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
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