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Scompenso cardiaco o insufficienza cardiaca



 

Definizione

Lo scompenso cardiaco o insufficienza cardiaca è una condizione patologica caratterizzata dall’incapacità del cuore di pompare una quantità di sangue (portata cardiaca) adeguata alle necessità metaboliche dell’organismo o, comunque, di essere in grado di farlo solo a spese di un aumento delle pressioni di riempimento in una o più camere cardiache nel circolo venoso a monte.

Epidemiologia

Lo scompenso cardiaco è una condizione patologica di frequente riscontro per il medico. In Europa la prevalenza oscilla dal 2 al 3%; pertanto sono affetti circa 15 milioni di persone. L’incidenza dello scompenso nella popolazione aumenta con l’età e raddoppia per ogni decennio dai 40 agli 80 anni.

 

Eziologia

Dal punto di vista clinico è utile classificare le cause dello scompenso in due categorie: cause primarie e cause precipitanti.

Cause primarie

Una condizione di scompenso cardiaco è nella maggior parte dei casi il risultato di un’ insufficiente funzione miocardica. Questa può essere determinata dalla perdita di una quota rilevante di tessuto miocardico, come nell’ infarto miocardico (la causa più frequente di scompenso cardiaco nei paesi occidentali), oppure da alterazioni strutturali e funzionali diffuse del miocardio, come nella cardiomiopatia dilatativa non ischemica o nelle miocarditi.

Cause precipitanti

I pazienti con insufficienza cardiaca sono spesso sufficientemente compensati, vale a dire asintomatici, almeno a riposo, in condizioni cliniche stabili, grazie a meccanismi endogeni di compenso. Tuttavia diversi fattori, che sopraggiungono in modo più o meno improvviso,  possono alterare l’equilibrio, talora precario, raggiunto dal paziente e causare un aggravamento del quadro clinico, determinando un peggioramento della funzione cardiaca o imponendo al cuore un carico di lavoro supplementare. In questi casi è importante individuare la causa che ha determinato l’aggravamento, perché spesso si tratta di condizioni reversibili che possono essere risolte con una terapia appropriata.

I fattori che più frequentemente sono implicati come cause precipitanti uno scompenso cardiaco sono:

Stress fisico, psichico, alimentare, ambientale

Ogni brusco cambiamento delle condizioni di vita che comporti per il cuore un sovraccarico di lavoro ( caldo, freddo, eccesso di sale nella dieta, emozioni, superlavoro ecc..) può rendere manifesto o peggiorare uno scompenso.

Ipertensione

Bruschi aumenti della pressione arteriosa impongono al cuore un significativo aumento di lavoro, che può far precipitare o aggravare uno scompenso cardiaco.

Aritmie

La comparsa di aritmie è un evento frequente nei pazienti cardiopatici e può far precipitare uno scompenso cardiaco in equilibrio precario. 

Infezioni sistemiche

Le infezioni possono far precipitare uno scompenso cardiaco sia in quanto determinano un aumento del lavoro cardiaco (a causa della tachicardia secondaria all’iperpiressia), sia per un aumento di citochine proinfiammatorie circolanti, che possono deprimere la contrattilità miocardica.

Aumento della portata cardiaca

La richiesta di aumento della portata cardiaca, per motivi fisiologici ( es. gravidanza) o per lo sviluppo di alcune condizioni fisiologiche (es. anemizzazione, tireotossicosi), può essere causa di aggravamento o anche del primo manifestarsi di uno scompenso cardiaco prima clinicamente latente.

Malattie renali

L’insufficienza renale, acuta e cronica, è associata a una ridotta secrezione di sodio, che può esacerbare la ritenzione idrica tipica dello scompenso.

Embolia polmonare

In alcuni casi fenomeni microembolici possono determinare un aumento della pressione nel circolo polmonare che si manifesta con un aggravamento di uno scompenso del ventricolo destro.

Riduzione inappropriata della terapia

La causa più frequente di peggioramento dello scompenso cardiaco è un’inappropriata autoriduzione della terapia da parte del paziente. E’ importante che qualsiasi variazione venga concordata con il medico curante.

Assunzione di farmaci controindicati o di sostanze tossiche

L’assunzione di farmaci che riducono la contrattilità cardiaca o di farmaci che aumentano la ritenzione idrica sono un’altra causa frequente di uno scompenso cardiaco. Inoltre, lo scompenso può essere aggravato da un’assunzione eccessiva di bevande alcoliche o sostanze tossiche (es. cocaina).

Altre malattie cardiache

Il sovrapporsi di una nuova malattia cardiaca (infarto miocardico, endocardite infettiva, miocardite) alla cardiopatia di base può fare precipitare in maniera drammatica, un’insufficienza cardiaca in precario equilibrio.

 



 

Classificazione dello scompenso cardiaco

Scompenso cardiaco cronico e acuto

Lo scompenso cardiaco cronico indica uno stato di insufficienza cardiaca, più o meno compensata, stabile nel tempo.

Il termine scompenso cardiaco acuto indica in genere la comparsa improvvisa o in breve tempo di sintomi e/o segni di insufficienza cardiaca importanti, che richiedono un trattamento rapido e urgente. Uno scompenso cardiaco acuto può verificarsi a causa di patologie che impongono improvvisamente al cuore un carico di lavoro eccessivo (es. grave crisi ipertensiva, rottura di un lembo valvolare per endocardite ecc..). Quadri clinici specifici molto gravi di scompenso cardiaco acuto sono: l’edema polmonare acuto e lo shock cardiogeno.

Scompenso cardiaco destro e sinistro

Scompenso cardiaco sinistro: è dovuto alla compromissione del ventricolo e/o dell’atrio sinistro, l’aumento della pressione venosa la congestione e l’edema si verificano nel circolo polmonare.

Scompenso cardiaco destro:gli stessi processi patologici hanno luogo nella circolazione venosa sistemica.

Nello scompenso cardiaco sinistro prevarranno i sintomi di dispnea e segni di stasi polmonare all’auscultazione toracica.

Nello scompenso cardiaco destro prevarranno i segni di una significativa congestione venosa periferica (turgore delle giugulari, edemi periferici, epatomegalia). Lo scompenso cardiaco sinistro è di gran lunga più frequente e ciò, perché le malattie cardiache che più spesso sono causa di insufficienza cardiaca (la cardiopatia ischemica, l’ipertensione arteriosa e i vizi valvolari importanti) coinvolgono esclusivamente o prevalentemente le sezioni sinistre del cuore.

 

Scompenso cardiaco sistolico e diastolico

L’insufficienza cardiaca sistolica è la forma più frequente; in questo contesto predomina l’incapacità del ventricolo di espellere la quantità di sangue sufficiente (diminuisce il volume sistolico e aumenta il volume telediastolico). La causa più frequente di scompenso sistolico è la cardiopatia ischemica, seguita da cardiomiopatia dilatativa.

Nell’insufficienza cardiaca diastolica il ventricolo non è in grado di rilasciarsi adeguatamente e di riempirsi in modo normale durante la diastole, mentre la frazione di eiezione rimane normale. Le cause principali di insufficienza cardiaca diastolica sono l’ipertensione arteriosa e l’ischemia. In ogni caso la condizione che si incontra con maggiore frequenza è la presenza di un’insufficienza cardiaca mista dovuta ad aterosclerosi coronarica che da un lato porta alla perdita di tessuto contrattile (insufficienza cardiaca sistolica) e dall’altra diminuisce la distensibiltà miocardica a causa della fibrosi (insufficienza cardiaca diastolica).

Scompenso anterogrado e retrogrado

Retrogrado: i sintomi si devono all’incapacità del ventricolo di espellere il sangue in quantità sufficiente, causando un aumento delle pressioni e dei volumi a monte che provoca congestione venosa.

Anterogrado: i sintomi sono causati dall’incapacità del ventricolo di far pervenire la quantità di sangue sufficiente al sistema arterioso, causando ipoperfusione periferica e diminuzione della perfusione renale,con conseguente aumento del riassorbimento tubulare di sodio e acqua.



Manifestazioni cliniche 

Sintomi di insufficienza cardiaca sinistra

La malattia causale dell’insufficienza cardiaca (vizi valvolari, ipertensione arteriosa, coronaropatia) ha la sua propria sintomatologia.

I segni e sintomi comuni a qualunque insufficienza cardiaca sinistra sono i seguenti:

  • Dispnea da sforzo: precipita come una sensazione di mancanza di respiro sotto sforzo. Si accompagna spesso a fatica, tosse, oliguria diurna e poliuria notturna, emottisi.
  • Ortopnea: sensazione di mancanza di respiro che compare quando il malato è disteso e si riduce quando si siede o si alza in piedi. Segno più grave della semplice dispnea da sforzo che può evolvere verso la respirazione ciclica di Cheyne-Stokes.
  • Dispnea parossistica notturna: compare nella notte nelle cardiopatie sinistre gravi (stenosi mitralica, vizio aortico, ipertensione arteriosa). Si accompagna a tosse, espettorato roseo e può preannunciare un edema polmonare, che è la manifestazione più drammatica dell’insufficienza cardiaca sinistra acuta. 

Sintomi dell’insufficienza cardiaca destra

E’ spesso secondaria a insufficienza cardiaca sinistra, i cui sintomi dominano in genere il quadro clinico.

  • Disturbi digestivi: nausea meteorismo, diarrea, epatalgie spontanee da sforzo.
  • Nella donna: disturbi mestruali, aborti, sterilità.
  • Oliguria diurna e poliuria notturna.
  • Cianosi, subittero.
  • Vene giugulari: sono turgide, si può osservare un reflusso epato-giugulare e alla compressione manuale del fegato.
  • Fegato: ingrandito, dolente, margine liscio e regolare.
  • Edemi e versamenti: gli edemi possono essere limitati agli arti inferiori (edemi malleolari) o essere generalizzati (anasarca) con versamento pleurico unilaterali o bilaterale, ascite.



Diagnosi

 

L’anamnesi e l’esame obiettivo sono sufficienti per porre diagnosi di insufficienza cardiaca.

Radiografia del torace

Le alterazioni radiologiche possono comparire prima dei sintomi. Quando la pressione venosa polmonare è normale in ortostatismo, le basi polmonari sono meglio perfuse rispetto ai vertici ed il calibro dei vasi è  maggiore a livello delle basi rispetto a quelli dei segmenti più apicali.

In caso di aumento della pressione capillare si osservano:

  • Edema settale, con comparsa di opacità lineari denominate linee di Kerley.
  • Edema perivascolare e peribronchiale che causa perdita di definizione e offuscamento del profilo dei vasi e dei bronchi di calibro medio.
  • Edema subpleurico (si visualizzano radiologicamente le scissure lobari). E’ denominato “tumore evanescente” perché scompare con la terapia diuretica.
  • Edema alveolare: che si manifesta con un infiltrato bilaterale prevalentemente centrale ad “ali di farfalla”. 

ECG

Può portare dati utili per riconoscere la presenza di eventuali patologie (cardiache, valvolare ecc..) o aritmie. E’inoltre, utile per identificare i pazienti che possono beneficiare di una terapia di resincronizzazione cardiaca.

 

Analisi di laboratorio

il BNP (peptide natriuretico cerebrale) è un nuovo marcatore tumorale, la cui determinazione può essere utile nel contesto della diagnosi dell’insufficienza cardiaca. Può aumentare in condizioni diverse dallo scompenso cardiaco per cui la sua specificità non è molto alta.

Ecocardiogramma colordoppler

L’esecuzione di un ecocardiogramma colordoppler possiede due finalità nel paziente con scompenso cardiaco:

  • Valutare l’eziologia dello scompenso (cardiopatia ischemica, valvulopatia  ecc..).
  • Monitorare gli effetti del trattamento.

Permette di valutare la massa ventricolare, le dimensioni delle camere cardiache, la cui funzionalità sistolica e diastolica è di riconoscere eventuali patologie cardiache e reversibili. Serve per valutare la risposta del trattamento intesa come miglioramento della frazione di eiezione e per valutare il rimodellamento ventricolare.

Coronarografia

Si deve effettuare in tutti i pazienti con disfunzione ventricolare sinistra di origine sconosciuta, per scartare la presenza di cardiopatia ischemica.

 



 

 

Terapia dello scompenso cardiaco cronico 

I principi alla base della terapia dello scompenso cardiaco cronico sono:

  • Prevenire il deterioramento della funzione cardiaca.
  • Diminuire il lavoro cardiaco.
  • Migliorare la contrattilità.
  • Prevenire la morte improvvisa (soprattutto dovuta ad aritmie ventricolari).
  • Identificare i pazienti candidati al trapianto.

 

Misure generali

  • Restrizione dell’apporto di sale. E’ una misura fondamentale e diminuisce la necessità di trattamento diuretico.
  • Esercizio fisico regolare. Tenendo conto delle limitazioni dovute alla malattia.
  • Limitare o evitare, soprattutto nella cardiomiopatia alcolica, il consumo di alcol.
  • Evitare i fans che possono provocare un peggioramento della funzione renale e ventricolare.
  • Controllo stretto della pressione arteriosa, del peso, come dato di aumento della congestione, e di tutti di rischi cardiovascolari in generale.​

La terapia farmacologica varia da paziente a paziente a seconda delle cause scatenanti.

Tra i farmaci prescrivibili rientrano:

  • ACE-inibitori: sono indicati in tutti i pazienti con insufficienza cardiaca sistolica, fino al momemento della diagnosi. Sono vasodilatatori misti, venosi e arteriosi; diminuiscono il precarico grazie all’effetto venodialtore; prevengono la progressione verso l’insufficienza cardiaca nei pazienti con disfunzione ventricolare sinistra asintomatica. Diminuiscono il rischio di morte improvvisa.
  • Beta bloccanti: migliorano la funzione ventricolare, e, come gli ACE-inibitori, riducono il rimodellamento e riducono il rischio di morte improvvisa.
  • Antialdosteronici (spironolattone e eplerenone): si utilizzano solo in pazienti che permangono sintomatici nonostante la terapia con farmaci che inibiscono il sistema renina-angiotensina-aldosterone e beta-bloccanti.
  • Ivabradina: l’ivabradina è indicata in presenza di ritmo sinusale e frequenza cardiaca > 70 bpm in pazienti con scompenso cardiaco a ridotta frazione di eiezione in caso di persistenza di sintomatologia e disfunzione ventricolare sinistra dopo trattamento medico ottimizzato con beta-bloccanti, inibitore del sistema renina-angiotensina-aldosterone ed antagonista dell’aldosterone.
  • Diuretici: i diuretici sono la terapia sintomatica di prima scelta. Il loro utilizzo non ha dimostrato aumentare la sopravvivenza. I più utilizzati sono i diuretici dell’ ansa. Al ridurre il volume di fluidi intracorporei, producono una diminuzione del precarico.
  • Digossina: si tratta di un farmaco inotropo positivo e inotropo negativo. Nei pazienti con insufficienza cardiaca a ritmo sinusale, il suo uso ha dimostrato una riduzione del numero di ricoveri ospedalieri per insufficienza cardiaca ma contemporaneamente un aumento dell’incidenza di artmie  e nessuna riduzione della mortalità.
  • Oltre a questi farmaci, il cardiologo potrà prescrivere nitrati per i dolori anginosi, statine per abbassare i livelli di colesterolo e farmaci anti-aggreganti e/o anticoagulanti per prevenire la formazione di trombi nei vasi.

Qualora la sola terapia farmacologica non fosse sufficiente oppure non ben tollerata dal paziente, è necessario associarvi anche la terapia elettrica attraverso l’impianto di dispositivi di resincronizzazione cardiaca. Si tratta di pacemaker tricamerali, che producono una stimolazione biventricolare che riduce la dissincronia intra e interventricolare.

Bypass aorto-coronarico 

Riparazione o sostituzione delle valvole cardiache 

Dispositivi di assistenza ventricolare (VAD) 

 

 Dispositivi di assistenza ventricolare etrapianto cardiaco

Il trapianto cardiaco è un trattamento efficace, che si riserva per quei pazienti con insufficienza cardiaca severa, refrattario alle terapie mediche abituali (terapia farmacologica e resincronizzazione), nei quali i rischi e la spesa sono realmente giustificati.

In caso di insufficienza cardiaca cronica con sintomi severi refrattari possono essere impiegati dispositivi di assistenza ventricolare. Possono essere utilizzati come ponte al trapianto, come ponte per valutare se il paziente è candidato a trapianto o come terapia di destinazione.

 

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