7/26/2019 Epa 2016

1/50

Insufcienta cardiaca

acuta

Andreea Catarina

Popescu, MD, PhD

7/26/2019 Epa 2016

2/50

Insufcienta cardiaca acuta

Acuta

Cronica acutizata

Tratamentul adecvat presupune

dg etiologic corect

identifcarea corecta a profluluihemodinamic al pacientului

7/26/2019 Epa 2016

3/50

Simptome

Dispnee de repaus, ortopnee

Edeme

Fatigabilitate hipoperuzie

7/26/2019 Epa 2016

4/50

Semne clinice in insufcienta

cardiaca

Ale retentiei hidrosalinecongestiei

!rtopnee

Staza "ugulara #itm de galop

#aluri subcrepitante

Edeme perierice Ascita

Staza hepatica

7/26/2019 Epa 2016

5/50

Semne clinice in insufcienta

cardiaca

Debit cardiac scazut

Tahicardie

$ipotensiunepresiunea pulsuluiscazuta

E%tremitati reci

Conuzie !ligurie

&ulsus alternans

7/26/2019 Epa 2016

6/50

Profluri hemodinamice ininsufcienta cardiaca

Cald si umedDiuretic si vasodilatator

Fara inotrope

Rece si umed'asodilatator ar putea f necesar inotrop vasodilatator

(blocant si IEC intrerupte temporar

Rece si uscatDg di cu soc hipovolemic

Inotrop balon de contrapulsatie

)onitorizare hemodinamica

*mplere cu gri"a in caz de campuri pulmonare clare la #g

Cald si uscat

&rofl tinta

Cald/rece peruzia perierica; umed/uscat cu/ara congestie pul

7/26/2019 Epa 2016

7/50

7/26/2019 Epa 2016

8/50

7/26/2019 Epa 2016

9/50

7/26/2019 Epa 2016

10/50

7/26/2019 Epa 2016

11/50

Cauze ale insufcienteicardiace(oala cardiaca ischemica + cronica sau inarct

(oala valvulara + cronica sau acuta inarct, endocardita-

Aritmii

$ipertensiune

Tamponada cardiaca

)iocarditaCardiomiopatie

Disectie de aorta + inarct, reg aortica acuta

Insufcienta renala + supraincarcare de volum

Debit cardiac crescut + anemie, hipertiroidism, fstulearteriovenoase

Abuz de alcool

7/26/2019 Epa 2016

12/50

Cauze ale decompensarii

Complianta la tratament scazuta

$TA necontrolata

Aritmie

Tratament inadecvat

Inectie pulmonara

Tratament cu AI.S, Cablocante

Supraincarcare de volumInarct

tireoto%icoza

7/26/2019 Epa 2016

13/50

7/26/2019 Epa 2016

14/50

7/26/2019 Epa 2016

15/50

7/26/2019 Epa 2016

16/50

&araclinic

$/0 anemie, inectie

Creat, ionograma

TroponinaEC0

#grafe C&

(.&Ecocardiografe

EA(

7/26/2019 Epa 2016

17/50

Diagnostic dierential aldispneei

(&!C raluri bronsice, poate avea ortopnee, tuseproductiva, emfzem hipersonoritate, )' diminuat-

Embolie pulmonara dispnee de repaus, eort mic, ara

raluri pulmonare, eventual revarsat pleural-

Test negativ (.& ace improbabil dg de IC

(.&1233pgml.T4pro(.&1533pgml

Cresteri in SCA, stenoza Ao, reg mitrala, C)$

7/26/2019 Epa 2016

18/50

monitorizare

A', TA, EC0, Sa36 automat in primele 67h

0azometrie arteriala la internare in caz IC severa, repeta ptmonitorizarea terapiei

In caz de C&A& la intervale bine stabilite

linie arteriala + rar insu cardiaca persistenta, hipotensiune- Creatinina, ionograma

Diurezasonda urinara

&resiunea venoasa centrala

de e%ceptie, CI in E&A

Cateter in a pulmonara rar necesarreractari la tratamenthipotensiune persistenta, presiunea de umplere in 'S nupoate f estimata, prechirurgie-

7/26/2019 Epa 2016

19/50

obiective

In cazurile nemonitorizate hemodinamic

Simptome

Sa36189:

&erierie calda

TAS183mm$g

;'&

7/26/2019 Epa 2016

20/50

obiective

In cazurile monitorizate hemodinamic

&C>& 2?42@mm$g

C!16,9/minm6 S'# 89342533dneBseccm6

7/26/2019 Epa 2016

21/50

Semne adverse

ipotensiunestop vasodilatatoare, prudentala diuretic, SF proba, inotrope-

!ligo/anuriecorectare hipotensiune, umplere,vasodilatator daca TA 183mm$g, diureticperuzie, monitorizare diureza obiectiv peste63mlh-, hemofltrare

"PA persistent o%igenare adecvata Sa36189:,diuretic peruzie cu cel mult 7mgminurosemid, la TAB233mm$g .T0 pev, C&A&

Conuzie, somnolenta de e%clus hipo%ia sihipercapneea, trat hipotensiunii

7/26/2019 Epa 2016

22/50

7/26/2019 Epa 2016

23/50

7/26/2019 Epa 2016

24/50

7/26/2019 Epa 2016

25/50

7/26/2019 Epa 2016

26/50

7/26/2019 Epa 2016

27/50

Cazuri speciale insucardiaca acuta

I)A

#uptura de papilar

'SD Inarct de 'D

Tireotozicoza

Stenoza aortica stransa

7/26/2019 Epa 2016

28/50

Soc cardiogen

&A)

7/26/2019 Epa 2016

29/50

7/26/2019 Epa 2016

30/50

Tratamentul soculuicardiogen

Inotrop, in caz de hipoperuzie +vasopresor

(alon de contrapulsatie ca bridge

/' assisted device 'entilatie mecanica

Tratamentul cauzei

&rognostic rezervat

7/26/2019 Epa 2016

31/50

"demul pulmonar acut

cardiogen

7/26/2019 Epa 2016

32/50

Pro#leme in urgenta

Diagnostic al "PA

al etiologiei

$ratament de urgenta specifc cauzei

7/26/2019 Epa 2016

33/50

%orma de insufcientarespiratorie acuta hipo&emica

Diagnostic dierential al "PA cardiogen denecardiogen

istoricRadiologie

'(P

"cocardiografe

%inal presiunea capilara #locata )*+mmg

7/26/2019 Epa 2016

34/50

Diagnostic clinic de "PA

Dispnee de repaus, ortopnee, polipne

$usee&pectoratie spumoasa, rozata

Raluri su#crepitante pana la arurilepulmonare

7/26/2019 Epa 2016

35/50

Diagnostic radiologic

7/26/2019 Epa 2016

36/50

Diagnostic etiologic

Anamneza

"& clinic

Rgrafe

"C-

Pro#e #iologice

"cocardiografe

7/26/2019 Epa 2016

37/50

7/26/2019 Epa 2016

38/50

7/26/2019 Epa 2016

39/50

7/26/2019 Epa 2016

40/50

7/26/2019 Epa 2016

41/50

7/26/2019 Epa 2016

42/50

7/26/2019 Epa 2016

43/50

!#iectiele tratamentuluiIn acut .P/$IC/A$I0

$ratamentul simptomelor

Resta#ilirea o&igenarii

Ameliorarea hemodinamicii si a peruziei de orga

1imitarea aectarii cardiace si renale

Preentia trom#em#olismului

Minimizarea spitalizarii in $IC

7/26/2019 Epa 2016

44/50

!#iectiele tratamentului

Intermediar .in spital0

2ta#ilizare si optimizarea tratamentuluiInitierea si titrarea spre doze tinta a terapie

armacologice cu eect prognostic

Implantare dispozitie cardiace

"tiologie si comor#iditati

7/26/2019 Epa 2016

45/50

Tratament armacologic

etapa precoce

Diuretic iv + urosemid 63mg iv repetat

)orfna 6,9 4 23mg an%iolitic si venodilatator-

.itroglicerina in peruzie 23min crescatorpana la 263 la cei cu TA peste 233mm$g

.itroprusiat de sodiu 3,94@mcg=g min + cazurisevere, reg mitrala acuta

7/26/2019 Epa 2016

46/50

Inotrop 4 dobutamina + la cei cuhipotensiune 9423 ma%im 63=gcorpmin

#isc de tahicardie, aritmii

/evosimendan

milrinona

Tratament armacologic

etapa precoce

7/26/2019 Epa 2016

47/50

Inotrop pozitie si asopresoare

#olus rata inuzieido#utamina

nu 34356g/7g/min .890

dopamina nu :6g/7g/min eectrenal .asopresor.?90

milrinona 3=4@=6g/7g in =4*5min 5,@=45,@=56g/7g/min

eno&imone 5,=4*mg/7g oer =4*5min

=4356g/7g/min

leosimendan

*36g/7g in *5 min.optional0

5,*6g/7g/min , carepoate f redus la 5,5=

sau crescut la

7/26/2019 Epa 2016

48/50

'entilatia non invaziva

Indicatie de clasa IIa nivel de evidenta (

metaanalize neutre pe mortalitate, dar ameliorare asimptomelor

(enefciu ma%im

cei ce necesita intubare

p$

7/26/2019 Epa 2016

49/50

'entilatie invaziva

&rincipalele indicatii

$ipo%emie necorectata Sa36

7/26/2019 Epa 2016

50/50

Flash pulmonar edema

Stenoza a renala

Ischemie reversibila

Tahiaritmii intermitente

'ronhospasm seer astm cardiac

bronhodilatator