Per anemia si intende una riduzione della quantità totale di emoglobina circolante nel sangue periferico e all’interno degli eritrociti. La quantità totale di emoglobina si misura conoscendo la sua concentrazione nel sangue periferico e il volume totale ematico. La determinazione di quest’ultimo parametro richiederebbe l’impiego di una metodica lunga e complessa, per cui non è possibile utilizzare routinariamente la conoscenza del patrimonio emoglobinico totale per porre diagnosi generica di anemia. Per questo si è giunti alla convenzione di utilizzare semplicemente la concentrazione dell’emoglobina, assumendo che il volume totale ematico si mantenga costante.
Questa situazione non si verifica in due condizioni:
l’emorragia acuta e la gravidanza.
Subito dopo un’ emorragia acuta, anche imponente, la concentrazione dell’emoglobina può non subire variazioni e può non essere la spia della condizione di anemia naturalmente presente. Nella donna in gravidanza c’è un aumento del volume totale plasmatico, che comporta una riduzione della concentrazione emoglobinica al di sotto dei limiti inferiori della norma senza che vi sia una riduzione del patrimonio emoglobinico totale e quindi anemia.
Tenute presenti queste eccezioni, si deve porre diagnosi generica di anemia quando la concentrazione dell’emoglobina nel sangue periferico è :
inferiore a 12,0 g/dl nella donna
inferiore a 13,0 g/dl nell’uomo.
Il numero di globuli rossi non deve essere utilizzato né per porre diagnosi di anemia nè per valutarne la gravità. Infatti, se è vero che una riduzione del numero degli eritrociti al di sotto della norma (4.500.000/µl nell’uomo e 4.200.000/µl nella donna) è sempre espressione di anemie, non è vero che avere un numero di globuli rossi superiore non esclude una possibile anemia; esistono infatti, e sono frequenti anemie con numero di globuli rossi normale o anche aumentato (anemia sideropenica e talassemia eterozigote). Nell’ambito delle anemie distinguiamo in base al livello emoglobinico:
anemia lieve (Hb superiore a 10 g/dl)
anemia moderata (Hb tra 8 e10 g/dl)
anemia severa (Hb inferiore a 8 g/dl)
SINTOMI E SEGNI CLINICI
I sintomi e i segni clinici del paziente con anemia dipendono dalla riduzione della concentrazione emoglobinica e dal meccanismo patogenetico che è alla base dell’ anemia. La riduzione della concentrazione dell’emoglobina è responsabile del pallore della cute e delle mucose e si traduce in una riduzione della capacità di trasporto di O2 nel sangue e in una conseguente ipossia tessutale, che è alla base dei sintomi che il paziente ha in quanto anemico. Si possono definire questi sintomi “sintomi generali” perché comuni a tutte le anemie. La presenza e l’entità di questi sintomi dipendono dal grado di anemia e dal tempo in cui questa si è sviluppata. Una anemia ad inizio insidioso con lenta e progressiva riduzione del livello emoglobinico permette infatti all’individuo, che abbia un sistema cardiocircolatorio e respiratorio integri, di adattarsi fino a concentrazione di emoglobina pari a 7-8 g/dl (a volte anche inferiori ) senza presentare una sintomatologia apprezzabile. Accade così che gli unici disturbi presentati da pazienti con gravi anemie croniche (anemia sideropenica, anemia refrattaria, anemia emolitica cronica, ecc..) siano:
una moderata astenia;
esauribilità fisica;
dispnea da sforzo;
tachicardia;
riduzione delle capacità di concentrazione e della memoria.
La preesistenza di condizioni patologiche che riducono la riserva funzionale cardiaca e respiratoria determinerà la comparsa della sintomatologia anche in anemia di grado moderato. Inoltre nelle persone anziane, la riduzione della concentrazione emoglobinica associata a ridotta portata circolatoria distrettuale può far emergere a livello clinico quadri di:
insufficienza coronarica;
insufficienza arteriosa degli arti inferiori;
disturbi ipossiemici cerebrali.
La sintomatologia soggettiva e l’obiettività sono più eclatanti quando la riduzione del livello emoglobinico si instaura acutamente. Nell’ anemia acuta infatti viene meno la possibilità di adattamento dell’organismo, e in particolare del sistema cardiovascolare alla nuova condizione, anche per riduzioni relativamente modeste della concentrazione emoglobinica. Così il paziente che ha in atto una crisi emolitica, o il paziente con anemia aplastica acuta, riferiranno al medico una transizione rapida da una condizione di completo relativo benessere a una condizione caratterizzata da:
astenia intensa;
dispnea al minimo sforzo;
cardiopalmo;
cefalea pulsante;
incapacità di applicarsi a qualsiasi attività sia fisica che intellettuale;
vertigine;
lipotimie, etc..
I segni clinici dell’ anemia acuta saranno quelli di un apparato cardiocircolatorio ipercinetico:
tachicardia;
aumento della pressione sistolica;
riduzione della pressione diastolica.
La valutazione dei sintomi e segni clinici generali permette quindi una prima fondamentale distinzione fra anemie acute e croniche.
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