Scompenso Cardiaco in Medicina Generale

La medicina generale è ormai sempre piú orientata alla gestione del paziente cronico. A questo proposito una non irrilevante porzione di pazienti con malattie croniche è rappresentata da quelli con scompenso cardiaco. La gran parte dei pazienti con scompenso cardiaco acuto infatti ha una esacerbazione di uno scompenso cronico, con solo il 15-20% di patologie ’’de novo’’. Approssimativamente il 50% dei pazienti con scompenso cardiaco acuto ha una frazione di eiezione conservata. Meno del 5% dei pazienti presentano ipotensione e richiedono terapia con inotropi. Con un tale background, qual è il ruolo del medico di medicina generale in questo setting?

L’intenzione di questo articolo è quindi quella di analizzare la patologia da un punto di vista pratico con accenni diagnostici ma soprattutto terapeutici, tralasciando momentaneamente anamnesi, segni, sintomi, classificazioni e stadiazione (che è possibile trovare al seguente LINK).

LEGENDA: Durante il corso dell’articolo troverete vari avvisi colorati come ”Attenzione” o ”NB”; questi rappresentano suggerimenti pratici o spunti interpretativi da integrare con le varie indicazioni delle linee guida sopra riportate.

Ho un sospetto di Scompenso Cardiaco, quali esami sono necessari per un inquadramento di base (completo)?

L´American College of Cardiology Foundation/American Heart Association (ACFF/AHA) e l´ Heart Failure Society of America (HFSA) assieme all´ European Society of Cardiology (ESC) raccomandano i seguenti test di laboratorio ed approfondimenti al fine dell´inquadramento del paziente con sospetto scompenso cardiaco:

NB: Si riportano gli esami con un breve razionale del perché richiederli a lato

Esami di Laboratorio

-Emocromo (anemia/infezione come cause dello scompenso?)
-Analisi delle urine (proteinuria? Talvolta associata a patologie cardiovascolari)
–Elettroliti (ritenzione di fluidi? Disfunzioni renali?)
–BUN + creatininemia (riduzione dell´afflusso renale?)
–Glicemia a digiuno ( alti livelli possono indicare un aumentato rischio di scompenso cardiaco, sia nei diabetici che nei non diabetici)
–Funzionalitá epatica (disfunzione epatica/congestione da scompenso cardiaco?)
–BNP e NT-proBNP (aumentati nello scompenso cardiaco, stretta correlazione con classificazione NYHA) –>molto utili in caso di dubbio diagnostico in quanto bassi valori rendono improbabile la presenza di scompenso.
–TSH + profilo lipidico

Attenzione: BNP e NT-proBNP hanno probabilmente maggiore valore in una popolazione non selezionata come puó essere quella di un medico di medicina generale piuttosto che in una popolazione di soggetti ad alta probabilità di scompenso come in un reparto di cardiologia dove la loro utilità nel discriminare un reale scompenso cardiaco (o riacutizzazione) rispetto ad altre problematiche è probabilmente molto ridotta (raramente si avranno pazienti con BNP in range).

NB: Se esiste il sospetto di una sindrome coronarica acuta, come raccomandato dalla ESC, é opportuno provvedere ad ottenere livelli di Troponina come indici di danno miocitico.

Attenzione: va tenuto ben presente che la Troponina misurata in una popolazione di scompensati, probabilmente sarà positiva in una buona percentuale (generalmente con valori non elevatissimi, ma comunque decisamente superiori al cut off tradizionale). Quindi occorre che la richiesta di Troponina vada fortemente motivata sulla base del sospetto clinico per non catalogare erroneamente i pazienti come sindromi coronariche acute.

Esami strumentali

-ECG 12 derivazione (aritmia,ischemia/infarto, coronaropatie?)

–Rx del torace (2p PA+LL) (congestione polmonare,immagine cardiaca allargata?)

–Ecocardiografia + doppler (disfunzioni ventricolari/anormalitá valvolari?)

–Arteriografia coronarica in caso di storia di angina o sospetta disfunzione ventricolare sx ischemica (piú frequentemente richiesta giá in ambitio specialistico)

La ESC non suggerisce di eseguire test per la funzione polmonare poiché poco utili nella diagnosi di scompenso cardiaco. Tuttavia questo tipo di esami sono comunque da tenere presente nel caso sia necessario escludere cause polmonari di dispnea.

 

Di seguito si riporta per completezza una breve Flow-chart (linee guida ESC) per una migliore integrazione ed interpretazione degli esami sopra suggeriti

 

 

TRATTAMENTO

 

 

Scompenso cardiaco acuto

La terapia medica per lo scompenso cardiaco si focalizza nella gran parte dei casi su:

1)riduzione del precarico e del postcarico tramite vasodilatatori e diuretici (con risoluzione a breve termine della sintomatologia)

2)inibizione della cascata neuro-ormonale deleteria quale è quella di renina-angiotensina-adlosterone e quella del sistema simpatico (di Ace inibitori, Betabloccanti e Antagonisti dell´aldosterone).

In caso di scompenso cardiaco acuto la triade terapeutica di base è Ossigeno-Diuretici-Vasodilatatori

NB: Generalmente l´ossigeno é necessario soprattutto in presenza di SaO2 inferiore al 90%

Diuretici

Rappresentano ancora oggi il punto chiave della terapia dello scompenso cardiaco acuto nonché i farmaci di prima linea, il cui capostipite é rappresentato da diuretici dell´ansa (Furosemide, Torasemide ecc ecc).
In questi pazienti NON è consigliata la somministrazione del farmaco per OS poiché il probabile edema dell´intestino potrebbe ostacolarne l´assorbimento con formulazione orale. Le altre forme sono accettate, in particolar modo é suggerita quella endovenosa, la quale rappresenta il gold standard.

NB in pazienti con scompenso cardiaco ipertensivo è possibile utilizzare i diuretici tiazidici (es. metolazone, idroclorotiazide) per il loro maggior effetto antipertensivo nel tempo.

La dose (20-200 mg/die) e la frequenza dei diuretici è molto variabile e dipende dalla risposta del paziente dopo 2-4 h, non é saggio quindi fornire uno standard universale. Se la diuresi permane inadeguata si raccomanda un aumento di dose o l´aggiunta di un diuretico tiazidico, anche se in generale è sempre meglio evitare l’associazione tra diuretici dell’ansa e tiazidici, a meno che sia possibile controllare frequentemente elettroliti e creatinina, poiché il rischio di ipopotassiemie è tangibile.

NB: l´equivalenza tra Furosemide e Torasemide è circa di 2:1 , ovvero 40 mg/die di Furosemide equivalgono a circa 20 mg di Torasemide. L´equivalenza tra Furosemide endovena/i.m e Furosemide per OS è di 1:2, ovvero 20 mg e.v. equivalgono a 40 per OS, mentre la Torasemide ha equivalenza Os:e.v/ di 1:1.

Attenzione: Se il paziente con scompenso è iperteso non è per forza un male!!! Significa maggior spazio per la titolazione della ”vera terapia antiscompenso’’ (es. ACE-inibitori, Betabloccanti ecc.), la quale è l´unica in grado di modificare la storia della malattia.

Vasodilatatori

Raccomandati come adiuvanti alla terapia diuretica con la seguente restrizione:

Cautela al loro uso nei pazienti con Pressione Sistolica < a 100 mmHg o con significativa stenosi mitralica o aortica

1)I nitrati sono potenti venodilatatori e vasodilatatori coronarici. Possono essere usati in diverse forme (sublinguale, orale, transdermica ecce cc) ma in questa condizione la via suggerita rimane comunque, ove possibile, l´endovenosa.

2)Il Nitroprussiato sodico è un potente farmaco dilatatore arterioso, particolarmente utile per i pazienti che presentano congestione polmonare severa, ipertensione e rigurgito mitralico. Purtroppo necessita di un attento monitoraggio sia emodinamico che per la tossicitá (cianidi).

Attenzione: Nello scompenso acuto, al di là di ciò che dicono le linee guida, non è così frequente avere lo spazio all’utilizzo reale dei vasodilatatori e.v. Questo perché i pazienti sono generalmente ipotesi e non conviene ”giocarsi nell’uso del nitrato’’ quei pochi mmHg di PA che invece possono servire alla titolazione della terapia antiscompenso senza rischiare di creare ipotensione sintomatica ( es. ipoperfusione renale). Al contrario, è molto più frequente l’utilizzo degli inotropi, tipici del setting ospedaliero. Diverso invece il caso di paziente iperteso, nel qual caso i nitrati possono avere un maggiore spazio.

Ma posso davvero trattare fuori dall´ospedale uno scompenso cardiaco acuto?

In linea generale un paziente che risulta refrattario alla terapia standard necessita sempre di ospedalizzazione al fine di ricevere diuretici, vasodilatatori e agenti inotropi e.v. in un regime controllato.
L´ Heart Failure Society of America (HFSA) raccomanda l´ospedalizzazione per lo scompenso cardiaco acuto in caso di:

-Scompenso acuto severo (bassa pressione, riduzione funzionalitá renale,alterazione attivitá mentale)
-Dispnea a riposo
-Aritmie emodinamicamente significative-Sindrome coronarica acuta
-Congestione in peggioramento con o senza dispnea-Peggioramento dei segni e sintomi della congestione sistemica o polmonare, anche in assenza di aumento di peso
-Anormalitá maggiori degli elettroliti-Presenza di comorbiditá (es. Polmonite,embolia polmonare, chetoacidosi diabetica, stroke, sintomi stroke-like)
-Nuova diagnosi di scompenso cardiaco CON segni di congestione attività sistemica/polmonare
-Ripetute scariche dell´ ICD (implantable-cardioverter-defibrillator)

Da questo se ne deduce come i casi di scompenso acuto che possono essere gestiti sul territorio sono molto limitati (se non virtuali), tuttavia un precoce e corretto inquadramento grazie alle indagini di base indicate in precedenza potrebbe accelerare il processo diagnostico portando ad un intervento terapeutico piú rapido in massima sinergia con gli specialisti e le strutture ospedaliere.

 

Scompenso cardiaco cronico  Sx con ridotta Frazione di Eiezione

TRATTAMENTO FARMACOLOGICO 

 

 Il trattamento farmacologico di pressoché ogni tipo di scompenso cardiaco è il seguente e puó essere riassunto in TRE regole fondamentali:

UNO: In tutti i pazienti con FE (frazione di eiezione) < 40% l´uso di un Ace inibitore o Sartanico (ARBs) in aggiunta ad un betabloccante é consigliato.

DUE: Un Antagonista del recettore dei mineralcorticoidi dovrebbe essere utilizzato in tutti i pazienti con sintomi persistenti (NYHA II-IV) nonostante l’utilizzo di Ace inibitori e Betabloccante. In caso di impossibilitá all’utilizzo di un Antagonista dei mineralcorticoidi é possibile tentare l’aggiunta di un Sartanico (doppio blocco Ace-inibitori + Sartanico)

TRE: Se vi é persistenza di sintomi o intolleranza a Betabloccanti + Frequenza Cardiaca > 75 bpm (ritmo sinusale) + FE molto depressa (< 35%) é suggerito l’uso di Ivabradina

Attenzione: Nella visione attuale, per parlare di scompenso cardiaco a FE preservata (HFpEF), la FE deve essere davvero preservata (cioè >50%) in tutti gli altri casi in cui c’è disfunzione sistolica si parla comunqe di HF classico (HFrEF). Il cut off del 40% era ed è ancora riportato in alcune linee guida perché nei vecchi studi sullo scompenso sistolico  venivano tendenzialmente arruolati solo pazienti con FE severamente compromessa, mentre nella visione attuale tale limite è stato progressivamente innalzato (fino ad arrivare all’attuale concetto della “reale” preservazione della FE).In realtà, per quegli stessi motivi (e in una visione più concreta e attuale) i benefici di questi farmaci probabilmente si estendono a tutti i pazienti con Scompenso Cardiaco e FE ridotta (ovvero <50%);

NB: La digitale può essere data nei casi di Scompenso Cardiaco a Frazione di Eiezione preservata in caso di persistenza dei sintomi nonostante terapia ottimale. In realtà,visto il trade-off tra rischio/beneficio si tende ad usare solo nei pazienti con HFpEF + fibrillazione atriale (generalmente in una strategia di controllo della FC).

ACE INIBITORI/ARBs

Si riportano le dosi Target di alcune molecole che hanno dimostrato di aumentare la sopravvivenza/ridurre la mortalitá/ridurre ospedalizzazioni.Importante è iniziare da una dose più bassa (di partenza) andando a crescere nel tentativo del raggiungimento della dose target (titolazione).

Ace inibitori

Captopril: 25/50 mg TID (dose di partenza  6,25 mg TID)
Enalapril 10/20 mg BID (dose di partenza  2,5 mg BID)
Lisinopril 20/35 mg/die (dose di partenza  2,5/5 mg/die)
Ramipril 5 mg BID (dose di partenza  2,5 mg/die)

NB: Le maggiori evidenze sono comunque a carico degli Ace inibitori che sono quindi sempre da preferire

ARBs

Valsartan 160 mg BID (dose di partenza  40 mg/die)
Candesartan 32 mg/die (dose di partenza  4/8 mg/die)

Attenzione: Dopo l’avvio di Ace inibitori (o Sartanici), un certo grado di peggioramento della creatinina rispetto al basale, nei limiti di normalitá, può essere atteso, e non deve indurre alla sospensione (o alla riduzione) del farmaco, a patto che tale peggioramento si stabilizzi su valori accettabili.

 

BETA BLOCCANTI

Si riportano le dosi Target di alcune molecole che hanno dimostrato di aumentare la sopravvivenza/ridurre la mortalitá/ridurre ospedalizzazioni. Importante è iniziare da una dose più bassa (di partenza) andando a crescere nel tentativo del raggiungimento della dose target (titolazione).

Con azione alfa 1 bloccanti:
Carvedilolo 25-50 mg BID (dose di partenza  3,125 mg BID)

Selettivi per recettori Beta-1:
Metoprololo 200 mg/die (rilascio prolungato) (dose di partenza  12,5/25 mg/die)
Bisoprololo 10 mg/die (dose di partenza  1,25 mg/die)

Attenzione: In generale, tra i betabloccanti, nello scompenso il più usato è il Bisoprololo. Al contrario il Carvedilolo determina maggior ipotensione (e quindi meno possibilità di titolazione), per quanto riguarda il Metoprololo si tende a preferire di solito nei pazienti con cardiopatia ischemica.

 

ANTAGONISTI ALDOSTERONE

Si riportano le dosi Target di alcune molecole che hanno dimostrato di aumentare la sopravvivenza/ridurre la mortalitá/ridurre ospedalizzazioni. Importante è iniziare da una dose più bassa (di partenza) andando a crescere nel tentativo del raggiungimento della dose target (titolazione).

Eplerenone 50 mg/die (dose iniziale 25 mg/die)

Attenzione: A dispetto di ciò che dicono le linee guida, in Italia si usa sostanzialmente lo Spironolattone (spesso in associazione con la Furosemide, dose standard 25+37 mg/die), oppure, il Canrenone (metabolita dello Spironolattone) 50/100 mg/die, il quale tuttavia non ha alla base citazioni in grandi studi.

 

IVABRADINA

Dose iniziale 5 mg BID valutando Frequnza Cardiaca dopo circa 2 settimane:

– FC tra 50-60 bpm: mantengo la dose
– FC < 50 bpm: riduco la dose a 2,5 mg BID
– se > a 60 bpm: aumento la dose a 7,5 BID

Attenzione: Per una questione di sicurezza il Target di Frequenza Cardiaca é verosimilmente meglio tenerlo ai limiti superiori intorno ai 60 bpm (senza superare i 70 bpm) in modo da non ridurre troppo la portata cardiaca, dato che il paziente non puó essere monitarato h 24 e le variazioni di frequenza circardiane sono molteplici.

 

ALTRI

Dosi piú comunemente utilizzate, tenendo ben presente che in questo caso il target è mantenere l´euvolemia del paziente o il cosiddeto ‘’dry weight’’ con la minor dose possibile di diuretico, evitando disidratazione, ipotensione e disfunzione renale.

Diuretici dell´ansa:
Furosemide 40-240 mg (dose di partenza 20-40 mg/die)
Torasemide 10-20 mg (dose di partenza 5-10 mg/die)

Diuretici Tiazidici:
Idroclorotiazide 12,5-100 mg (dose di partenza 25 mg/die)
Indapamide 2,5-5 mg (dose di partenza 2,5 mg/die)

NB: se un diuretico potassio disperdente è utilizzato in concomitanza a Ace inibitori (o Sartanici) e Antagonisti dell´Aldosterone la supplementazione di potassio sovente non è necessaria. Non è consigliato invece generalmente utilizzare diuretici risparmiatori di potassio assieme a Ace inbitori (o Sartanici) e Antagonisti dell´Aldosterone.

Attenzione: Importantissimo é il costante e preciso monitoraggio della dose dei diuretici anche mediante l´automisurazione del peso del paziente (cosa in cui alcuni pazienti possono essere educati). In caso di ipotensione sintomatica é corretto ridurre la dose del diuretico piuttosto che sospendere i veri farmaci ”antiscompenso” quale per esempio Ace inibitori e Betabloccanti, ma sempre con prudenza e attenzione perché la riduzione troppo brusca o eccessiva determina riacutizzazione dello scompenso stesso.

 

NB: in questo articolo non si parlerá di TAO; in linea molto generale la sola depressione della Frazione di Eiezione in assenza di fattori di rischio/indicazioni a scoagulazione non sono fattori sufficienti a giustificarne l’inizio.

Farmaci non raccomandati

 L´ ACCF/AHA e l´ESC sconsigliano fortemente l´uso di:

1)FANS (attenzione anche ai prodotti da banco, che i pz tendono ad assumere al bisogno talvolta con leggerezza)
2)Antiaritmici (tra questi ultimi l´Amiodarone ha dimostrato uni dei profili piú sicuri)
3)Calcioantagonisti (I Diidropiridinici tuttavia, come Amlodipina e la Barnidipina, possono essere considerati relativamente sicuri per il trattamento dell´ipertensione o delle patologie ischemiche in questi pazienti)
4)Tiazolidinedioni: non dovrebbero essere impiegati per  trattare pazienti con diabete mellito e scompenso cardiaco.

NB: Particolare attenzione anche alle terapia con Corticosteroidi in particolar modo se a dosi elevate e per periodo prolungato. Antidolorifici suggeriti: Paracetamolo, Oppiodi, cardioASA.

Attenzione: Prima di procedere occorre sottolineare che le dosi consigliate come ”target” nelle linee guida sono difficilmente raggiungibili nella ”vita reale”,poiché i pazienti inclusi nei trial sono spesso purtroppo profondamente diversi dai pazienti reali. La titolazione del farmaco va tuttavia tentata ed eventualmente mantenuta ad un dosaggio inferiore, che rappresenti peró il miglior livello di sicurezza per il paziente. Il Medico di Medicina Generale ha un ruolo fondamentale in questa fase della cura del paziente. Infatti spesso i pazienti vengono dimessi dagli ospedali ancora in fase di titolazione (con ampi margini per ottimizzarla); la terapia non si dovrebbe quindi cristallizzare su quella delineata nella lettera di dimissione

 

TRATTAMENTO NON FARMACOLOGICO

 

1)Trattare ipertensione e disordini lipidici
2)Incoraggiare la cessazione del fumo
3)Scoraggiare l´uso di alcol e droghe
4)Promuovere controllo e prevenzione ottimali di diabete mellito, insulino-resistenza e rischio vascolare
5)Incoraggiare attivitá fisica aerobica al fine di migliorare le capacitá funzionale e i sintomi. L’attività fisica tuttavia dovrebbe essere limitata durante l’esacerbazione di scompenso cardiaco e in pazienti con sospetta miocardite
6)Incoraggiare la perdita di peso se il paziente è obeso o sovrappeso
7)Il sodio nella dieta dovrebbe essere ridotto a 2-3 g/die in accordo con ACCF/AHA,ESC e HFSA
8)La quota totale di fluidi non dovrebbe superare i 2 L/die  per i pazienti con evidenza di iponatremia (<130 mEq/dL) e per i soggetti il cui ”fluid status’’ è difficile da controllare nonostante la restrizione di sodio e l´uso di alte dosi di diuretici.

Scompenso cardiaco cronico sx con Frazione di Eiezione conservata

 

Attualmente quasi nessun trattamento ha dimostrato in modo convincente di ridurre morbiditá e mortalitá in pazienti con Scompenso Cardiaco e FE conservata. Il trattamento è infatti fondamentalmente indirizzato ad alleviare i sintomi.

1)La terapia diuretica rimane comunque raccomandata per ridurre la ritenzione di fluidi.

2)Ace inibitori/Sartanici sono generalmente i piú indicati per i pazienti diabetici, ipertesi, con pregresso infarto miocardico, o con aterosclerosi. Candesartan, Irbesartan o Perindopril non hanno dimostrato di ridurre la mortalitá ma hanno prodotto un primo trend di miglioramento per quanto riguarda la morbiditá e le ospedalizzazioni. Alcune evidenze mostrano come Losartan e Valsartan potrebbero promuovere un miglioramento nella funzione diastolica riducendo l´ipertrofia ventricolare sinistra.

3)I Betabloccanti sono indicati per i pazienti con pregresso infarto miocardico o ipertensione e per il controllo della frequenza.

4)I Calcioantagonisti non sembrerebbero controindicati.

NB nel registro ADHERE i soggetti trattati con Betabloccanti hanno dimostrato una piú alta mortalitá. Le modifiche dello stile di vita (vedi “Trattamento non farmacologico”) suggerite per lo scompenso cardiaco a frazione di eiezione ridotta valgono in linea di massima anche per lo scompenso a frazione di eiezione conservata.

 

 

Quali accorgimenti avere invece in un paziente con decompensazione di uno scompenso giá noto (ADHF)?

L´ACCF/AHA raccomanda quanto segue:

1)La terapia orale dovrebbe essere continuata ed eventualmente aumentata nella gran parte dei pazienti con scompenso cardiaco con ridotta frazione di eiezione.

2)Continuare Ace inibitori o Sartanici e betabloccanti poiché statisticamente ben tollerati e associati ad outcomes migliori nella gran parte dei pazienti

3)Sospensione di beta-bloccanti o riduzione di dose dovrebbe essere considerata SOLO in pazienti ospedalizzati dopo un recente inizio di beta-bloccanti o un recente aumento di dosaggio, oppure nei soggetti con franco sovraccarico di volume o basso output cardiaco

4)Nei pazienti con significativa riduzione della funzionalitá renale, la riduzione di dose temporanea o interruzione di Ace inibitori, Sartanici e/o Antagonisti dell´Aldosterone dovrebbe essere considerata fino al miglioramento della funzione renale

 

AUTORE

Daniele Angioni

Si ringrazia  la dott.ssa Silvia Busceti per l’aiuto fornito alla realizzazione di questo articolo

Un ringraziamente speciale al Dott. Enrico Boggio (spec.ndo Cardiologia) che ha contribuito alla revisione di questo articolo in nome della sinergia tra specialisti e medici di medicina generale, preziosi alleati per la gestione e la cura ottimale del paziente.  

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