l
orpr ecordial
e
Act ivitateaf i
zicat rebui ecr escut ai nli
mi tatolerantei
Mi nim 30demi nut ez ilnic,5zi l
epesapt amanar i
sccar diov ascularr
edus
cu26%
Benefi
ciulefortului fizicser ef l
ect ai n
Cr est er eacirucl ati
ei col ateral
e
Reducer eapr ogr esiei ateroscler ozeicoronar i
ene
Reducer eastat usul ui protrombot i
c
Amel i
or areaf unct iei endot eli
ale
Aportredusdeal cool maxi m 20- 30g/ zi
Controlulgreut atii:memnt i
ner eaunui IMCi nt r
e18, 5si 24,9kg/ m2pr ini ncuraj
area
efor
tuluifizi
c, ar egi mului igieno- dietet i
csi modi fi
car east i
lul
uidev iata.

119.Tr
atamentcubet
abl
ocant
einAPI
/NSTEMI
Repr
ezent
ant
i:Met
opr
olol
,Car
vedi
l
ol,
Bisopr
alol
,Nebi
vol
ol

Ef
ect
e

o Reducer
eaf
recv
ent
eicar
diace

o Reducer
eaconsumul
uideoxi
gen

o Scader
ear
aspunsul
uicont
ract
ilmi
ocar
dic

Sunti
ndi
catelatot
ipaci
enti
icuSindr
om Coronar
ianAcutf
araSubdeni
vel
aredeST,
din
momentuldi
agnosti
cul
ui,
petermenindef
ini
t.

Cont
rai
ndi
catl
apaci
ent
iicu

o BAVI,I
I,
III
,astm br
onsi
c,i
nsuf
ici
entacardi
acsauv
ent
ri
cul
arast
angasev
era,
la
paci
ent
iicusimptomedesoccardiogen

oI
ntol
erant
alapr
odus

o React
iiadv
ersei
mpor
tant
e

93
 o Fr
act
iedeej
ect
ieaVSr
edusadozel
etr
ebui
ecr
escut
etr
ept
at

120.Tr
atamentcucal
ci
ubl
ocant
einAPI
/NSTEMI
I
ndi
cat
ii
:

Candbet
a-bl
ocantelesuntcont
rai
ndicat
esaunur
eusescsar
educasi
mpt
omel
e
saupr
ovoacaefecteadver
senetol
erate

Reducecont
ract
iacel
ulel
ormuscul
arenet
edemi
ocar
dicesi
vascul
are

- Scade: postsar
cina,f r
ecvent
a cardiaca,contr
act
ia miocar
dul
ui,rel
axeaza
ventr
iculi
i
-Indicatel aceicuf enomeneischemicer ecur
ent
e,subtrat
amentcunitrat
isi
betablocant
eadrenergi
cecarenutoler
eazadozeleadecv
atesaucareauangina
derepaus.

- LaHTAcusi
ndr
om cor
onar
ianl
acar
enucedeazadur
eri
l
epr
ecor
dial
e
Di
l
tiazemul
aiv
erapami
l
ul

Nuser ecomandalapacient
iif
enomenedei
nsuf
ici
ent
avent
ri
cul
arast
angasau
edem pulmonarcar
diogen

Recomandat
edoari
nangi
nar
ecur
ent
alapaci
ent
iicusi
ndr
om cor
onar
ianacut

Combinat
iacubet
abl
ocant
elepoat
einhi
basupli
mentaracti
vit
ateanodul
uisi
nusal
sipot
depr
imafunct
iadeej
ect
ieaVSnecesitacont
rol
ulstr
ictaldozel
or

121.Angi
nav
ari
ata(
Pri
nzmet
al)
For
madeangi nai
nst
abil
acareaparespont
ansisemanif
est
apr i
ndurer
ipr
ecor
dial
e
conseci
ntaunui
spasm cor
onar
ianpecelput
inunt
eri
tor
iuvascul
ar

Supr
adeni
vel
aret
ranzi
tor
iepeEKGcar
eser
emi
tespont
ansaudupani
tr
ogl
i
cer
ina

Ar
ter
elepotf
inor
mal
esaui
mpr
egnat
eat
eroscl
erot
ic

Pat
ogeni
a:

Ar
elabazadi
sfunct
iaendot
eli
alacar
eexpunemedi
avascul
araef
ect
uluiunor

94
 substant
ev asoconst
ri
ctoar
edet
ipulendot
eli
nel
or,t
romboxanul
ui,ser
otoni
nei
,
catecol
aminel
or

Cri
zel
edur er
oaseapardeobiceidi
mineata,l
apacienti
ifumator
i,f
araal
tifact
oride
ri
sccoronari
an,f
ii
ndpreci
pit
atedeemot i
i
, hi
per
ventil
ati
e,ef
ortfi
zi
csauf r
ig

Compl
i
cat
ii
le

Moar
tesubi
tacar
diaca

I
M

Si
ncopa

Bl
ocur
iat
ri
ovent
ri
cul
aredegr
adi
nal
t

Tahi
car
dii
vent
ri
cul
are

Di
agnost
icul

Supr
adeni
vel
areat
ranzi
tor
ieEKGi
nti
mpul
cri
zei
angi
noasei
nrepaus

Nusepoat
erepr
oducel
atest
eledepr
ovocar
eadur
eri
i

Poat
efi
compl
etatdemoni
tor
izar
eaHol
ter
,test
uldeef
ortECG.

Ecocar
diogr
afi
a bi
dimensi
onal
a cu subst
ant
a de cont
rast r
elev
aischemi
a
tr
ansmurala

Tr
atament
ul

Ni
tr
ati
cudur
atal
ungadeact
iune

Ant
agoni
steal
ecanal
elordecal
ciuv
erapami
l
,di
l
tiazem si
nif
edi
pina

For
meler ebel
e combi
nat
iii
ntr
ecel
e2 l
acar
esepotasoci
aal
fa-
blocant
e
adr
ener
gice

Pr
ognost
icul

Excel
entl
acei
cucor
onar
elei
ntact
e

I
nci
dent
adeI
Mla7ani
est
e5-
7%

95
 122. Trat
ament
ul de r
evascul
ari
zat
ie mi
ocar
dica i
n
API/
NSTEMI
1.I
ndi
cat
iider
evascul
ari
zar
emi
ocar
dicaper
cut
anadecl
asaI

Paci
ent
iicul
ezi
uni
cor
onar
ienecor
ect
abi
l
efar
acomor
bidi
tat
iasoci
ate

Far
alezi
uni
monosaubi
vascul
arecusauf
arai
mpl
i
car
eaar
ter
eidescendent
e
ant
eri
oar
e

Ri
scmar
eexpr
imatl
atest
elenon-
inv
azi
ve

Paci
ent
iif
aradi
abetzahar
atcuboal
acor
onar
ianamul
ti
vascul
arasi
fract
iede
ej
ect
ieaVSnormala

2.I
ndi
cat
iider
evascul
ari
zar
emi
ocar
dicaper
cut
anadecl
asaI
I

Lezi
uni
multi
plecor
onari
enetr
atat
imedi
cament
osant
eri
orsi
car
epr
ezi
ntar
isc
maredeint
erv
enti
echir
urgi
cal
a

Cudi
sfunct
iesi
stol
i
cami
ocar
dicamoder
ata

Lezi
uni
monosaubi
cor
onar
iene

3.I
ndi
cat
iider
evascul
ari
zar
emi
ocar
dicaper
cut
anadecl
asaI
Ib

Paci
ent
iicuangi
nai
nst
abi
l
a

UNSTEMIcar
enuauf
act
ori
der
iscsemni
fi
cat
iv

Bol
i
leaor
tei
123.Di
agnost
ici
ndi
sect
iadeaor
ta
Tabl
oucl
i
nic:
-durer
esev er
a,cudebutbruscsii ntensi
tatemaxima,local
izat
atoraci
canter
ior,cu
i
r adi
ereingat,mandibul
a,fatasaul ocali
zat
ai nt
erscapul
overt
ebralcui
radier
ei n
abdomen, l
anivel
ulmembrelorinferi
oare
-durer
etoraci
cacucaract
erpleuretic
-i
nsufici
entaaor
ti
caacutasiinsufi
cientacardi
aca:edem pul
monar ,
soccar
diogen

96
 -sincopa, stopcar diac, moar tesubita, survindatorit
at amponadeicar diacesaudaca
seexi ti
ndedi sectial aarterelecor onare, cuischemi emi ocardicaasociata.
-tamponadacar diacasemani festapr inhi potensiune,j ugular
et ur
gescente,puls
par adoxal siasurzireazgomot el
orcar diace
-AVC simani festar ide i schemi e al e di v
erselor or gane,ce sur vi
n datorit
a
compr omi t
eriii
ri
gat iei
-foarterarsei ntalnest ecompr esiaorganel ordinmedi astindecat reaortadil
atat
a
-rupturaaor teicupr oducereat amponadeicar diace( dacasepr oducei ncav i
tat
ea
per i
cardica)sausochemor agi c
Par acli
nic:
Markerideinfl
amat i
ecrescuti
ECG: i
schemi e
Radiografi
ecor d-
pulmon:medi ast
inlargit
,largir
eaaortei
,pr
ezentadelichi
din
pl
eura,regurgi
tareaort
ica,evi
denti
ereastariivasel
orcor
onareetc
Ecocardiogr
afiat r
ansesofagiana evidentier
ea fal
duluii
n2i nci
dente,cu
miscareindependentadeper etesial
testructuri
.

124.Anev
rism aor
ti
c
Tabl
oucl
i
nic
asimpt
omat i
c
semanifest
apri
ndurer
esaucompli
cat
ii
: embl
oli
, compr
esi
e asupr
a
st
ruct
uri
lordi
njursaur
upt
uraint
r-
ocavi
tat
e
1.Inanev ri
smel eaorteitoracice:dureretoracica,insuf
ici
etaaor t
icasii nsuf
ici
enta
cardi
cadi l
atareadeinelvalvular, poatecompr imav enacav asuper i
oara(edem
i
npelerina,
turgescentavenoasai njumatateasuper i
oaraacor pul
ui)
,traheea( wheezi
ng,
tuse,
dispnee,atel
ectazi
e),nervullar
ingeurecurent(di
sfoni
e),esofag(disfagie)
Rupt
urasepoat
epr
oduce
- Pl
eurahemotorax
- Peri
cardtamponadacardiaca
- Traheehemopti
ziimasiv
e
- ADsauVDsuntdr eapta-
stanga,
suf
lucont
inuu,
insuf
ici
ent
acar
diaca

2.I
nanev
rismel
eAor
tei
abdomi
nal
e
-Dur
ereapoatefil
ocal
i
zatainhipogast
rusaur
egiunealombara,cui
radi
erei
nghi
nal
a,
sprefesesauinmembrel
einfer
ioar
e;est
ededurat
alunga,chi
nuit
oar
esiconst
ant
aca
i
ntensit
ate

97
-
Sepoat
epal
paf
ormat
iuneaabdomi
nal
apul
sat
il
a
-
Suf
lur
ilani
vel
ulr
egi
uni
ipar
aombi
l
ical
edat
edest
enozeal
evasel
ordi
njur
-
Incazder
upt
uraev
olut
iaest
egr
avaspr
esochemor
agi
csi
deces
Par
acl
ini
c
Radi
ogr
afi
ecor
d-pul
mon:
-
Largir
eamedi ast
inul
uii
n2/3super
ioar,abutonul
uiaor
ti
c
-
Deplasareatr
aheei
Ecocardi
ograf
iatr
anstor
aci
casautransesofagi
ana
- Anevrismul
- I
nsuficient
aaor t
icaasociat
a
- Prezentadet r
ombi nanev r
ism
Tomografi
acuemi si
edepozi t
roni
o Metodacost i
sit
oare
o Aratacrestereaacti
vit
ati
imetabol
icel
anivel
ul anev
rismul
ui
o Estepredictoareaexpansiuni
isir
uper
iianev
rismale
Mar
ker
iseri
cinespeci f
ici
deinfl
amatie
o Cr
estereaf
ibr
inogenul
ui,
cerul
opl
asmi
nei
etc.
o ev
alueazar
isculderupt
ura

125.Def
ini
ti
esi
clasi
fi
car
edi
sect
iedeaor
ta
Defi
niti
e:ruptur
aai nt
imeiaor t
ice,inurmacar ei
aest eexpusamedi acaredat
orita
fl
uxuluisanguincupr esiunemar eestedisecatalongitudi
nalant
erogradsaumair ar
ret
rograd.Inint
eri
orulmedi eisecr eazaunspat i
ufals,pl
incusange,numitl
umenfals.
Fal
duli nt
imalestepor t
iuneai nt
er naapereteluiaorti
c,deopar t
esideal t
aacar eia
exi
sta2col oanedesangecupr esiunidif
eri
te.
Cl
asi
fi
car
e:
1.DeBakey
TipIor i
gineinaort
aascendent
a,sepr
opagal
aar
culaor
ti
csiadeseadi
stal
,
cupr
inzandint
reagaaor
ta
Ti
pIIl
i
mit
atal
aaor
taascendent
a
Ti
pII
Ior
igi
nei
naor
tadescendent
a,seext
indedi
stal
2.St
anf
ord
Ti
pAdi
sect
iicar
ecupr
indaor
taascendent
a

98
 Ti
pBnucupr
indaor
taascendent
a
3.Soci
etat
eaeur
opeanadecar
diol
ogi
e(cl
asi
fi
car
einf
unct
iedesubst
rat
)
Cl
asa1di
sect
iedeaor
tacl
asi
ca,
cuf
aldi
nti
mal
int
rel
umenul
adev
aratsi
fal
s
Cl
asa2r
upt
uramedi
eicuf
ormar
edehemat
om
Cl
asa3di
sect
iedi
scr
eta,
far
ahemat
om
Cl
asa4r upt
urapl
aci
icar
educel
aul
cer
ati
eaor
ti
capenet
rant
asihemat
om
ci
rcumscr
is
Cl
asa5di
sect
iei
atr
ogenasi
traumat
ica.

Bol
i
lear
ter
elorper
if
eri
ce
126.Def
ini
ti
esi
pat
ogeni
elaar
ter
iopat
iaobl
i
ter
ant
a
-reprezi
ntamanif
estar
eaaproapeexcl
usi
vaaateroscl
erozeicearecar
ezult
atscader
ea
progresi
vaaf l
uxul
uisangui
ncuapar i
ti
aclaudi
cati
eilanivelulmembr
elorinspeci
ala
celorinf
eri
oar
e
Pat
ogeni
a
1.
Teor
iadi
sfunct
iei
endot
eli
ale
Cr
est
ereaper
meabi
l
itat
iimembr
anei
pent
rul
i
popr
otei
nesi
alt
emol
ecul
eat
erogene
Alt
erar
eahemostazei
,gener
areadet
rombi
naanor
mal
a f
act
oresent
ialalbol
i
i
ocl
uziv
ear
ter
ial
e
Cr
est
ereaadezi
vi
tat
iipl
achet
aresi
leucoci
tar
e
Al
ter
arear
egl
ari
itonusul
uiv
ascul
arsi
procesul
uidecr
est
erecel
ular
a
Fact
ori
icar
eal
ter
eazahomeost
azi
aendot
eli
ului
reducdi
sponi
bil
uldeoxi
dni
tr
ic:
- Fact
oriclasicideri
sccecr escstresuloxi
dat
ivfumat
ul,HTA,di
abet
ulzahar
at,
obezi
tatea,di
sli
pidemi i
l
e,sedentari
smul
- Efor
tulf
izicexcesiv
- I
nfecti
i
lesi alt
estaricar
acteri
zat
epr i
ninf
lamati
e
2.Teor
iainfl
amat or
ie al
atur
ide cr
est
erea st
resul
uioxi
dat
iv est
eimpl
i
cat
ain
mecani
smulpatogeni
c
Cr
est
ereanumarul
uidel
eucocit
espor
est
eri
sculdeev
eni
ment
ecar
diov
ascul
are
pr
inf
ormareademicr
oemboli

99
 Radi
caliili
berieli
berat
idel eucoci
tecrescri
gidi
tat
easiagregabi
l
itat
ealorsia
hemat i
i
lor
Neutrofi
lel
esi r
adical
ii
li
beri
Efor
tulfi
zicreducenumar ul
degr anul
ocit
e
Toate modi fi
cari
le sunt ar gument
ate la diabeti
ci,f
umatori
, hiper
tensi
vi
,
di
sli
pidemici

127.Fi
zi
opat
ogeni
esi
fact
ori
der
iscai
art
eri
opat
iei
obl
i
ter
ant
e
Fiziopat ogeni asebazeazapei chemiat eri
tori
uluii
ri
gat
,ini
ti
all
aef
ortsiapoii
nrepaus,
consecut ivscader i
i debituluisipresi
uniisanguine.
Mecani smel ecompensat or i
i
:
-dezv olt
ar eaci r
cul atieicolateraleefi
ciente
-raspunsadecv atal microci r
culati
ei
-exercitiulfizicsigr adul deant renamenti ndiv
idual
-remodel areaper et eluiarteri
al
Fact orider i
sc:
-fumat
-hipertensi unear teriala
-hipercol esterolemi e
-diabetzahar at
-i
nsuf ici
ent ar enalasaucar diacacronica
-i
nf ectii
,traumat i
sme

128.Di
agnost
iccl
i
nic
Tabl
oul
cli
nicar
elabazadur
erea:
-
claudi
catiei ntermitent
al aefor t
-
durereder epaus,mai al esnoct urna,ceprecedetulburar
il
etrofi
ce
-
durerenev riti
ca,cupar est ezi
i noctur
ne
Examenul cl i
nicevidentiaza:
-
culoareat egument ului
, car eest ei
nit
ialpal
id,ul
teri
orcianot
ic
-
temper at
ur ascazut ainper manent a
-
colabarev enoasa
-
modi f
icari tr
ofice:
ami ot rofi
i,ulcer
ev ar
icoase,scadereapil
ozit
ati
i
-
pulsper i
fericslabsauabsent

129.Di
agnost
icpar
acl
i
nic
Ecogr
afi
evascul
ara:ut
il
ain ev
ident
ier
etul
bul
ent
elordat
e de t
romboze,st
enoze

100
v
ascul
are,
anev
risme.
Ecogr
afi
eint
rav
ascul
ara:
li
mit
atadecostsi
mar
imeav
asul
ui(
mini
m 2mm)
Tomodensit
ometri
esit
omogr
afi
ecomput
eri
zat
aof
eradet
ali
iasupr
aper
fuzi
eit
isul
are,
aspect
ulpat
ului
dist
al
Osci
l
ometr
ie,pl
eti
smogr
afi
e,el
ectr
ost
imular
ea muschil
or sol
eari r ar ut
il
izat
e.
Pl
eti
smogr
afi
csepoat
emasurav
olumulpul
sul
uisi
indexul
depulsat
il
it
ate.
Ar
ter
iogr
afi
ast
andar
dul
deaur
,pr
ezi
ntai
nfor
mat
iisi
mil
areat
eroscl
erozei
RMNapr
eci
ereaci
rcul
ati
eidi
stal
ecol
ater
ale
Tomografi
e comput er
izat
a este de o sensibi
li
tat
ef oart
e mar ein stabi
li
rea
di
agnosti
cului
.Poateoferiinf
ormat
iiasupr
astenozel
or,st
ariici
rcul
ati
eicol
ater
alesi
pat
ului
arter
ialdi
stal
.

130.Pr
inci
pii
det
rat
ament
Pr i
nci pii:dezv ol tarea ci rcul atieicol ateral
e ef icient e,r egim i gieno-diet
eti
c adecv at,
regr esiamedi cament oasaaat erosclerozei,li
mi t areapr ocesul ui t
rombot ic.
Mi jl
oace:ant renament ulf izic,i giena t egument ara,cor ectarea obezi tat
ii
,ev it
area
traumat ismel orsi af rigului
Cor ect areaf act oril
order isc:
-aliment ati
a
-hiper tensiuni eaar terial a
-l
ipsadecont rol agl i
cemi eiser iceladi abetici
-valor i
leLDL, cor ectat ecust atine
-valor i
lescazut eHDL, corect at ecuni aci nsifi
br at i
-scader eat r
igl i
cer idel or
Tr atament ul cuv asodi latatoar e:
-cil
ost azol scadeni vel ul t
rigliceri
del orsiLDL; indicati ntimpul cri
zei declaudicati
e
-prost aglandi nelescadagr egar eat romboci telor ,v asoconst ri
ct i
a,scadLDL
-ant i
coagul ant e:hepar ina,admi nitratainf aze acut e cand est e suspectata sio
ev ent ualaembol i
esaucompl icatieat erotr
ombot icaapl aciideat erom.
-ant i
agr egant e pl achet ar e:aspi rina,cl opi dogr el,reduc pr ogresia boliisiscad
mor talit
ateacar diov ascul arapr i
ninfar ctsauAVC.
-pent oxifi
lina,scadef oarteput infrecv entacr izelordecl audi cati
edari nacelasiti
mp
crest et olerant al aef or t.
Angi opl astia amel i
or eaza cl audi cati
a si cr est e conf ortul vieti
i,atunci cand
medi cament el enudaur ezul tat.
Tr atament ulchi r
urgi calsei ndi canumaii nsi t uatiiledei schemi ecr it
icaamembr ului

101
sauincazulcompli
car
iicuocluzi
ivascular
eembolice,compli
cati
ialepl
aci
ideater
om.
Amput at
iasefacei
ncazuriexcept
ionale(f
umatulsidiabet
ulzaharatcr
escacestr
isc)
Revascul
ari
zareasepoatefacepri
nby -
pass,pr
otezaintral
uminal
a.

131.Cauzedesi
ndr
om Ray
naud
Fenomenul
Ray
naudapar
esecundarmul
torbol
i
:
1.Vascul
are obst
ruct
ive:ateroscl
eroza,hi
per
tensi
une ar
ter
ial
a,hi
per
tensi
une
pul
monara,si
ndrom deaper
turatoraci
ca
2.Micr
otraumat
isme:laceicaresuntdepr
ofesi
epi
ani
stisaudact
il
ogr
afisau
ef
ectueazaef
ortf
izi
cmanualexcesi
v
3.Cauzemecani
ce:
lezi
uni
alecol
oanei
ver
tebr
ale,
coast
acer
vical
a
4.Cauzeendocr
inol
ogi
ce:
hiper
par
ati
roi
die,
acr
omegal
i
e,mi
xedem
5.Col
agenoze:
scl
erozasi
stemi
ca,
LES,
pol
i
art
ri
tar
eumat
oida
6.I
ntoxi
cat
iicr
oni
cecupl
umb,
arseni
u
7.Cauzeneur
ologi
ce:
pol
i
nev
rit
e
8.Post
medi
cament
os
9.Hemopat
ii
:l
imf
osar
com,
disgl
obul
i
nemi
i

Hi
per
tensi
unear
ter
ial
apul
monar
a
132.Def
ini
ti
esi
clasi
fi
car
e
-esteunsindrom cecupri
ndeungrupdebolicar
act
eri
zat
eprincr
est
ereaprogresi
vaa
rez
istent
eivascul
arepul
monare,
insuf
ici
ent
acardi
acadr
eaptasimoar
teprematura.
-HTAPr
epr
ezi
ntacrest
ereapresi
uniii
nar
ter
elepul
monar
e,pest
eval
oar
eanor
mal
ade
18-
30mmHg(si
stol
i
c)respect
iv4-12mmHg( di
ast
oli
c)
-
soci
etat
eaeur
opeanadecar
diol
ogi
edefi
nest
eHTAPcafii
ndcr
est
ereapresi
uni
imedi
i
i
nart
erapul
monarapest
e25mmHgi nr
epaussaupest
e30mmHglaefor
t.
1.Hi
pertensiuneapul
monaraar
teri
ala
Idiopati
ca
Fami l
iala
Asoci ata cu bol
i de tesut conj
unct
iv,i
nfect
ie HI
V,af
ect
iuni t
ir
oidi
ene,
hipertensi
uneport
ala

102
 Asoci
atacuoafect
aresemnif
icat
ivaacapi
l
arelorsauvenel
or
Hiper
tensi
uneapul
monaraper
sist
entaanou-nascutul
ui
2.Hi
per
tensi
uneapul
monar
aasoci
atacubol
i
lecor
dul
uist
ang

3.HTPasociat
acubol i
pulmonar esi
/sauhi
poxi
e
BPOC
Afect
iunicuhipovent
il
atieal
veol
ara
Expunerecroni
calaalti
tudi
nemar e
4.HTPdatorat
atrombozeisi
/sauembol i
eicronice
- Obst
ruct
iat r
ombotica a arterel
or pulmonare pr
oxi
mal
e sau di
stal
e,embol
i
e
pul
monaracutumori,par
azit
i,t
alc,cor
pistrai
ni
5.Diver
se: sar
coi
doza,compr
esi
a v
asel
or pul
monar
e (
tumor
i,medi
ast
in f
ibr
ozat
,
adenopat
ii
)
133.St
rat
egi
ededi
agnost
ic
1.Suspiciunecl i
nica
Simptomesi examenf izi
c
Proceduri descr eeni ng
Descoper i
riintampl at oare
2.DetectareaHTP
EKG
Radiografietoracica
Ecografietranst oracica
3.I
dent i
fi
careacl asei HTP
Testefunct i
onal epul monar esi gazometri
e
Scinti
grafi
epul monar adev enti
lati
e/per
fuzi
e
CTdei naltar ezolutie, CTspi ral
Angiografiepul monar a
4.EvaluareaHTP
a.Tipul
Testesangui nesi imunol ogice
TestulHIV
Ecografieabdomi nal a
b.Capacitateadeef ort
Testuldemer s
Consumul maxi m deoxi gen

c.Hemodinamica
Cat
eter
ism car
diacdr
ept

103
 Test
edev
asor
eact
ivi
tat
e

134.Tabl
oucl
i
nic
1.Di spneeal aef or tcel mai frecv entsi mptom
2.Fat igabil
itate, st aredesl abiciune
3.Dur er
eat or acica
Apar edat oritai schemi eivent r i
culului dr
ept
I
ncazur irarear ter apulmonar adi latatapoat
ecompr imaor amuraacoronar
ei
4.Sincopal aef ort
Conseci nta def i
ci t
uluide cr est ere a debitul
uicor dul
uidreptin condi
ti
ide
sol
i
cit
aredat oritar ezist entei vascul arepul monarecrescute
5.Al tesimpt omemai r
are
Tuseaseaca
Hemopt i
zia
Disfonia
Distensiaabdomi nala
6.Semnecl inice
Accent uareacomponent eipul monar eazgomot ul
uiII
Sufluhol osist olicdei nsuf icient at ri
cuspidi
ana
Sufludiast olicder egurgitarepul monar a
Galoppr ot odiast oli
cdev ent riculdr ept
Turgescent aj ugul arelor
Hepat omegal ie
Edemeper iferice
Asci t
a
Cirozapr indebi tscazutsausuntst angadreapta

135.Aspect
eel
ect
rocar
diogr
afi
cesi
radi
ologi
ce
ECG normalnuexcludedi agnosti
culdeHTP i nt r
ucatnuexi st
amodi f
icaripeECG
specif
ice pentr
u HTP, el ect
rocardi
ograma f urnizeaza doar i
nformatii despr
e
suprasol
ici
tar
easauhi
per
trofiadeventr
iculdr
ept
,r espectivdi
l
tar
eaat
ri
uluidrept
.
-
semnededi
latar
eaat r
iul
uidrept:undaPampla,axul
undeiPestedevi
atl
adreapt
a
-
semnedehipert
rof
ieventr
icular
adr eapt
a:Rinal
tinaVR,subdeni
vel
areasegmentul
ui
ST,
undaTnegati
va,axulQRSdev i
atladreapt
a,bl
ocderamuradeapta
Radiogr
afi
etoraci
ca:
-l
amaj ori
tat
eapacient
il
orcuHTP i
diopat
ica,i
nmoment
uldi
agnost
icar
ii
,radi
ogr
afi
a
esteanormala

104
-
dil
atar
eaart
erel
orpulmonare,i
ncont r
astcuvascul
ari
zati
eperif
eri
cascazut
a
-
dil
atar
eaatr
ial
asiventr
icul
aradreapta
-
radi
ograf
iat
oraci
canormala,casi ECG,nuexcl
udediagnost
iculdeHTP.

136.Pr
inci
pii
det
rat
amentmedi
cament
os
Ant icoagulant eor ale:
-INRt intade2- 3
-ser ecomandal apaci ent i
icar eaut rombozal anivelulcir
culati
eipulmonar esaul a
ceicar epr ezintaf act or ider i
scpr otrombot i
c:trombof i
li
i
,sedentarism,insufi
cienta
car diaca.
Diur eti
ce:
-i
ndi catelacei cui nsuf icientacar diacadr eapta
Tr atamenti not roppozi tiv:
-digoxinulcr est edebi t ulcar diac,esteut i
li
zatmaialesl aceicuf ibril
ati
esauf l
utter
atrial,pentrucont rolulf recvent ei
v entricul
are
Blocant eal ecanal elordecal ci
u
-efectv asodi l
atat orasupr aci rcul
at i
ei pulmonare
-dilt
iazem, nifedi pina
Inhibitoridef osf odiest eraza5
-efectv asodi l
atat or,amel ioreazasi capaci t
ateadeef ortsihemodinami ca
Tr atamenti nter ventional :
Sept ostomi eat riala pr esupuner eal i
zareauneicomuni carii
nteratri
ale,cusunt
dreapt a-stanga, cr ester eadebi tuluisistemic,reducer
eapost sarci
niiVD
Tr
anspl
antpul
monarsaucar
dio-
pul
monar
-
indi
catlapaci
ent
iicusi
mpt
omedecl
asaI
IIsauI
V NYHA,r
efr
act
arel
ater
api
e
medicament
oasamaxi
mal
a.

Tr
ombozav
enoasapr
ofunda
137.Def
ini
ti
esi
epi
demi
ologi
e
TVP esteo afect
iunecar
act
eri
zat
aprinfor
marea detr
ombiin si
stemulv
enos
pr
ofund,asoci
atacuinf
lamat
iaper
etel
uiv
enos,st
azaret
rogr
adasiri
scmajorde
emboli
e.
Trombulpoat efilocal
i
zati nvenel
e cav
e,v enel
e bazi
nul
ui,v
enel
e membr
elor
i
nferioar
e, v
enajugul
arai
nter
na,venapor
taetc.
Epidemiologie:
-
TVPsi TEPsuntocauzaserioasademorbi
ditat
esimortal
i
tat
e

105
 -
inci
dentaestedeaproximativ100la100.000
-
ot r
eimedinpacient
i auTEPsi douatrei
mi auTVP
-
inci
dentacrest
ecuv arstasicuprezentafactori
lorder
isc
-
boalaestemai f
recventadecatsediagnosticheaza

138.Et
iol
ogi
esi
fact
ori
der
isc
Condit
ii
lefavori
zantealeformari
itr
ombul
uisuntreprezent
atedet
ri
adaVi
rchow:st
aza
venoasa,hi
percoagulabi
l
itat
e,l
ezi
uneaper
etel
uivenos.
Staza este dat afrecventde compr esi
a externa a venei( t
umora,sarci
na,chi st
),
obstr
uctieinter
napr intr
-untr
ombr ezi
dualaluneiTVPpr ecedente,
imobi
li
zare(fr
acturi
),
obezi
tate, insufi
cienta cardiaca, vene v ar
icoase, diminuar
ea presi
unii negativ
e
i
ntrat
oracicesi di
mi nuareapr
esei abdominale(event
rat
ii)
Lezi
uneaperet
eluiv
enosest esecundarafor
mari
itr
ombul
ui,desipoat
efiasoci
atasi
uneiagr
esi
unimecanice(
traumati
sme),sauchi
mice.
Hiper
coagul
abil
it
ateapr i
marasausecundar a,poateficauza:defi
cit
elordepr
otei
neC
siS,defici
tde antit
rombina I
II
,deshi
dr at
are,poligl
obulie,sarci
na,efectadver
sla
medicamentel
or(cont
racepti
ve)
,mutat
iigeneticeetc
Fact
ori
der
isc:
-
put
ernici
:fr
act
uradesol
d,pel
vi
s,pi
cior
,chi
rur
gie,
traumat
ism maj
or,
lezi
unidecol
oana
v
ert
ebrala
-moderati
:catet
erv
enoscentr
al,cancer
,insuf
ici
ent
acar
diacasaurespi
rator
ie,AVCcu
paral
izi
e,ter
apiedesubst
it
uti
ecuhor moni,t
erapi
ecucontracept
iveoral
e,trombol
i
i,
postpar
tum
-
slabi
:sar
cina,obezi
tat
e,venevar
icoase,v
art
sai
nai
ntat
a,chi
rur
gial
apar
oscopi
casi
r
epausmai multde3zil
elapat
.

139.Tabl
oucl
i
nic
Semnelesisi
mpt omelesuntl
egat
e de:l
ocal
i
zar
e,gr
aduldeobst
ruct
ie,i
nfl
amat
ia
per
etel
uiv
enos,exist
ent
aembol
il
or.
Edemul di
staldezonatrombozat a
Seaccent ueazadacamembr ulet i
nuti
npozi t
iedecli
va
Init
ialest
emoal esei ndureazadupai nst
alareasi
ndromul uipostt
romboti
c
Dacaedemul est
ei mportanttegumentelesuntnetedesilucioase
Durer
eaest ecorelat
acugr aduledemul ui
,accentuat
ai npozit
iedecliva,
lastr
anut,tuse,
sau i
n manev r
e de pr ovocar
e pr ecum compr esia manuala a gambei ,presiunea

106
punct
elor(
sol
ear
,popl
i
teu,
inghi
nal
)
I
nunelecazur
ipoatefipalpatcor
donulv
enost
rombozat
,sepoat
eobser
vadi
l
atar
ea
r
etel
eiv
enoasesuper
fi
cial
e
Exi
sta2f
ormepar
ti
cul
aredeaf
ect
are
Phlegmasiacoer
uleadol
enst
rombozaext
insai
ncar
emembr
uli
nfer
iorest
e
ci
anot
ic,cupetesi
i
Phl
egmasi
aal badolens trombozamasivaili
ofemur
alaasoci
atacuspasm
ar
ter
ial
;membrul
afectatpali
d,r
ece,pul
sdi
minuatsauabsent
Semnegener
ale:
febr
a,t
ahi
car
die

140.Par
acl
i
nic
D-
dimer
ii
,pr
odusidedegr
adar
eaif
ibr
ineigener
atipr
inf
ibr
inol
i
za,cr
esci
nsi
tuat
ii
lei
n
careexi
statr
ombozasifibr
inoli
za(i
nfect
ii
,traumati
sm,sarcina)
.Rezult
atulnegat
iv
excl
ude TVP numail
a paci
ent i
icu pr
obabil
i
t at
e mica.Rezult
atulpozi
ti
v necesi
ta
confi
rmar
epri
nmetodeimagi
stice.
Ecogr
afi
e2DsiDoppl
er:
-
cri
ter
iulmaj
or:l
i
psadecompr
esi
bil
i
tat
eal
umenul
uiv
enos,dat
adepr
ezent
atr
ombul
ui
ocl
uzi
v .
-
modi
fi
car
eaf
luxul
uiv
enos
Venogr
afi
edecont
rast
-
standar
dul
deaur
,put
anddet
ect
atr
ombi
idi
stal
idarsi
pecei
proxi
mal
i
CTsiRMN
-
uti
l
eint
rombozadev
enai
l
iacasauv
enecav
e
Dozar
eapr
otei
neiC,S,ant
it
rombi
neiI
IIi
ndi
cat
elapaci
ent
iti
ner
i,dacat
rombozaest
e
r
ecur
ent
asauar
eol
ocal
i
zar
eneobi
snui
ta.

141.Tr
atamentmedi
cament
os
1.Hepar
inanef
ract
ionat
a
-uti
l
izat
aindozemici
,laceicuvar
stapeste60ani
,cubolihepat
icesasurenal
ecroni
ce.
-durat
amedietr
atament:5-
7zil
e,asoci
atacuanti
coagul
anteorale,
panaseatingeI
NR2
-3.
2.Hepari
nefr
acti
onat
e
-
enoxapar
ina1mg/
kgc/
zi

107
-seadminist
reazaindozef
ixe,subcutanatsaui
ntr
avenos
-st
andarduldetrat
amentanti
coagulantinTVP
3.Anti
coagulanteoral
e
-seadministreazaconcomit
entcuhepar
inel
e,del
ainceput
,ti
mpde4-5zil
e
-dur
atatratament ului
:6saptamanii
nTVPdegamba,3l uniinTVPfemuropopl
i
tee,6
l
uniinTVPi l
i
acasaudev enacavainf
eri
oara
4.Tr
ombof ibrinol
i
tice
-reducereamaseitr
ombului
,amel i
orar
easi
mpt
omel
or,r
est
abi
l
ireaci
rcul
ati
eiv
enoase,
pr ev
enireasi
ndr
omul ui
post
tromboti
c
-nupr ev
inemboli
zareasaur
ecurentaTVP
5.Tratamentchi
rur
gical
-
tr
ombect
omie,
riscant
a, sepoat
efacelati
neri
saulaceicuTVPdev enai
l
iaca
-
fi
lt
redev
enacava:implantat
etemporarsaupermanent
,reducr
iscul
deTEP
142.Pr
ofi
l
axi
einf
unct
ieder
isc
-
est
eindi
catalatotipaci
ent
iicuf
act
orideri
scpr
otr
ombot i
ciper
manent
isaupasager
i,
i
nsi
tuat
iicandri
sculdetr
omboemboli
sm est
esemni
ficat
iv
-se bazeaza pe mi j
loace far
macol ogi
ce (hepar
ina nefr
act
ionat
a sau fr
act
ionat
a,
fondapari
nux,ant
icoagulant
eorale)sinon-far
macologi
ce(compresi
eexter
nacucior
api
elast
ici
,di
spozit
ivedecompr esi
epneumat ica)
1.Ri
scmi
c
-i
nterventi
ichi
rur
gial
eminor
elapaci
ent
imaiti
ner
i,f
arafact
ori
der
isc
-pr
ev enti
e:mobil
izar
epr
ecoce,
far
aprof
il
axi
especif
ica
2.Riscmoder at
-i
nterventi
ichi
rur
gical
eminoredarlapaci
enti
cufactor
ideri
sc
-i
nterventi
ichi
rur
gical
elapaci
entif
arafact
orider
iscdarcuvar
stai
ntre40-
60deani
-pr
ev enti
e:hepari
nanef r
acti
onat
ai ndozemi cila12 ore,compresi
ecuciorapi
externi
3.Riscmar e
-i
nterventi
ichi
rur
gical
elapacient
ipest
e60deanisaui
ntre40-
60cufact
orider
isc
aditi
onali
-pr
ev enti
e:hepar
inanefract
ionat
ai ndozemi
cila8or e,compr
esi
epneumatica
i
ntermi t
enta
4.Riscmaxi mal
-
int
erv
ent
iichi
rur
gical
elapaci
ent
icunumer
osi
fact
ori
der
isc

108
-
chirurgi
asol dul
ui,
genunchiului
-
traumat i
sm maj or
-
leziunedecoal anaver
tebrala
-
prev ent
ie:hepari
nanefract
ionata,
fondapar
inux
,ant
icoagul
antor
alcut
int
aINR2-
3

Tr
omboembol
i
sm pul
monaracut
143.Def
ini
ti
esi
fizi
opat
ologi
e
-af
ect
iunefr
ecv
entacei
mpl
i
caocl
uzi
apat
uluiar
ter
ialpul
monardecat
reunembol
denat
uratr
omboti
ca
Fi
zi
opat
ologi
e
-consecintablocar i
ipatuluiart
eri
alpul
monarest
ehemodi nami
capr incr
esterea
brutal
aar ezi
stenteivascular
epulmonar
esiunniv
elalpost
sarci
niicar
edepaseste
capacitateaventri
culul
uidrept
-
sincopasihi
potensi
uneasist
emicapotev
oluaspr
esocsidecesi
ncondi
ti
il
eunei
i
nsufici
ent
ecar
diacedrept
enetrat
ate
-hi
per
tensiuneapulmonar
adet
ermi
nami
scar
easept
uluii
nter
vent
ri
cul
arsidi
sfunct
ia
deventr
iculstang
-l
apacient
iicar
esupravi
etuiescepisoduluiacutarel
ocact i
var
easistemul
ui si
mpatic,
cucrester
eaconsecuti
vaapr esi
uni
iar t
erial
epulmonare,careajut
al arestaur
area
fl
uxul
uipulmonarde r epaus,a pr esiuni
ide umpl ere sia debit
uluiVS.Acest e
mecanismepotr est
aur
apr esiuneaarteri
alasist
emica
-aldoi
l
eaepisoddedestabi
li
zar
ear
el ocdupa24-48ore,caurmareaepuizari
iVD,
sauaunort rombir
ecur
enticar
ecrescsimaimul tpr
esiuneaar
ter
ial
apulmonara,
saupursisi mpl
ucaurmar eaepuizar
iimecani
smelorcompensator
iii
notropesi
cronot
rope.
-
alt
ernanta zonel
orslabper
fuzat
e di
nt er
itor
iulbl
ocatcu zonel
e supr
aperf
uzat
e
v
ecine,duceladezechi
li
brul
rapor
tul
uivent
il
ati
e/per
fuzi
esi
hipoxemiesev
era.

144.Ti
pur
i
Inf
uncti
edelocal
izar
eaobstructi
eiexi
sta:
a.obstr
ucti
eproximalaaarterel
orpulmonare(decat
retrombivol
uminosi
,emboli
tumoral
i,
masividinvenacavainfer
ioar
a,ADsauVD)
-se mani
festa pr
in TEP acutmasi v,asoci
atcu scader
ea pr
esi
uniiart
eri
ale

109
 sistoli
cesub90mmHgsaucumaimul tde40mmHgf atadev al
oril
ebazal e,
pent r
umaimul tde15mi nutesicar enupoat ef iexpli
catapr i
nhipov ol
emi e,
sepsissauar it
mi ecar di
acanou- aparuta.
-ducel ainsufi
cientav entri
cularadr eaptaacutasev era,ladecesi ncatevaorede
l
adebut
b.obst r
ucti
edi stalaaar t
erelorpul monar edeter minatadepar ticulecudi amet r
u
maimar ede10mi croni(tr
ombi ,t
esutt umoral,fr
agment edet esutadipos,lichi
d
amni oti
c,parazitisiouadepar aziti
,mat er
ial
est r
aineetc)
-semani festacaTEPacutsubmasi v
,cuinstalaremail entasiformemaibl ande
dei nsufi
cient
av entricul
aradr eaptaacut a
Infunctiedeet i
ologie
Embol i
epul monar acut r
ombi( >95%)
-aparecl i
niclacazuril
ecuTVPi nteritori
il
ev eneicaveinferi
oare
Embol
i
epul
monar
acut
esutt
umor
al
-
embol
i
itumor
ali
nupr
oducmet
ast
azeci
doart
rombozai
nsi
tu
Embol
i
epul
monar
acuaer
-
dupai
nter
vent
iichi
rur
gical
e,t
raumat
isme,
boal
adedecompr
esi
une
Embol
i
epul
monar
acul
ichi
damni
oti
c
Embol
i
epul
monar
agr
asoasa
Embol
i
epul
monar
acutal
capar
eladependent
iidedr
oguri
Embol
i
epul
monar
asepti
caasoci
atafr
ecventcuendocardi
tapev
alv
atr
icuspi
da,l
a
uti
li
zat
oriidedrogur
iint
ravenoase,ceicudispozi
ti
veint
racardi
ace
Embolie pulmonara cu cor
pist r
aini ruperea cat
eter
elor,ghi
dur
il
orendov
enoase,
fi
l
trel
ordev ena

145.Fact
ori
der
isc
Puter nici:
-
fract uradesol d,pelv i
ssaupici
or
-
prot ezar edesol dsaugenunchi
-
chirur giegener ala
-
traumat i
sm maj or
-
leziunedecol oanav ert
ebral
a
Moder ati:
-
chirur gieartroscopi caagenunchiului
-
catet erv enoscent ral
-
cancer
-
insuf icientacar diacasaur espi
rat
orie
-
terapi edesubst i
tutiehormonalasaucucont
racept
iveor
ale

110
-
AVCcupar ali
zie
-
tromboembol ism venosinantecedent
e
-
trombof i
lii
Sl
abi:
-
repausl apatmai mul tde3zi
le
-
varstai naintata
-
chirurgiel aparoscopica
-
obezitat e
-
sarcina, perioadaant epart
um
-
venev aricoase

146.Di
agnost
icpozi
ti
v
Clinic:
-di
spneeacuti nstalatasauexacer bar eauneidi spneicr oni cedef ond,asoci ataunei
dur ericucar acterpl eur i
ti
csauuneidur er inon-ret r
ost ernal e,farasemnesaucar actere
desuf erint acor onar iana
-hemopt i
zi e,t use f r
ecatur a pleur ala,ci anoza,t ahi cardie,t ahi pnee,hepat omegal i
e
sensi bilal apal pare, accent uarezgomot ul ui2, colapsci r
cul ator(semndemar egrav i
tate)
D-di mer iipr odusidedegr adar eaif i
brinogenul uipr i
nf ibrinol i
za, carelaoconcent rati
e
serica>500mg/ l,ausensi bili
tatede95%i ndi agnost icul TEPacut .
Par aclinic
ECG:dev iereaxi aladr eapta,t ahicar diesi nusal a,sol i
ci t
areat ri
aladr eapta,Ppul monar ,
undeTnegat ive,cuampl i
tudinecr escat oar e(V1- V3) ,aspectdebl occompl et/i
ncompl et
der amur adr eapt a
Ecocar diogr afiet r anstoracica:est e de o i mpor t
ant a maj orai n di agnosticulsi
star t
ifi
car ear i
scului inTEP
Semne:hi pokinezi aper et
eluiliberalVD,car eest edi latat,r apor tVD/ VS>1,cr esterea
velocitat iijetuluider egurgitaretricuspi di ana( 33, 5m/ s) ,dil
atar eaar t
er eipulmonar e
proxi mal e, fl
uxt urbul entint r
aiectul deej ectieal VD, dilatareav enei cav ei
nf eri
oare
Tomogr af iecomput eri
zataspi ral
a: metodader utinaindi agnost icar eaTEP
Scint i
gr afiedev ent il
atieper f
uzie: zonabl ocat a=rece
Angi ogr af iepul monar aof erai magi ni directeal et rombul ui

147.St
rat
if
icar
ear
iscul
ui
Mar
ker
ider
isc
Ri
scde
Cl
ini
ci(soc, Leziune Di
sfunct
ie I
mpl
i
cat
iit
erapeut
ice
mor
tal
it
ate
hi
potensiune) miocardi
ca deVD

111
 Tr
ombol
i
za/
Mar
e>15% + + +
embol
ect
omi
e
+ +
I
nter
medi
ar
- + - I
nter
nar
e
3-
15%
- +
Ext
ernar
epr
ecoce/
Mi
c<1% - - -
t
rat
amentambul
ator

148.Pr
inci
pii
det
rat
ament
1.Hi
poxemi
esihi
pocapni
e
-
oxigennazal
incazuri
TEPdeint
ensitat
emoderat
a
-
venti
lat
iemecani
ca,candest
eprezentfor
amenoval
e
2.Echi
l
ibr
arehemodi
nami
ca
-umpl erev olemica
-i
sopr oterenol v asodil
atati
epulmonar a
-norepinef rina amel i
oreazaperfuziacoronarasifuncti
aVD( ef
ectinot
roppozi
ti
v)
-dobut ami na cr esteoxigenareatisul
ara,tr
ansportuldeoxi gen,cr
estecu30%debi t
ul
siindexul car di
ac,presi
uneaar t
eri
ala
-epinefrina combi naefectel
ebenef i
ceal enorepinefr
ineisidobutamineif
araefect
ul
vasodi latator
-vasodi latatoareleaucaef ectadvershipotensi
uneaar ter
ialasist
emica
3.
Trombof
ibr
inol
i
za
-
sefacecustrept
oki
nazaint
rav
enos
-
dist
rugetr
ombiiocl
uziv
i
-
amelior
eazahemodinamica
4.
Embol
ect
omi
echi
rur
gical
a
-
laceicuTEPmasiv,car
enecesi
tasir
esusci
tar
ecar
diovascular
a
-
trombii
ntr
acar
diaci
,for
amenovalepr
ezent,
esecal
trombolizei
5.
Cat
eterembol
ect
omi
etr
anscut
ana
-
TEPmasi v
-
deschi
dearter
apul
monarasaur
amur
il
esal
emar
i,bl
ocat
e
-
nusefolosest
epeart
eremi
ci
6.
Ant
icoagul
ant
ele
-
hepar
inaf
ract
ionat
a:sepoat
efol
osi
chi
arsi
inai
ntedest
abi
l
ireadi
agnost
icul
ui

112
-
hepar i
nanefr
acti
onata:sefol
osest
einTEPmasi v
-
anticoagul
anteoral
e,fol
osit
econcomitentcuhepar
inel
e,peodurat
ade6lunilaceicu
r
iscintermedi
arsipeoper i
oadanedef
init
alaceicar
eaur i
sccr
escutder
eci
div
are
-
tint
at er
apeut
icaINR=2- 3

I
nsuf
ici
ent
acar
diacacr
oni
ca
149.Def
ini
ti
e,cl
asi
fi
car
e
-si
ndrom cli
nicdeter
minatdeincapacit
ateaini
miideaasiguradebi
tulci
rcul
atornecesar
acoper i
ri
inecesi
tati
l
ormet abol
icealeor gani
smuluisau,deaasi guraacestdebitcu
pret
ul crest
eri
isi
mpt omat
iceapr esi
uni
ideumpl er
eacor dul
ui.
-
disf
uncti
ecardi
acasi
mptomati
ca,fi
eprinmanif
est
aridedebi
tcar
diacscazutsau
i
nadecvat
,fi
epri
nmani
fest
ari
destazapul
monar
asausist
emi
ca
Cl
asi
fi
car
eAHA/
ACCst
ruct
ural
a
Stadi
ulAr i
scmar edeadezv
olt
ainsuf
ici
ent
acar
diaca,f
araanomal
i
ist
ruct
ural
esau
funct
ional
e,f
arasemnesi
simpt
ome
St
adi
ulBri
scput
erni
cdeadezv
olt
aIC,af
ect
arest
ruct
ural
acar
diaca,f
arasemnesi
si
mptome
St
adi
ulCi
nsuf
ici
ent
acar
diacasi
mpt
omat
ica,
afect
arest
ruct
ural
acar
diaca
St
adi
ulDaf ect
arecardi
acaav
ansat
a,si
mpt
omat
ologi
emar
cat
achi
arsii
nrepaus,i
n
ci
udat
erapi
eimedical
emaximal
e.
Cl
asi
fi
car
eNYHAf
unct
ional
a
Clasa I f
aralimi
tar
e a act
ivi
tat
iif
izi
ce,deoar
ece act
ivi
tat
ea f
izi
ca obi
snui
ta nu
deter
minaapar
it
iasi
mptomelor
ClasaIIli
mi t
areusoaraact
ivi
tat
iif
izi
ce,
far
asi
mpt
omei
nrepausdaract
ivi
tat
eaf
izi
ca
obisnui
tadeterminaapar
it
ial
or
ClasaII
Il i
mit
areimport
antaaacti
vi
tat
iif
izi
ce;act
ivi
tat
eaf
izi
camaiput
indecatcea
obisnui
tadet
erminaapar
it
iasi
mptomelor
ClasaIVi
ncapabi
ldeaef
ect
uaor
iceact
ivi
tat
efi
zi
ca;si
mpt
omel
esuntpr
ezent
esii
n
repaus

150.Di
agnost
iccl
i
nicpozi
ti
v

113
Si
mpt
omat
ologi
a

1.Di
spneeadeef
ort

o Pe masura ce I
C pr
ogr
eseaza scade i
ntensi
tat
ea ef
ort
uluice det
ermi
na
di
spneea

2.Or
topneea

o Pacientulmenti
netoracel
esicapulr
idi
catpent
ruapr
eveni
iapar
it
iadi
spnei
i
paroxist
icenoct
urne

3.Tusea

o Poat
efi
det
ermi
nat
adecongest
iapul
monar
a

4.Di
spnneapar
oxi
sti
canoct
urna

o Tr
ezescpaci
ent
ulbr
usccusenzat
iedeanxi
etat
esi
suf
ocar
e

5.Edemul
pul
monaracut

o For
maceamai
sev
eradedi
spneeder
epaus

Si
mpt
omedeI
Cdr
eapt
a

- Hepatomegal
i
a ce pr
oduce di
sconf
ort gast
ri
c,anor
exi
e,gr
eat
a,met
eor
ism,
const
ipat
ie

Examenul
cli
nici
nIC

Semnepul
monar
e(expr
esi
east
azei
)-submat
it
atebazal
asir
alur
isubcr
epi
tant
edat
e
deICst
g

Semnedehi
pot
ensi
unev
enoasasi
stemi
ca:
o Tur
gescent
ajugul
arel
or,
crest
esemnul
Kusmaul
l

o Ref
lexul
hepat
o-j
ugul
ar

o Hepatomegali
e,splenomegal
i
a-l
a paci
ent
iicu af
ect
aret
ri
cuspi
diana sau
per
icardi
taconst
ri
cti
va

o Edemel
e

o Asci
ta
Semnecar
diace:

114
- Mar
ir
eaar
iei
mat
it
ati
icar
diacel
aper
cut
ie

- Depl
asar
eal
ater
alasi
inf
eri
oar
aasocul
uiapexi
an

- Mat
it
atecar
edepasest
emar
gineadr
eapt
aast
ernul
ui

- Gal
oppr
otodi
ast
oli
c(zgomot
ulI
II
)apar
edupazgomot
ulI
I

- Accent
uar
eacomponent
eipul
monar
eazgomot
ului
II

- Suf
lur
isi
stol
i
ce

Al
tesemne:
pal
oar
e,ci
anoza,
tahi
car
diesi
nusal
a,ext
remi
tat
ireci
,tr
anspi
rat
ie

151.Fact
ori
eti
ologi
ci
-cauzefunti
onale:af
ectareasaupier
dereadetesutmiocar
dic,ischemiaacut
asau
cronica,
crest
erearezi
stentei
vascul
areper
if
eri
ce,t
ahi
ari
tmiiprecum fi
bri
l
ati
aatr
ial
a
-
afectarea cor
onar
iana est
e ev
ident cea maif
recv
ent
a cauza de af
ect
area
miocardica
Cauzef
recv
ent
edei
nsuf
ici
ent
acar
diaca:
Car diopat i
aischemi ca
Hi pertensiuneasoci at acuHVSsi fracti
adeej ectieprezervat
a
Car diomiopat i
ile:hipertrofi
ca,dil
atativa,rest
ricti
v a(CMR)
Medi cament e:-blocant e,cal
ciublocant e
Toxi ne:medi cat i
e,alcool ,
mercur
Endocr i
nopat i
i:diabetul zahar
at,hipo/hiperti
roidism, si
ndromul Cushing
Nut riti
onale:def i
cientadet imina,seleniu,obezitate,casexie
Inf i
lt
rati
ve: sar
coi doza, amiloi
doza, hemocr omat oza, bol
idet esutconjunct
iv
Al tecauze:i nfectieHI V,cardi
omi opatiaper i
par t
um,i nsufi
cientarenalainstadi
ul
ter
mi nal
Factoripredispozant iai I
C
Embol ii
lepul
monar e-producsauagr aveazaHTP
Tireotoxi
cozacr estedebi
tulcardi
ac
Anemi ar educecapacitat
eadet r
ansportaO2sidet er
minacrester
eadebi
tului
car
diac
Infecti
il
epr i
nfebrasitahi
cardiecrescnecesi
tati
l
eti
sularedetr
atament
Mi ocardi
tel
edepr imacontract
ibil
i
tateamiocardi
ca,
iarpri
ntahi
cardi
esereduce
umplereadiast
oli
ca

115
 Endocardi
tai nf
ect
ioasa producer emanier
iv al
vul
areurmat
eder
egur
git
ari
acut
e,f
ebra,anemie
Crest
erisubit
ealepresiuni
iar
teri
alesi
stemicesipulmonar
e
Administr
areademedi camenteionotr
opnegativ
e

152.Expl
orar
ipar
acl
i
nice
1.Examenedel
abor
atorder
uti
na

Det
ermi
nar
eael
ect
rol
i
til
orser
ici

Ev
aluar
eaf
unct
iei
renal
e

Ev
aluar
eaf
unct
iei
hepat
ice

Test
ehemat
ologi
ce

Det
ermi
nar
eapept
idel
ornat
ri
uret
ice

Det
ermi
nar
eat
roponi
nei

2.Radi
graf
iet
oraci
ca

car
diomegal
i
einst
adi
aav
ansat
edeboal
a

r
edi
str
ibui
reaci
rcul
ati
eii
nzonel
epul
monar
esuper
ioar
e

mar
ir
eaumbr
elorhi
l
are

accent
uar
eadesenul
uiv
ascul
ar

mi
cir
evar
sat
epl
eur
ale

3.EKG

Hi
per
trof
iev
ent
ri
cul
ara

Fi
bri
l
ati
eat
ri
ala

Bl
ocat
ri
ovent
ri
cul
ardegr
adi
nal
t

Ext
rasi
stol
event
ri
cul
are

Tahi
car
diev
ent
ri
cul
ara

4.Ecocar
diogr
afi
atr
anst
oraci
ca

116
 Def
inest
ecauza

Ar
atadi
l
atar
easi
hiper
trof
ia

Ar
atasev
eri
tat
eat
ulbur
ari
l
ordeki
net
icapar
iet
alav
ent
ri
cul
ara

Ev
alueazaf
unct
iadi
ast
oli
caaVS

5.Ecocar
diogr
afi
atr
ansesof
agi
anaest
erecomandat
ala

Paci
ent
iicuf
ereast
raecogr
afi
cat
ranst
oraci
cadi
fi
cil
a

Lapaci
ent
iicuv
alv
ulopat
iicompl
i
cat
e

I
nsuspi
ci
uneadeendocar
dit
ainf
ect
ioasa

Bol
icar
diacecongeni
tal
e

Pent
ruaexcl
udet
rombozaar
ti
cul
arast
angai
ncazdef
ibr
il
ati
eat
ri
ala

6.Ecocar
diogr
afi
adest
res

7.RMNev
alueaza

Vol
umel
eVDsi
VS

Funct
iagl
obal
avent
ri
cul
ara

Gr
osi
meaper
eti
l
orcor
dul
ui

Pr
ezent
eidemasesi
tumor
imi
ocar
dice

8.Test
uldeef
ort

9.Moni
tor
izar
eHol
ter

10. Angi
ogr
afi
acor
onar
iana

Dupast
opcar
diac

Lacei
cupr
ofi
lder
isccor
onar
iancr
escut

Ur
gentl
apaci
ent
iicuI
Csev
era

11. Bi
opsi
aendomi
ocar
dica

117
 153.Medi
cat
iei
not
roppozi
ti
vasi
diur
eti
ce
1.
Gli
cozi
zi
i di
git
ali
ci-digoxi
n
- cel
emai folosit
emedi
cament
eionot
roppozi
ti
vei
ntr
atament
uli
c

- ef
ect
ehemodi
nami
cedi
rect
ecar
diace

- det
ermi
nacr
est
ereaact
ivi
tat
iiv
agal
esi
scader
eacel
eisi
mpat
ice

- cr
est
ereasensi
bil
i
tat
iibar
orecept
ori
l
orar
ter
ial
i

-i
nducconst
ri
cti
epesegment
elev
ascul
arei
zol
ate

Pecor
duli
nsufi
cientdi
git
ali
cel
epr
oduc
-vasoconstri
cti
e

- cr
est
ereacont
ract
il
it
ati
i

- cr
est
ereav
olumul
uibat
aie

- scader
eav
olumul
uit
eledi
ast
oli
c

- cr
est
ereadebi
tul
uicar
diac

- scader
eat
onusul
uiv
asoconst
ri
ctor

Cr
it
eri
idedigit
ali
zareadecvata
o Scadereafr
ecventeicar
diacel
a60-
70bpm

o Cr
est
ereadi
urezei
sir
educer
eagr
eut
ati
icor
por
ale

2.
Toni
car
dicenedi
git
ali
ce

Dopami
na

oI
ninsuf
ici
ent
acar
diacaacut
a

o Ef
ecti
onot
roppozi
ti
v,ef
ectv
asoconst
ri
ctor

o Sepoat
eadmi
nist
ranumai
int
rav
enos

Dobut
ami
na

o Agentst
imul
ant1adr
ener
gic

o St
abi
l
izeazapaci
ent
ulcur
iscdecol
apshemodi
nami
c

I
nhi
bit
ori
aif
osf
odi
est
erazei
-Mi
l
rinona

118
 o act
ioneaazaper
ecept
ori
i-
adr
ener
gici

Lev
osi
mendanul

oI
mbunat
atest
econt
ract
iacar
diaca

o Cr
est
ereausoar
aaf
recv
ent
eicar
diacesi
scader
eaTA

3.
Diur
eti
cel
e

Cr
escel
i
minar
eadesodi
usi
apa

Reducv
olumul
sangui
nci
rcul
ant

Reducepr
esi
uneacapi
l
arapul
monar
asi
presi
uneav
enoasasi
stemi
ca

Amel
i
oreazadi
spneea

Di
spar
:edemel
e,hepat
omegal
i
a,t
urgescent
ajugul
arel
or

Ser
eabsor
brev
arsat
eleper
it
oneal
e,pl
eur
ale,
per
icar
dice

Di
uret
icel
edeansa-f
urosemi
d
- Cr
est
eexcr
eti
adesodi
u

- Det
ermi
nav
asodi
l
atat
ie

- Scadepr
esi
uneadeumpl
erev
ent
ri
cul
ara
Di
uret
icel
eti
azi
dice-hi
drocl
orot
iazi
da
oi
ndi
cat
iepr
efer
ent
ial
aint
rat
ament
ulI
Ccr
oni
ceusoar
esaumedi
i
Di
uret
icel
ecar
eeconomi
sescpot
asi
ul-Spi
ronol
act
ona
o potcauzahi
per
pot
asemi
esi
afect
areaf
unct
iei
renal
e

o potdet
ermi
nagi
necomast
iedur
eroasa

154.Medi
cat
iebet
a-bl
ocant
asi
IECA
1.I
ECA

Mecanism: Blocheazat ransf or

mar eaAgIi nAgI Ivasodil
atati
e
Crestef r
act iadeej ect
ie,r educeHVSsipr evineremodelareacardiac,ef
ect
elecli
nice
fi
i
ndamel iorareadi spneei ,crest
ecapaci t
ateadeef for
t,reducer
eanrdespi tal
i
zarisi
durataint
er nari
lor,
reducer eamor t
al i
tat
iisiprel
ungireadurateidevi
ata
Reprezentanti:captopr i
l
, enalapri
l
,lisi
nopr i
l
,trandolapri
l
I
ndicati
i

119
 I Cmedi cati
edepr i
mal i
nielatotipacienti
icusauf arasimptomecar eaufract
iade
ejecti
er edusa
Seadmi nistr
eazacat ratamentiniti
alinabsentar etent
ieidefl
uide
Lapaci ent i
icuretenti
vedef lui
deseasoci azacudiureti
ce.
Efecteadv erse:tusea,hi
pot ensi
une, i
nsufici
entarenala,hi
perpotasemie,angi
oedemul
Contraindi
cat einprezentast enozeibil
ateraledeartererenal
esi aangioedemuluiapar
ut
i
ncont extual administr
ari
i anter
ioar
edeI ECA.
2.et
a-bl
ocant
e

Excesulde cat ecolamine endogene ar e efectet oxi

ce di r
ecte asupra cor dului.
Catecol ami neler educdur atadiastoleisiaumpl eri
iventri
culareprinv asoconstricti
e
sist
emi casi efectelelorari
tmogene.
B-blocant eler educ consumuldeoxi gen,protejeazami ocarduldeact iuneat oxicaa
catecol ami nelor, amel i
oreaza r elaxarea di astoli
ca, diminueaza v asoconstrict
ia
sist
emi ca.
Mecani sm: bl ocheaza r eceptor
ii bet aadrenergice scade cr onotropi
smul si
i
onot r opi
smul
Repr ezent anti
: metroprol
ol,carv
edilol,nebi
volol
, bi
soprol
ol,ti
mol ol
Indi
cat i
i:
I C st abi l
a,moder ata,car di
omiopat iii
schemi cesaunon- ischemice,cuf racti
ede
ej ecti
er edusa.

Reducspi
tal
i
zar
ea

Cr
escf
ract
iadeej
ect
ie

Combi
nat
iacuI
ECA r
educemor
tal
i
tat
eadecauzacar
diov
ascul
ara

Dozaini
ti
alatrebui
esafi
emi casisacreascaprogresi
vpanalaodozat
int
a.
Contr
aindi
cati
i:astmulbr
onsi
c,blocul
atr
ioventr
icul
ardegradulI
IsauI
II

155.Tr
atamentchi
rur
gical
1.Di
spoz
iti
vedeasi
star
event
ri
cul
ara

Bal
onul
decont
rapul
sat
ieaor
ti
ca

Ut
ili
ninsuf
ici
ent
avent
ri
cul
arast
angaacut
a

Pr
esupuneint
roducer
eauneisondecuunbal
onasi
nar
ter
apr
oxi
mal
acar
ese
umfl
aindiast
olasisedesumfl
ainsi
stol
a

120
 Scadepost
sar
cinasi
asi
gur
aopr
esi
unedi
ast
oli
cai
ntr
aaor
ti
cacr
escut
a

Amel
i
oreazaper
fuzi
aper
if
eri
ca

2.Rev
ascul
ari
zar
ea

Amel
i
orar
eaapor
tul
uisagui
ncat
remi
ocar
d

Amel
i
oreazaf
unct
iav
ent
ri
cul
arast
anga

Nuest
erecomandat
acai
nter
vent
ieder
uti
na

Cor
onar
ograf
iaesterecomandatalapaci
enti
icuri
scmaredeafect
arecor
onari
ana,
cuaf
ect
areval
vular
asemni fi
cat
ivasil
aceicarei
nciudat
erapi
eimedi
camentoase
i
ncaausi
mptomedur eroase.

3.Chi
rur
giav
alv
ular
a

4.Anev
rismect
omi
a

I
ndicatalapaci
ent
iicar
epr
ezi
ntaanev
rismemar
icar
edet
ermi
naapar
it
ia
i
nsufici
entei
cardi
ace

5.Car
diost
imul
atoar
e

pent
rut
rat
areabr
adi
car
diei

Lapaci
ent
iicudi
sfunct
iesi
stol
i
ca

6.Ter
api
ader
esi
ncr
oni
zar
e

St
imul
eazaambi
ivent
ri
cul
iapr
oapesi
mul
tan

Amel
i
oreazacoor
donar
eacont
ract
iei
vent
ri
cul
are

Reducesev
eri
tat
ear
egur
git
ari
imi
tr
ale

7.Car
diov
ert
erel
edef
ibr
il
atoar
eimpl
ant
abi
l
e

I
mpl
ant
areai
ncombi
nat
iecupaci
ngul
scademor
bidi
tat
eal
apaci
ent
iicuI
Csev
era

Amel
i
oreazasi
mpt
omat
ologi
a

Ser
ecomandal
apaci
ent
iicu:
stopcar
diacr
esusci
tat
,cusauf
arai
schemi
e

8.Tr
anspl
ant
ulcar
diac

Tr
atamentpent
rust
adi
i
let
ermi
nal
edeI
C

121
 Cr
est
esemni
fi
cat
ivsupr
avi
etui
rea,
capaci
tat
eadeef
ort

156.Tr
atamentf
armacol
ogi
csi
non-
far
macol
ogi
c
1.Tr
atament
ulf
armacol
ogi
c

I
nhi
bit
oriaienzi
meideconver
sieaiangi
otensi
nei
:capt
opr
il
,enal
apr
il
,l
isi
nopr
il
,
t
randol
apr
il
Ant
agonist
ibet
a-adr
energi
ci:
bisoprolol,
metoprol
ol,carvedi
l
ol,nebi
volol
Di
uret
ice:deansa(fur
osemid),ti
azidice(hi
drocl
orotiazi
da),ant
ial
doster
oni
ce
(
spi
ronol
act
ona)
Antagonistiaireceptoril
orangiotensi
nei:
candesartan,
losar
tan,
val
sar
tan
Tonicardi
acegl icozi
dice:digoxin
Agentivasodi l
atator
i:nitr
ati
,hidr
alazi
na,nit
rogli
ceri
na
Agentiionotroppozitivi:
dopami na,dobutamina,l
evosi
mendan
Anti
coagulant e:heparine
2.
Trat
ament
ulnon-
far
macol
ogi
c
a.Rev
ascul
ari
zar
ei
nter
vent
ional
sauchi
rur
gical

b.Al
tei
nter
vent
iichi
rur
gical
repar
areav
alv
eimi
tr
ale

c.Car
diost
imul
arebi
vent
ri
cul
ara

d.Car
diov
ert
er

e.Tr
anspl
antcar
diac,
dispozi
ti
vedeasi
star
event
ri
cul
ara

f
. Hemodi
ali
za

I
nsuf
ici
ent
acar
diacaacut
a
157.Def
ini
ti
e,cl
asi
fi
car
e
Est
ecar acter
izat
aprindebutulr
api
dsauprogr
esivalsimptomelorsisemnelorde
i
nsufi
cientacardi
aca,
caredet
ermi
naspi
tal
i
zar
eaurgent
a,nepl
ani
fi
catasaupr
ezentar
ea
l
adepar t
ament ul
deurgent
a.

Cel
e3el
ement
ecar
edef
inescI
Cacut
asunt
:
Debutulsi
mpt
omelorsisemnel
orest
erapi
d,desiuneor
isepoat
edesf
asur
apeo
per
ioadamail
unga

122
 Si
mpt
omesi
semnedei
nsuf
ici
ent
acar
diaca

Sev
eri
tat
eacar
edet
ermi
nanecesi
tat
eai
nter
vent
iei
deur
gent
a(spi
tal
i
zar
e)
Ghi
dul
Soci
etat
iideCar
diol
ogi
edescr
ie6t
abl
orur
icl
i
nicecar
edef
inescI
CA
Agr
avar
eaunei
insuf
ici
ent
ecar
diacecr
oni
ce

Edemul
pul
monaracut

I
nsuf
ici
ent
acar
diacahi
per
tensi
va

Socul
car
diogen

I
nsuf
ici
ent
acar
diacadr
eapt
aizol
ata

I
CAsi
sindr
omul
cor
onar
ianacut

Pr
imeletr
eisi
tuat
iisuntr
esponsabi
l
epent
ruapr
oxi
mat
iv90%di
ncazur
il
ede
i
nsuf
ici
entacardi
acaacuta.

158.Et
iol
ogi
esi
fact
ori
preci
pit
ant
i
Poat
efi
det
ermi
nat
ade:
ischemi
e,ar
it
mii
,di
sfunct
iiv
alv
ular
e,bol
iper
icar
dice

Al
tecauze:crester
eapostsarci
niidator
it
aHTAsauHTP,cr ester
eapresar
ciniidat
ori
ta
i
ncar
car i
idevolum sauretenti
eisali
ne,insuf
ici
entacircul
atori
ecareapareinsi t
uati
il
e
cudebitcar
diaccrescut
(i
nfecti
i,anemie)
,nerespectar
eat r
atamentul
uiigi
eno-diet
eti
csi
medicamentos,admini
str
areadeAI NS.

Cauzesi
fact
ori
preci
pit
ant
i:

Boal
a car
diaca i
schemi
ca:i
nfar
ctde v
ent
ri
culdr
ept
,si
ndr
oame cor
onar
iene
acut
e

Bol
ival
vul
are:
stenozesi
regur
git
ari
val
vul
are,
disect
iedeaor
ta,
endocar
dit
a

Mi
opat
ii
:car
diomi
opat
iepost
par
tum,
miocar
dit
aacut
a

Hi
per
tensi
une,
ari
tmi
i

Tul
bur
ari
cir
cul
ator
ii
:sept
icemi
e,anemi
e,t
amponada,
embol
i
epul
monar

Decompensarea i nsufi
cient
ei car diace cr onice: lipsa ader entei
,
i
nfecti
i(
pneumonie)
,l ezi
unicerebr
ovasculare,i
nterv
ent i
ichi
rurgi
cal
e,di
sfunti
i
renal
e,ast
m bronsi
c,BPOC, abuzdedrogurisaual
cool.

123
 159.Tabl
oucl
i
nicEPA
EPA esteceamaidr amati
caf or
maainsuf
icient
eicardi
acest angi
,deter
minatade
di
sfunct
ia si
stol
ica sidi
astol
i
ca a v
ent
ri
cul
uluistang,crest
erea presi
uni
iin AS si
di
fi
cult
ateagoli
ri
iAS.

Cl
i
nic

Di
spneea este si
ndr
omulprinci
pal.Ea debut
eaza br
usc sise accent
ueaza
pr
ogresi
v,apar
emai f
recv
entnoapteai
nsomn or t
opnee,
tuse,
tahi
pnee

Respi
rat
iezgomot
oasazgomot
edebar
bot
aji
ntense

Ret
ract
iai
nspi
rat
ori
easpat
ii
lorcost
alesi
afosei
subcl
avi
cul
are

Tr
anspi
rat
iipr
ofuze

Tegument
er
eci
sici
anot
ice

Auscul
tat
ia:car acter
izat
ader onhusur
i,wheezi
ng,ral
uricr
episisubcrepit
ant
elabaza
pl
amanului i
nit
ial,apoiseextendcatreapexdacaEPAseagr aveaza.Sepotasoci
aral
uri
br
onsicesibi
lante.Sepoat eauziizgomotul3cardi
acsiint
ari
reazgomotului2.

TAest
ecr
escut
a

I
ncazulevol
uti
einef
avor
abi
l
e:
Apar
ebronhopl
egia

Degr
adar
eahemodi
nami
cascadeTA

Seaccent
ueazadezechi
l
ibr
ulaci
do-
bazi
chi
poxemi
esi
hiper
capni
e

Seal
ter
eazast
areadeconst
ient
apanal
acoma

Decesul
sepr
oducepr
insoccar
diogensaui
nsuf
ici
ent
arespi
rat
ori
eacut
a

160.Tr
atamentEPA
Esteuntr
atamentdeurgent
a
Seadmini
streazaO2catmaiprecocenazalsaupri
nvent
il
ati
easi
stat
a
Obi
ect
ivel
eameliorar
easi
mptomelorsistabi
li
zarehemodi
namica
Tr
atamentf
armacol
ogi
c:
1.Di
uret
icel
e

Sef
olosesci
nICAsi
congest
iepul
monar
a

124
 - Fur
osemi
dul
di
uret
icul
deansacel
mai
fol
osi
t

- seev
itai
ncazdeTA<90mmHg,
hiposodemi
esev
era,
aci
doza

Asoci
ereacudi
uret
icear
eef
ici
ent
asuper
ioar
asi
mai
put
ineef
ect
esecundar
e
2.Vasodi
lat
atoar
ele

Recomandat
epaci
ent
il
orcuI
CAsi
hipot
ensi
unesaust
enozev
alv
ular
e

- Exempl
e:ni
tr
ati
i(ni
tr
ogl
i
cer
ina)
,ni
tr
opr
usi
atul
desodi
u

- Ef
ect
elenit
rogl
icer
inei
:v asodil
atat
ie,scader
eapresi
uni
ivenoasepul
monaresia
pr
esi
uniideumpl erevent r
icul
are,arteri
odi
lat
ati
ecureducereapostsar
cini
isi
cr
est
ereadebit
uluicar
diac

3.Medi
cat
iei
onot
roppozi
ti
ve

Lapaci
ent
iicusoccar
diogen,
debi
tcar
diacscazut

Seadmini
streazaimedi
atdupaconst
atar
easocul
uidart
rebui
eopr
it
aimedi
at
dupacesereali
zeazaef
ect
eledor
it
e

a.
Dobut
ami
na

-I
nbunat
atest
eper
fuzi
arenal
a

b.
Dopami
na

- Cr
est
econt
ract
il
it
ateami
ocar
dica,
debi
tul
car
diac

- pr
oducet
ahi
car
die,
ari
tmi
isi
vasoconst
ri
cti
e

c.
Nor
epi
nef
ri
na

- cr
est
erezi
stent
avascul
araper
if
eri
ca

d.
Lev
osi
mendanul

- cr
est
econt
ract
il
it
ateasi
vasodi
l
atat
iaper
if
eri
ca

e.
Digi
tal
icel
e

- scadf
recv
ent
avent
ri
cul
arai
ncazdef
ibr
il
ati
eat
ri
alacual
urav
ent
ri
cul
arar
api
da

4.Ant
agoni
sti
dev
asopr
esi
na

- Amel
i
oreazasi
mpt
omel
edeI
CA

125
 - Det
erminaoscader
esemni
fi
cat
ivai
ngr
eut
ate
5.Morf
ina

Recomandat
alapaci
ent
iidi
spnei
cicuanxi
etat
esi
dur
erepr
ecor
dial
a

Ri
scul
car
diov
ascul
ar
161.Fact
ori
ider
isc
Var
sta:pest
e 55 anil
a bar
bat
isi65 l
afemei
,cr
est
eri
sculde boal
a
car
diov
ascul
ara(
BCV)
Sexul
:i
nci
dent
amai
micaabol
i
icar
diov
ascul
arel
afemei
panai
nmenopauza
Fumatul
:ceamaii mport
ant
acauzadedeces,cr
est
eri
sculdeBCV,st
imul
eaza
apar
it
iaater
oscl
erozei
HTA:
fact
order
iscmaj
orpent
ruBCV
Sedent
ari
smul
siobezi
tat
ea
Di
abetulzahar
at:di
abet
ici
iaur
isccar
diov
ascul
arechi
val
entcucei
car
eausuf
eri
t
uni
nfarctmiocar
dic
Si
ndr
omul
met
abol
i
ci
nsul
i
nor
ezi
stent
a:pr
oducedi
sli
pidemi
eat
erogena,
HTA.
I
nfl
amat
iasi
bol
i
lei
nfect
ioase
Di
sli
pidemi
i
le:ni
vel
uricr
escut
edecol
est
erolt
otal
,LDL,t
ri
gli
cer
ide,ni
velscazut
deHDL.

162.Di
abet
ulsi
riscul
car
diov
ascul
ar
75%di
ndecesel
edi
abet
ici
l
oraucauzacar
diov
ascul
ara

Di
abet
ici
iaur
isccar
diov
ascul
arechi
val
entcupaci
ent
iicar
eausuf
eri
tuni
nfar
ct
mi
ocardi
c

Di
sli
pidemi
a
Conseci
ntaai
nsul
i
nor
ezi
stent
ei

Muschi
ischel
eti
cinumai
prei
auaci
zi
igr
asi
li
brei

Cr
est
epr
oduct
iadeVLDL

Scadeni
vel
ulHDL

Mol
ecul
eleLDLsuscept
ibi
l
elaoxi
dar
esi
for
mar
edepl
aci
ater
ogene

126
St
resul
oxi
dat
iv
Hi
per
gli
cemi
aseasoci
azacucr
est
ereasi
ntezei
despeci
ireact
ivedeO2

Ef
ectulnoci
v est
e datde r
eact
ia cu di
fer
it
e subst
rat
e pr
otei
ce car
oral
e
al
ter
eazastr
uct
ura

Pr
odusi
idegl
i
car
eav
ansat
a(AGE)
Sef
ormeazai
nper
etel
evascul
ar,per
sist
aindef
ini
tsidecl
anseazaunr
aspuns
i
mun

Rol
inf
ormar
eapl
aci
iat
eroscl
erot
ice

Hi
per
gli
cemi
apr
oduce:
Act
ivar
easi
stemul
uir
eni
na-
angi
otensi
na-
aldost
eron

HTAf
recv
entpr
ezent
aladi
abet
ici

Pr
event
iabol
i
icardi
ovascul
arepresupune:
- sti
ldevi
atasanat
os:regi
m ali
mentaradecv
at,
efor
tfi
zi
cmoder
atsi
zil
nic

- I m2
MC<25kg/

TA<130/
85mmHg

LDLcol
est
erol
<100mg/
dl

Col
est
erol
tot
al<175mg/
dl

HbA1C<6.
5%

Gl
i
cemi
aaj
eun<100mg/
dl

163.Si
ndr
omul
met
abol
i
csi
riscul
asoci
at
-Reprezi
ntaoasoci
eredeel
ement
ecar
ear
ecapunct
ecent
ral
eobezi
tat
easii
nsul
i
no-
rez
ist
enta

I
nsul
i
no-
rezi
stent
a
Inducedi
sli
pidemi
eat
erogena:cr
esct
ri
gli
cer
idel
e,scadeHDL,mol
ecul
edeLDL
suntmici
sidense

HTA

Tesut
uladipos sint
eti
zeaza medi
atoriaicrest
eri
i angiotensi
nogen,f
act
or
ti
sul
ar,ef
ect
elef
iindinf
lamati
asist
emicasist
atusprocoagul
ant.

127
 Fi
ecar
eelementinpar
ter
epr
ezi
ntaunf
act
order
isccar
diov
ascul
arsideapar
it
iea
di
abet
ului
zahar
at.

Defi
nit
ia si
ndr
omul
uimet
abol
i
c (
NCEP-
ATP I
II
),se f
ace pe baza a celput
in3
componente:

Obezi
tat
ecent
ral
aci
rcumf
eri
ntat
ali
ei>102l
abar
bat
i,>88l
afemei

Tr
igl
i
cer
ide>150mg/
dl

HDL-
col
est
erol
<40mg/
dll
abar
bat
i,<50l
afemei

TAsi
stol
i
ca>130mmHg,
TAdi
ast
oli
ca>85

Al
ter
areagl
i
cemi
eiaj
eunsaudi
abetdet
ipI
Idi
agnost
icat

Def
ini
ti
asi
ndr
omul
uimet
abol
i
c(I
DF)
Obezi
tat
ecent
ral
at
ali
e>94cm l
abar
bat
isi80cm l
afemei+2di
nur
mat
oar
ele4
component
e:

Tr
igl
i
cer
ide>150mg/
dl

HDL-
col
est
erol
<40l
abar
bat
i,50l
afemei
mg/
dl

TAsi
stol
i
ca>130mmHg

TAdi
ast
oli
ca>85mmHg

Al
ter
areagl
i
cemi
eiaj
eunsauDZdi
agnost
icat

Far
macol
ogi
e
164.Di
git
ali
ce
Mecani
sm deact
iune:i
nhi
baNa/KATP-azapr
incupl
arepesit
usulpentr
uionuldeK.
Pompascoate3i onidesodi
usir
eint
roduce2ionidepotasi
u.Caur mareabl oar
ii
enzi
meiarelococr est
ereint
racel
ularadesodiu.Ul
ter
ior
,pri
nschi Ca2+ ,
mbul2Na/
sodi
ulest
eschimbatcucal ci
u cr est
econcent
rat
iacal
ciul
uii
ntr
acel
ular ef
ect
i
notr
oppozit
iv cr
estefor
tadecontr
act i
eamiocar
dul
ui.
Repr
ezent
ant
isi
doze:
-
digit
oxina2mg( dozadesaturat
ie)
-
digoxin,i
nit
ial
0.5-
1mgi nt
ravenos
-
lanatozi
dC

128
-deslanozid
-str
ofantina
Contr ai
ndicat
ii
: hi
per
cal
cemi
e, i
ntoxi
cat
ie di
git
ali
ca, t
ahi
ari
tmi
i v
ent
ri
cul
are,
hipopotasemie
I
ndi
cat
ii
:ICcongest
iva,
fibr
il
ati
eat
ri
alacur
it
mrapi
d,f
lut
terat
ri
al
Efect
e adverse:di
sconf
ortabdomi
nal
,voma,gr
eat
a,cef
alee,f
ati
gabi
l
itat
e,agi
tat
i,
extr
asist
oleetc

165.Di
uret
icedeansa
Mecanism:sediuldeact i
uneest
el aport
iuneagroasaar amuriiascendenteaansei
Henle;ocanti
tateapreci
abil
adesodiudinf i
lt
rat
ulglomer
ularramaneneabsor bi
tasi
ajungeinpor
ti
uneafinalaatubul
uicont
ortdist
alsil
anivel
ultubuluicol
ector cr
est
e
reabsor
bti
asa.
I
ndi
cat
ii
:EPA,
IRA,
HTA,
hiper
cal
cemi
e
Repr
ezent
ant
i:f
urosemi
d200mg/
zi,
bumet
ami
da,
indacr
inona,
ticr
inaf
en
Ef
ect
eadv
erse:hi
ponat
remi
e,hi
popot
asemi
e,hi
pocal
cemi
e,al
cal
ozasi
stemi
ca.

166.Di
uret
icet
iazi
dice
Mecanism:reducabsort
iadesodi ulani
vel
ultubul
uicontortdistal
.Acestprocesse
real
i
zeazacuajutor
ulunuicotr
ansport
ori
mpreunacuionuldeclor.El
eblocheazaacest
cotr
anspor
torsiast
felopartedinsodi
unusemai r
eabsoarbe.
Repr
ezent
ant
i:hi
drocl
orot
iazi
da25-
50mg,
cicl
opent
iazi
da,
indapami
d,cl
opami
d.
I
ndi
cat
ii
:edeme,
HTA,
diabeti
nsi
pidnef
rogen
Efecte adv er
se: hi
ponatremie, al
cal
oza sist
emica, hi
per
uri
cemi
e, hi
per
gli
cemi
e,
parestezi
i,oboseal
a,cef
alee,di
aree,
impot
entasexual
a.

167.Di
uret
iceant
ial
dost
eroni
ce
Mecanism deact
iune:bl
ocheazaf
ixar
eaaldost
eronuluiperecept
ori
ispeci
fi
ci,
reducand
absor
btiadesodi
udinlumen seel i
minasodi
usi sereti
nepotasi
u.
Repr
ezent
ant
i:spi
ronol
act
ona10-
20mgde2-
4or
ipezi
I
ndi
cat
ii
:hi
per
aldost
eroni
sm,
IC,
cir
oza,
ari
tmi
i
,edeme
Cont
rai
ndi
cat
ii
:hi
per
pot
asemi
e,aci
doza
Ef
ect
eadv
erse:
hir
sut
ism,
amenor
ee,
hiper
pot
asemi
e,aci
doza

129
 168.Bet
a-bl
ocant
e
Mecani
sme:ant i
hipert
ensi
ve,anti
i
schemi
ce,r
educ el
i
ber
area r
eni
nei
,amel
i
orar
ea
f
unci
eicar
diace,
efectant
iar
it
mic
Repr
ezent
ant
i:
-
nesel
ect
ive:
nadol
ol,
sot
alol
,pr
opanol
ol(
40-
180mg/
zi)
,ti
mol
ol,
pindol
ol;
-
sel
ect
ive:
met
opr
olol
(50-
100mg/
zi)
,esmol
ol,
atenol
ol,
labet
alol
I
ndicati
i
:cardi
opati
ai schemi
ca,I
M,HTA,ar
it
miisupr
avent
ri
cul
are,f
ibr
il
ati
esif
lut
ter
at
ri
al,ari
tmi
ivent
ri
culare.
Cont
rai
ndi
cat
ii
:ast
m br
onsi
c,hi
pot
ensi
une,
bradi
car
die,
ICCdecompensat
a,BPOC
Efecteadverse:bradicardi
eext r
ema,scadf luxulsanguint i
sular extremit
ir eci
(si
ndrom Ray naud),agr aveaz simptomatologi
a boli
lorv ascular
e per
ifer
ice,cresc
tonusulvasomot orcor onarian;hiper
gli
cemie,insul
inorezi
stenta,tul
bur
ride somn,
cefal
ee,ast
enie,depresi
e

169.Cal
ci
u-bl
ocant
e
Mecani
sm deacti
une:blocheazainf
luxull
entdei
onidecalci
uinmuscul
atur
anet
edasi
mi
ocard depri
maf uncti
il
emi ocar
dului
,pr
oducvasodi
l
atati
e.
Reprezent
ant
i:di
hidr
opi
ridi
nenif
edi
pina10-
40mgde2- 3or
ipezi
;benzodi
azepi
ne
di
lt
iazem 30mgde3or i
pezi;f
eni
l
alki
l
aminev er
apami
l40mgde2oripezi
I
ndi
cati
i:HTA,CMH,angi
nav
asospast
ica,
sindr
om Ray
naud,
angi
nadeef
ort
,tahi
ari
tmi
i
,
f
ibr
il
ati
esifl
utt
erat
ri
al
Cont
rai
ndicat
ii
:si
ndrom WPW, t
ulburar
ideconducer
einf
ranodal
e,i
schemi
emi
ocar
dica,
hi
pot
ensiuneart
eri
ala,
stenozaaort
ica
Ef
ect
eadv
erse:
hipot
ensi
unear
ter
ial
a,amet
eli
,cef
alee,
edemeper
if
eri
ce

170.I
ECA
Mecanism deacti
une:blocheazat ransf
ormareaangiot
ensineiIinIIcuvasodil
atat
ie
consecuti
vasidepr
imareasecr eti
eideal dost
eron,cuscadereavolumul
uiplasmati
c.
Esteblocat
adegr
adareabradi
kinineiunvasodil
atat
orcuefectmarcant.
Reprezent
ant
i:Enal
apri
l2,
520mg;
Fosi
nopr
il1040mg/
zi;
Lisi
nopr
il2,
510mg/
zi;
Peri
ndopri
l48mg/ zi
;
I
ndi
cat
ii
:IC,
IMA,
HTA
Cont
rai
ndi
cat
ii
:angi
oedem,
alt
efor
medeal
ergi
e;st
enozabi
l
ater
aladear
ter
arenal
a

130
Efecteadv erse:hipotensi
unearteri
alal
apr i
madozai nspecialdacaseasociazacuo
depleti
ev olemica( tr
atamentdiureti
c)saudiet
ahi posodat
a,lavarst
nici
,inI
CC;t use
uscata,astenie,depresie,
erupt
iicut
anate,
edem angioneur
oti
c.

171.Ant
agoni
sti
air
ecept
ori
l
ordeangi
otensi
na
Mecani
sm:
blocheazaspeci
fi
crecept
ori
idet
ipAT1
Repr
ezent
ant
i:Candesar
tan 8-
16mg/
zi;I
rbesar
tan75-
150-
300mg/
zi;Losar
tan50-
100mg/zi
I
ndi
cat
ii
:HTA,
ICcongest
iva,
DZ,
nef
ropat
iigl
omer
ular
e,I
M
Cont
rai
ndi
cat
ii
:angi
oedem,
alt
efor
medeal
ergi
e;st
enozabi
l
ater
aladear
ter
arenal
a.
Ef
ecteadverse:r
etent
ieazot
ata,ol
i
gur
ie,hi
per
pot
asemi
e,amet
eal
a,i
nsomni
e,dur
eri
muscul
are,
congesti
enazal
a

172.Ant
iagr
egant
epl
achet
are
Mecani sm deact i
une:i nhibapr oceseletromboci tar
e,dinf ormareat r
ombuluialb
palchet ar , pr elungesc t impul de sanger are, scad adezi unea si agregarea
tr
omboci t
ar a.
Clasificar e, dozesi repr ezentanti
1.
Inhi bitoar edeCOX- 1:
aspi ri
n75- 100mg/ ziideriv
aiisi(
tri
flusal)
sul finpirazona
i ndobuf en
2.
Ti enopi ri
di ne
t iclopi dina: 2x250mg/ zi
cl opi dogr el:
inatac300-600mgapoi
ntrei
nere75mg/ zi
3.
Di ver se:
di pi ridamol inasoci atiecuaspi ri
na
ket anser in:anti
hiper tensiv
I
ndi catii: t
rombozear terial
ecor onariene,
cerebrale,anginainstabi
la,
ischemii
Cont raindi cat i
i:
anemi esev era,tr
omboci topenie
Efecte adv erse :i ritatie gastro-i
ntesti
nala,al er
gii
,f ebra,anemi e,leucopenie,
tr
omboci t
openi e,cefalee, verti
ij
,voma
173.Ant
icoagul
ant
eor
ale
Mecanism deact
iune:suntsubst
ant
ecar
eact
ioneazacaant
imet
abol
i
tiaiv
itami
neiKl
a
ni
velhepat
ic.
Dozesi
repr
ezent
ant
i:

131
 Acenocumar
ol2mgdedouaor
ipezi
,ti
mpde2zi
l
e,apoi1-
2mg/
zisauodat
ala
douazil
e
Bi
scumacet
atdeet
il
:600-
1200mg/
zii
npr
imazi
,apoi
300-
400mg/
zi
War
far
ina:
40-
60mgi
npr
imazi
apoi
2,5-
15mg/
zi
I
ndi
cat
ii:
trmbof
lebi
te,
prot
ezev
alv
ular
e,f
ibr
il
ati
eat
ri
ala,
tromboembol
i
i
Contr
aindi
cati
i
:hemor
agi
i
,ul
cer
,HTA,pol
i
traumat
isme,AVC,i
nsuf
ici
ent
arenal
asau
hepat
icasevera.
Efect
e adver
se:echi
moze,gi
ngi
vor
agi
i
,epi
staxi
s,hemat
uri
e,mel
ena,hemopt
izi
i
,
hemoragi
icer
ebr
ale

174.Hepar
inanef
ract
ionat
a
Mecanism de ac
iune:se cupleaza cu anti
tr
ombi na II
Icar e arerolde pr ot
eaza
i
nhibi
toar
eacoagluraii
.Pri
naceastacuplarecuhepar i
na,anti
trombinaII
Iisiampli
fi
ca
act
iuneafoar
temultsii
nacti
veazatrombi
na,factor
iiplasmatici
,plasmati
cisikal
i
crei
na.
I
ndicat
ii
:tr
ombozav
enoasapr
ofunda,I
MA,pr
otezev
alv
ular
e,st
enoza mi
tr
ala,f
ibr
il
ati
e
at
ri
ala
Modedeadmi
nist
rar
e:
-i
nTVPsiemboli
epulmonaraseadmi ni
str
eazainj
ectabi
li
nit
ial5000UIint
rav
enos,apoi
secont
inuaadmi
nist
rar
eint
ravenoasapri
nperfuzi
e,cu1000UI/ora,
timpde4-5zi
le.
-
Terapi
a cu hepar
in i
mpune cont
roal
efr
ecv
ent
e al
e coagul
ri
iinumr
uluide
t
rombocit
e
-Hepar
inaNFt r
ebui
eutil
izat
ndozemaimi cil
aceicuvrst
epeste60deaniilacei
cubolihepat
icesaurenalecroni
ce;t
erapi
asentr
erupe
ncazulscder
iinumr
uluide
t
romboci
tel
a<100. mm3
000/

175.Hepar
inaf
ract
ionat
a
I
ndicat
ii
:tr
ombozav
enoasapr
ofunda,I
MA,pr
otezev
alv
ular
e,st
enoza mi
tr
ala,f
ibr
il
ati
e
at
ri
ala
Exempl
e:
-
enoxapar
in(
CLEXANE)
:2x40-
60mg/
zisubcut
anat
-
nadr
opar
in(
FRAXI
PARI
NE)
:38-
57u.
/kg/
zisubcut
anat
-
rev
ipar
in
-
ti
nzapar
in

132
 176.Medi
cament
eant
ihi
per
tensi
ve
1.Caremodi ficafunct i
il
esi mpat o-adr
energi
ce
a.cent rale: clonidina,alfa-met i
ldopa
b.perifer ice:guanet i
dina,f entolamina(al
fablocantsel
ect
iv)
,propranol
ol(bet
ablocant
neselect iv),atenol ol(betabl ocantselecti
v),
carvedi
l
olsil
abetal
ol(ambelesuntsial
fasi
betabl ocant e)
c.mixt e: rezer pina
2.Diuret ice
a.ti
azidi ce: indapami d,hidrocloroti
azi
da
b.deansa: f urosemi d,acidet acrini
c
c.antialdost eronice:spironol actona
d.carer etinK: amilorid
177.Cl
asi
fi
car
eant
iar
it
mice
1.Bl
ocantealecanalelordeNa
a.cl
asaIA:chi
nidi
na, procainami da
b.cl
asaIB:l
idocai
na, fenitoi
na
c.cl
asaIC:encai
anida, propafenona
2.Betabl
ocanteadrener gice:atenolol
,metoprolol,
propr
anol
ol
3.Bl
ocantealacanalelordeK: amiodarona,sotalol
4.Bl
ocantealecanalelordeCa: verapamil
,dil
ti
azem

178.Ni
tr
ati
Mecanism:nitrogli
cerinasist ructuri
leanalogesuntdeni trat
el ani
v el
ulmusculaturi
i
netedesialtort esuturi
,ionulni t
ricest emetaboli
zati nNO sauR- NO.Acumul area
acestorainmuscul aturanet edaact iveazaguani
latci
clazacust imular
easint
ezeide
GMPc,cr est
ereaconcent rati
eiintr
acelulareamesager uluisecundfi
indpri
maet apaa
procesul
uiderelaxareamuscul at
ur i
inetede.
Repr
ezent
ant
isi
doze:
Ter
apiacui sosorbiddinit
rat
:doze
ncardi
opat
iai
schemi
c:5-
40mgde2-
4or
i/
zi;
i
nsufi
cien
acardiac:i
nit
ial10mgde3or
i/
zi
Terapiacui sosor
bidmononi
tr
at:dozmaxi
m:240mg/
zi;ni
tr
ogl
i
cer
ina:2,
5-10mg
profi
lact
ic,
inIC5mg.
I
ndi
cat
ii
:angorpect
oral
inst
abi
l
,angi
nav
asospast
icai
nst
abi
l
a,I
C

133
Cont
rai
ndicat
ii
:anemie avansat
a;presi
une i
ntr
acrani
ana sau hemoragi
e cer
ebral
a,
admi
nist
rarea i
.v de ni
tr
ogli
cer
ina est
e cont
rai
ndicat
ain per i
car
dit
a const
ri
ctiv
a,
hi
pot
ensiune,hi
povol
emie.
Efect
eadv erse:cef
alee,amet
eal
a,hi
pot
ensi
une,gr
eat
a,v
arsat
uri
,ar
it
mii
, si
ncopa,
react
iicut
anate.

179.St
ati
ne
Mecani
sm:i nhi
ba compet
it
iv HMG-
CoA r
educt
aza,car
e medi
aza pr
ima et
apa a
bi
osi
ntezei
decolest
erol
.
Dozesi
repr
ezent
ant
i:Lov
ast
ati
n20mg/
zi;
simv
ast
ati
n20-
40mg/
zi;
ator
vast
ati
na
I
ndicat
ii: hi per
li
popr
oteinemii cu hi percol
est
erol
emie, I
M, at
eroscl
eroza,
hi
pertr
igl
icer
idemii
,di
sli
pidemii
,hi
per
col
est
erol
emiefamil
i
ala.
Cont
rai
ndi
cat
ii
:i
nsuf
ici
ent
ahepat
ica,
sar
cina,
alapat
are,
copi
i
Ef
ect
eadv er
se:great
adi sconfor
tabdominal
,bal
onar
ecuf l
atul
ent
a,t
oxi
cit
atehepat
ica
cucr
est
ereatransaminazelor
,miopat
ie,
durer
imuscul
are.

180.Fi
brat
i
Mecanism: r
educconcent
rat
ii
ledeVLDLpri
ncrest
ereaacti
vi
tat
iil
i
poprot
einl
ipazei
,scad
siLDL.Induccrest
ereaHDL,crescel
i
minar
il
edecolest
erolpri
nscaunsiinhibasi
nteza
hepat
icadecolester
ol
Repr
ezentantisidoze:Cl
ofi
brat
ul0,
5-1g;benz
afi
brat
ul200mg;f
enof
ibr
atul100mg;
gemfi
brozil
600mg.
I
ndi
cat
ii
:hi
per
col
est
erol
emi
i
,hi
per
tri
gli
cer
idemi
i
,IM
Cont
rai
ndi
cat
ii
:di
sfunct
iehepat
ica,
renal
a,sar
cina,
alapt
are
Ef
ecteadver
se:greata,disconf
ortabdomi
nal
,mi
algi
i
,cr
est
eredecr
eat
inf
osf
oki
naza,
l
it
iazabi
l
iar
a,ar
it
mi i
,disf
uncti
ehepati
ca.

134