47-Insuffisance cardiaque

VI#47&INSUFFISANCE&CARDIAQUE&
1!
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1!
Insuffisance&cardiaque&
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1. Définition&:&
"!#$%&'&%()*!+,!%-,.!/!&00,.1.!,$!+*2()!0&$3,($!0,44(0&$)!'5,.!%5,6.(.!710!2105($0!8*)&257(9,10!
1)!*$1.3*)(9,10!+10!)(00,0:!
;<($0,44(0&$%1!%&.+(&9,1!'1,)!=).1!>!!!
? @(3,A!5,!%B.5$(9,1!CD1.81!,7)(81!+<*657,)(5$!+1!$582.1,010!8&7&+(10!%&.+(5?6&0%,7&(.10E!
? F&,%B1!CGGGEH!+.5()1H!5,!3752&71!%5$310)(61!!
? IJ0)57(9,1!C&$58&7(1!+1!7<*K1%)(5$!61$).(%,7&(.1E!
? L(&0)57(9,1!C&$58&7(1!+1!.18'7(00&31E!!
? IJ0)575?+(&0)57(9,1!
!
Epidémio&:&
? M.5$50)(%!3.&61!>!NO!P!+1!+*%Q0!&'.Q0!N!&$0!+<*657,)(5$!
? ROO!OOO!'1.05$$10!%5$%1.$*10!1$!S.&$%1!!
? #$%(+1$%1!1$!'.53.100(5$!%58')1!)1$,!+,!6(1(77(00181$)!+1!7&!'5',7&)(5$!
? M.*6&71$%1!>!+1!OHTP!/!UP!0175$!710!'&J0!CVO!8(77(5$0!+1!'&)(1$)0!+&$0!7<W:X:E!
? #$%(+1$%1!>!+1!V!/!N!'5,.!VOOO!Y!&$!
? Z50'()&7(0&)(5$!7(*1!/!,$1!#[!>!THVP!+10!B50'()&7(0&)(5$0!1$!8*+1%($1!3*$*.&71!
? [5\)!+1!%1))1!'&)B5753(1!>!%58'.(0!1$).1!VHN!1)!UH]!8(77(&.+0!+<1,.50!!
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2. Etiologies&:&
4&grandes&causes&:&
? ^&,6&(01!%5$).&%)(7()*!
? _20)&%71!/!7<*K1%)(5$!!
? _20)&%71!&,!.18'7(00&31!!
? I,.%B&.31!657,8(9,1!
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2!
Etiologie
artère aorte
artère
pulmonaire
veine cave supérieure
veines pulmonaires
V.D
V.G
O.D
O.G
veine cave inférieure
valve
mitrale
valve tricuspide
valve aortique
(sygmoïde)
valve pulmonaire
! Mauvaise contractilité
- Cardiopathies ischémiques (angor, infarctus)
- Cardiomyopathies primitives (forme dilatée ++)
infectieuses (myocardite virale ++)
toxiques
4 grandes causes
- Mauvaise contractilité
- Obstacle à l’éjection
- Obstacle au remplissage
- Surcharge volumique
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&
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• Mauvaise&contractilité&:&
? [&.+(5'&)B(10!(0%B*8(9,10!C&$35.H!($4&.%),0E!!+*4(%()!+1!7&!45.%1!%5$).&%)(71!
? [&.+(58J5'&)B(10!>!
 '.(8()(610!C45.81!+(7&)*1!GGE!!
 ($41%)(1,010!C8J5%&.+()1!6(.&71!GGE!
 )5`(9,10!C&7%557H!&$).&%J%7($10aE!
&
• Obstacle&à&l’éjection&:&&,381$)&)(5$!+1!7&!'50)%B&.31&
o A&Gauche&:&
? ZJ'1.)1$0(5$!0J0)*8(9,1!CZD@E!>!1$).&($1!+<&25.+!,$1!BJ'1.).5'B(1!%&.+(&9,1!
',(0!'1)()!/!'1)()!+*%58'1$0&)(5$!1)!*',(0181$)!
? b*).*%(00181$)!&5.)(9,1!!
? [5&.%)&)(5$!&5.)(9,1!
o A&Droite&:!ZJ'1.)1$0(5$!',785$&(.1!'.(8()(61!C.&.1E!5,!01%5$+&(.1!/!,$1!8&7&+(1!
',785$&(.1!>!!
? [-,.!',785$&(.1!&(3,!C18257(1E!!
? [-,.!',785$&(.1!%B.5$(9,1!CcM[_H!&0)B81E!/!,$1!($0,44(0&$%1!%&.+(&9,1!3&,%B1!
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• Obstacle&au&remplissage&:&
o A&Gauche&:!b*).*%(00181$)!8().&7!
o A&Droite&:&
? b*).*%(00181$)!).(%,0'(+(1$!!
? M*.(%&.+()1!%5$0).(%)(61!

VI#47&INSUFFISANCE&CARDIAQUE&
3!
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3!
Insuffisance cardiaque
perfusion tissulaire
Physio-pathologie
vasoconstriction
activation !
fréquence cardiaque
consommation d’O2
down régulation récepteurs "
effet toxique sur cardiomyocytes
précharge et postcharge
aggravation
angiotensine
aldostérone
hypervolémie
activation SRA
• Surcharge&volumique&:&@,381$)&)(5$!+1!7&!'.*%B&.31!
o A&Gauche&:&
? #$0,44(0&$%1!8().&71!!
? #$0,44(0&$%1!&5.)(9,1!
o A&Droite&:&
? #$0,44(0&$%1!).(%,0'(+(1$$1!!
? [588,$(%&)(5$!($)1.%&6()&(.1!
!
• Valvulopathies&et/ou&malformations&:&
o Soit&par&rétrécissement&:!+(44(%,7)*!+<*K1%)(5$!
o ZJ'1.'.100(5$!+&$0!71!dF!
o ZJ'1.).5'B(1!.*&%)(5$$1771!+,!dF!
o L(7&)&)(5$!+1!7<5.1(771))1!F!C!4(2.(77&)(5$!&,.(%,7&(.1E!
o -+Q81!+,!'5,85$!
o soit&par&insuffisance&:!!.147,`!0&$3,($!61.0!7<5.1(771))1H!0)&01H!*',(0181$)!
!
• Autres&étiologies&:&
o [&.+(58J5'&)B(1!520).,%)(61!>!8&7&+(1!%5$3*$()&71H!1$).&($&$)!BJ'1.).5'B(1!+,!dF!
o [&.+(58J5'&)B(1!$5$!520).,%)(61!>!+(&2*)(9,1!
o ZJ'1.)BJ.5e+(1!"!%&.+(5)BJ.*501!>!'&.!1`%Q0!+1!b!2=)&!%&.+(9,10!!0)(8,7&)(5$!
%B.5$(9,1!+,!%-,.!
o #$0,44(0&$%1!.10'(.&)5(.1!"!%-,.!',785$&(.1!%B.5$(9,1!
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3. Physio#pathologie&:&
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4!
• Conséquences&de&l’insuffisance&:!!
o [5$0*9,1$%1!+<&6&7!>!
 L(8($,)(5$!+,!+*2()!%&.+(&9,1!!ZJ'5'1.4,0(5$!)(00,7&(.1!
 b1($!%&.+(&9,1!>!.*)1$)(5$!BJ+.5?05+*1!;(8()&)(5$!8,0%,7&(.1!45$%)(5$$1771!
o [5$0*9,1$%1!+<&85$)!>!
 ZJ'1.'.100(5$!61($1,01!
 I(3$10!+1!%5$310)(5$!>!!
? !!_1+Q81!',785$&(.1!($)1.0)()(17!'5,.!7<#dF!C'5,85$!%&.+(&9,1E!'5,6&$)!
+161$(.!&76*57&(.1!C_@ME!!
? !!!S5(1!%&.+(&9,1!1)!_1+Q810!'*.('B*.(9,10!'5,.!7<#dL!
!
• Mécanisme&compensateur&:!LJ045$%)(5$!+,!dF!>!!
o Activation&neuro#endocrine&:!
? @%)(6&)(5$!+,!0J0)Q81!0J8'&)B(9,1H!&6&$)!8=81!7f&''&.()(5$!+1!0(3$10!%7($(9,10!
 &,381$)&)(5$!+1!7&!$5.&+.*$&7($1!1$!%5..*7&)(5$!&61%!S1dF!1)!85.)&7()*!
 +(8($,)(5$!+1!7&!+1$0()*!+10!.*%1')1,.0!c=)&!C+5g$!.*3,7&)(5$!>!
.*%1')1,.0!+(0'&.&(00&$)!+1!7&!0,.4&%1!+10!%177,710H!+5$%!$5$!&%%100(271!
&,`!%&)*%B57&8($10!C".*%1')1,.0!+52,EE!!
? @%)(6&)(5$!+,!0J0)Q81!&$3(5)1$0($1!.*$($1!C[4!%5,.0!0,.!%51,.!'5,.!85+&7()*!+1!
8(01!1$!K1,E!>!!
 &$3(5)1$0($1!##!"h!&7+50)*.5$1!"h!.*)1$)(5$!017!!
 &$3(5)1$0($1!##!"!',(00&$)!6&05%5$0).(%)1,.!C"h!&,381$)&)(5$!M@EH!
0)(8,71!0J$)BQ01!%177,710!8J5%&.+(9,1!!
? I*%.*)(5$!+1!6&05'.100($1H!B5.85$1!BJ'5)B&7&85?BJ'5'BJ0&(.1!1$).&i$&$)!,$1!
.*)1$)(5$!BJ+.505+*1!!
? I*%.*)(5$!+f1$+5)B17($1H!0*%.*)*1!'&.!7f1$+5)B*7(,8!6&0%,7&(.1H!%f10)!71!'7,0!
',(00&$)!6&05%5$0).(%)1,.:!I&!0*%.*)(5$!'.*%5%1!75.0!+f($0,44(0&$%1!%&.+(&9,1!
1$).&i$1!,$1!BJ'5'1.4,0(5$!)(00,7&(.1!!
o Hypertrophie&myocardique&:!
? ^5+(4(%&)(5$!+1!7&!45.81!+,!dF!C+f177(')(9,1H!(7!+16(1$)!3752,71,`E!
? Z&,001!+1!7f*'&(001,.!8J5%&.+(9,1H!&,381$)&)(5$!%5$).&($)1!0J0)57(9,1!!
? L(0'&.()(5$!+10!.*01.610!+f($5).5'(081!/!7f5.(3($1!+f&.J)B8(1!61$).(%,7&(.10!!
? [1))1!BJ'1.).5'B(1!10)!2(1$!%5..*7*1!/!7&!85.2(+()*!!
o Dilatation&cardiaque&:&b185+17&31!61$).(%,7&(.1!C2(1$!%5..*7*!/!7&!85.2(+()*E!!
o Synthèse&de&collagène&cardiaque!

VI#47&INSUFFISANCE&CARDIAQUE&
5!
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5!
4. Clinique&:&
4.1 Différents&syndromes&:&
• Insuffisance&ventriculaire&gauche&(IVG)&:!
? Dyspnée&C0(3$1!8&K1,.E!>!
 +<1445.)!C'57J'$*1!0,'1.4(%(1771E!!
 +1!+*%,2(),0!C5.)B5'$*1E!!
 '&.5`J0)(9,1!C-+Q81!&(3,!+,!'5,85$E!
? Autres&signes&:!
 @0)B*$(1!GY?!(8'5.)&$)1!0175$!71!0)&+1!+<*657,)(5$!!
 ZJ'5)1$0(5$!!
 @!7<&,0%,7)&)(5$!>!
• bj710!+1!0)&01!',785$&(.1!C%.*'()&$)0H!2(7&)*.&,`!/!7<($0'(.&)(5$EH!
*'1$%B181$)!'71,.&7!
• D&%BJ%&.+(1!GY?!.*3,7(Q.1!!
• c.,()!+1!3&75'!C.J)B81!/!k!)18'0!ck!5,!cTE!!
• I5,4471!B5750J0)57(9,1!+<($0,44(0&$%1!8().&71!45$%)(5$$1771!
&
• Complication&:&œdème&aigu&du&poumon&:&
? Crise&de&dyspnée&paroxystique&#>&Inondation&alvéolaire&et&hypoxie&aiguë&
? Urgence&mettant&en&jeu&le&pronostic&vital&
? L*2,)!2.,)&7!C3=$1!.10'(.&)5(.1H!3.*0(77181$)!7&.J$3*E!
? #$0)&77&)(5$!.&'(+1!+<,$1!($)1$01!'57J'$*1!&$35(00&$)1!C)(.&31H!2&))181$)0!+10!&(710!+,!
$1lH!0,1,.!&25$+&$)1E!
? D5,`!1)!1`'1%)5.&)(5$!85,001,01H!'&.45(0!0&,85$*1!!
? bj710!%.*'()&$)0!0,.!)5,)!71!%B&8'!',785$&(.1!!
? c.,()0!+,!%-,.!&005,.+(0H!)&%BJ%&.+(1H!BJ'5)1$0(5$!
&
? Insuffisance&ventriculaire&droite&(IVD)&:!
? Dyspnée&:&s(!%&,0*1!'&.!>!($0,44(0&$%1!%&.+(&9,1!3&,%B1!5,!'&)B5753(1!',785$&(.1!
? Foie&cardiaque&:&!
 Z*'&)58*3&7(1H!Z*'&)&73(1!+<1445.)!>!05,0?%50)&71!+.5()1!5,!*'(3&0).(9,1!
C'10&$)1,.!5,!%5$0).(%)(5$E!!
 b147,`!B*'&)5?K,3,7&(.1H!),.310%1$%1!K,3,7&(.1!