sica

Dossier Thématique - Novembre 2017: Syndromes d'insuffisance cardiaque aiguë

  • Lignes directrices pratiques et factuelles
  • Diaporama commentés et téléchargeables
  • Take home message
  • Interview d'experts
  • 1) Introduction et Points clés

    2) Exposé

    3) Diaporama ppt

    4) Interview d'experts

    [02/06/2017]

    5) Bibliographie BUS

    Pour aller plus loin...

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    med_description_longue => '<p><strong>Introduction</strong></p> <p>Le parcours hospitalier des patients souffrants d&rsquo;insuffisance cardiaque aigu&euml; (ICA) n&rsquo;a jamais &eacute;t&eacute; analys&eacute;. La multiplicit&eacute; des fili&egrave;res pourrait influer la morbi-mortalit&eacute;.</p> <p><strong>Objectif</strong></p> <p>Caract&eacute;riser les parcours pr&eacute;-hospitaliers et hospitaliers de patients pr&eacute;sentant des sympt&ocirc;mes d&rsquo;ICA.</p> <p><strong>M&eacute;thodes</strong></p> <p>Enqu&ecirc;te prospective, multicentrique nationale, de suivi d&rsquo;une cohorte. R&eacute;alisation d&rsquo;une fiche de recueil de donn&eacute;es sur le parcours, les traitements entrepris, les caract&eacute;ristiques cliniques et biologiques et sur la mortalit&eacute; hospitali&egrave;re de patients atteints d&rsquo;ICA. Les donn&eacute;es &eacute;taient collect&eacute;es prospectivement dans chaque centre. Le crit&egrave;re d&rsquo;&eacute;valuation principal &eacute;tait la nature des fili&egrave;res suivies par les patients. Les crit&egrave;res secondaires concernaient les traitements administr&eacute;s, le profil clinique et biologique des patients et la mortalit&eacute; hospitali&egrave;re.</p> <p><strong>R&eacute;sultats</strong></p> <p>Entre le 1/6/2014 et le 1/5/2016, 1.822 patients ont &eacute;t&eacute; inclus dans 24 centres. L&rsquo;&acirc;ge moyen &eacute;tait de 78 ans et il y avait 52% d&rsquo;hommes. La dur&eacute;e m&eacute;diane des s&eacute;jours &eacute;tait de 7 jours et 16 heures. Soixante-treize pour cent des patients &eacute;taient pris en charge aux urgences, les soins intensifs de cardiologie repr&eacute;sentaient 29% et les services de cardiologie, 68%. Seize pour cent des patients &eacute;taient initialement pris en charge par un Smur. La fili&egrave;re la plus repr&eacute;sent&eacute;e &eacute;tait l&rsquo;admission directe aux urgences pr&eacute;c&eacute;dant un service conventionnel. La cardiologie repr&eacute;sentait 74% des hospitalisations conventionnelles. L&rsquo;appel au Samu repr&eacute;sentait 24% de la cohorte. Le d&eacute;lai entre l&rsquo;apparition des sympt&ocirc;mes et l&rsquo;entr&eacute;e dans une fili&egrave;re hospitali&egrave;re &eacute;tait de plus de 3 jours. La pression art&eacute;rielle moyenne &agrave; l&rsquo;admission &eacute;tait de 96 &plusmn;19 mmHg et la fr&eacute;quence cardiaque de 91 &plusmn;26/min. La moiti&eacute; des patients avait une fraction d&rsquo;&eacute;jection du ventricule gauche inf&eacute;rieure &agrave; 40%. Un tiers des patients pr&eacute;sentait une dysfonction r&eacute;nale. Aux urgences, il y avait un traitement par oxyg&egrave;ne dans 83% des cas, des diur&eacute;tiques 87%, les vasodilatateurs 26% et des inotropes 2%. La ventilation non invasive &eacute;tait utilis&eacute;e dans 17% des cas. La mortalit&eacute; hospitali&egrave;re &eacute;tait de 8% (142 patients).</p> <p><strong>Conclusion</strong></p> <p>Cette enqu&ecirc;te nationale a pu identifier les diff&eacute;rents parcours des patients atteints d&rsquo;ICA. Les urgences et les services de cardiologies conventionnelles sont les plus sollicit&eacute;s. Le recrutement se poursuit afin d&rsquo;identifier des pistes d&rsquo;optimisation du parcours de prise en charge des patients atteints d&rsquo;ICA.</p>'
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    med_titre => 'Enquête REZICA : parcours de soin des patients atteints pris en charge pour insuffisance cardiaque aiguë. Résultats préliminaires.'
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    med_affiliations => '<p>1. SAMU et Service d'Urgence, CHRU Nancy, Nancy, France 2. CIC-Plurith&eacute;matique 1433, CHRU Nancy - Institut Louis Mathieu, Nancy, France 3. SAMU-SMUR-SAU Nancy, CHRU Nancy - H&ocirc;pital Central, Nancy, France 4. SAMU et Service d'Urgence, CHU Nancy, Nancy, France</p>'
    med_annee => 2017
    med_auteurs => 'Tahar CHOUIHED (1, 2), Yann DELORME (3), Baptiste AGULLES (3), Adrien BASSAND (3), Aurélien BUESSLER (4), Julien JABBOUR (3), Nicolas GIRERD (2)'
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    med_date_maj => '2017-12-02 12:21:45'
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    med_description_longue => '<p><strong>Introduction&nbsp;:</strong> La dyspn&eacute;e aigu&euml; non traumatique est un motif fr&eacute;quent d&rsquo;appel au Service d&rsquo;Aide M&eacute;dicale d&rsquo;Urgence (SAMU). Les &eacute;tiologies les plus fr&eacute;quentes sont&nbsp;: les syndromes d&rsquo;insuffisance cardiaque aigu&euml; (SICA), l&rsquo;exacerbation aigu&euml; de BPCO, la pneumopathie et l&rsquo;embolie pulmonaire. Ce travail souhaite &eacute;valuer la mortalit&eacute; intra-hospitali&egrave;re des patients pris en charge pour dyspn&eacute;e aigu&euml; en pr&eacute;-hospitalier et en fonction du diagnostic port&eacute; en pr&eacute;-hospitalier. Les objectifs secondaires&nbsp;: comparer les caract&eacute;ristiques cliniques en fonction du diagnostic final et &eacute;tudier la concordance entre les diagnostics pr&eacute;-hospitalier et finaux ainsi que la qualit&eacute; du traitement initi&eacute; en pr&eacute;-hospitalier et ces cons&eacute;quences sur le pronostic.</p> <p><strong>Mat&eacute;riel et m&eacute;thode&nbsp;:</strong> &eacute;tude observationnelle r&eacute;trospective mono-centrique dans un CHRU sur 2014 et 2015. Les crit&egrave;res d&rsquo;inclusion&nbsp;: &acirc;ge &gt; 18 ans, dyspn&eacute;e aigu&euml; et une prise en charge pr&eacute;-hospitali&egrave;re par le SMUR. Les malades &eacute;taient r&eacute;partis en 2 bras&nbsp;: &laquo;&nbsp;syndrome insuffisance cardiaque aigu&euml;&nbsp;&raquo; (SICA) ou &laquo;&nbsp;non syndrome d&rsquo;insuffisance cardiaque aigu&euml;&nbsp;&raquo; (non SICA) sur la base des diagnostics pr&eacute;-hospitaliers et finaux. CIL: R2016-08 et &laquo;&nbsp;clinicaltrials.gov&nbsp;&raquo; NCT02800122.</p> <p><strong>R&eacute;sultats&nbsp;: </strong>823 premiers patients saisis. Age moyen 79 ans. Le sex-ratio est de 1,38. La mortalit&eacute; globale intra-hospitali&egrave;re est de 14.6 %&nbsp;; pour les SICA final&nbsp;: 8.6% et pour les non SICA final&nbsp;: 16.6 %, (p=0.016). La concordance entre les diagnostics pr&eacute;-hospitalier et finaux fixait un coefficient Kappa &agrave; 0.48 (0.40 &ndash; 0.56&nbsp;; IC 95 %). Les caract&eacute;ristiques cliniques r&eacute;v&eacute;laient pour les SICA et non SICA, une moyenne de SpO2 de 92% contre 95% (p=0.016), une PAS moyenne de 159 mm Hg contre 142 (p=0.007). On observe une baisse de 5,1 % de la mortalit&eacute; quand la prise en charge th&eacute;rapeutique pr&eacute;-hospitali&egrave;re est appropri&eacute;e. Apr&egrave;s les urgences, 40 % sont hospitalis&eacute;s en surveillance&nbsp;continue, quand 10 % regagnent leurs domiciles.</p> <div> <p><strong>Discussion&nbsp;et Conclusion&nbsp;:</strong> la dyspn&eacute;e aigu&euml; est un sympt&ocirc;me grave dont la mortalit&eacute; intra-hospitali&egrave;re toutes causes est &eacute;lev&eacute;e (14,6%). La concordance entre diagnostics pr&eacute;- hospitaliers et finaux &eacute;tait en faveur d&rsquo;un accord mod&eacute;r&eacute; montrant les difficult&eacute;s diagnostiques face &agrave; une dyspn&eacute;e aigue. Le diagnostic pr&eacute;-hospitalier est souvent erron&eacute; et n&eacute;cessite de d&eacute;velopper d&rsquo;autres outils diagnostics (Echo. Pulm. ou BNP pr&eacute;-hospitalier) afin de pouvoir initier le traitement plus rapidement qui permettrait d&rsquo;am&eacute;liorer le pronostic des patients.</p> </div>'
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    med_titre => 'Dyspnée aiguë en pré-hospitalier : Impact de la qualité du diagnostic et de la prise en charge thérapeutique en urgence sur le pronostic: Résultats préliminaires de PARADISE study ?PAthwAy of Dyspneic patIent in Emergency?'
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    med_annee => 2017
    med_auteurs => 'Clément Fayolle (1, 2), Mikaël Martinez (3, 1), Radia Spiga (1), Abdesslam Redjaline (1), Ludovic Cailasson (4), Albert Birynczyk (5), Pascale Cavalli (6), Alain Viallon (7)'
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    med_description_longue => '<p>Introduction&nbsp;: L&rsquo;insuffisance cardiaque aigu&euml; (ICA) est un motif fr&eacute;quent de consultation aux urgences. Cependant peu de donn&eacute;es concernant le profil des patients et leurs conditions de prise en charge en sont issues.</p> <p>M&eacute;thode&nbsp;: Etude observationnelle multicentrique d&eacute;crivant les caract&eacute;ristiques, la prise en charge et le devenir des patients pr&eacute;sentant une ICA. Tous les patients admis aux urgences pour insuffisance cardiaque dans sept structures d&rsquo;urgence d&rsquo;un r&eacute;seau territorial de m&eacute;decine d&rsquo;urgence ont &eacute;t&eacute; inclus pendant deux mois. Nous avons recueillis les ant&eacute;c&eacute;dents, les pr&eacute;sentations cliniques, le bilan paraclinique, les traitements administr&eacute;s, le diagnostic final et l&rsquo;orientation. ICSAU a b&eacute;n&eacute;fici&eacute; de l&rsquo;autorisation de la CNIL.</p> <p>R&eacute;sultats&nbsp;: 251 patients inclus du 4/01 au 03/03/2016, &acirc;ge m&eacute;dian&nbsp;: 85 [79-90] ans. Le vecteur d&rsquo;entr&eacute;e &eacute;tait une ambulance dans 66% des cas et un SMUR dans 3%. Les patients &eacute;taient &agrave; 72% hypertendus, &agrave; 45% insuffisants cardiaques connus, &agrave; 43% en fibrillation atriale et suivis par un cardiologue dans 53% des cas. 16% avaient &eacute;t&eacute; hospitalis&eacute;s pour ICA dans l&rsquo;ann&eacute;e pr&eacute;c&eacute;dente. Le principal sympt&ocirc;me &eacute;tait la dyspn&eacute;e (56%) avec comme facteurs d&eacute;clenchant une infection (31%) ou un trouble du rythme (19%). Bien que les sympt&ocirc;mes &eacute;voluaient depuis 7,8 jours en moyenne, aucune mesure th&eacute;rapeutique n&rsquo;avait &eacute;t&eacute; prise auparavant dans 64% des cas. Seuls 3% des patients &eacute;taient choqu&eacute;s. Le bilan paraclinique a inclus&nbsp;: ionogramme avec cr&eacute;atinine (98%), ECG (96%), dosage du BNP ou NTproBNP (96%), radiographie thoracique (94%), ETT (31%, dont un tiers par urgentiste). Furos&eacute;mide, oxyg&egrave;ne et d&eacute;riv&eacute;s nitr&eacute;s ont &eacute;t&eacute; administr&eacute;s dans respectivement &nbsp;90%, 61% et 10% des cas. 3% des patients sont d&eacute;c&eacute;d&eacute;s aux urgences et 81% ont &eacute;t&eacute; hospitalis&eacute;s dont un tiers en secteur cardiologique&nbsp;; 40% sont pass&eacute;s par l&rsquo;UHCD. La concordance de diagnostic entre la sortie des urgences et celui en sortie d&rsquo;hospitalisation retrouvait un accord mod&eacute;r&eacute; (test ? de Cohen &agrave; 0,41).</p> <p>Discussion&nbsp;: ICSAU est une des rares &eacute;tudes descriptives de la prise en charge de l&rsquo;ICA aux urgences. Elle d&eacute;crit une population &acirc;g&eacute;e, majoritairement suivie par un cardiologue avec cependant peu d&rsquo;&eacute;l&eacute;ments disponibles &agrave; l&rsquo;accueil en SU. Nous notons une bonne utilisation des peptides natriur&eacute;tiques mais une sous utilisation de l&rsquo;&eacute;chographie aux urgences expliquant une concordance de diagnostic perfectible entre SU et services d&rsquo;hospitalisation ainsi qu&rsquo;une sous utilisation des d&eacute;riv&eacute;s nitr&eacute;s.</p>'
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    med_titre => 'Insuffisance cardiaque en service d'urgence. Profil des patients et description de la prise en charge (ICSAU).'
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    med_description => '<h4>R&eacute;sum&eacute;</h4> <p><strong>Introduction </strong>: La dyspn&eacute;e aigu&euml; est un sympt&ocirc;me fr&eacute;quent incluant l&rsquo;insuffisance cardiaque aigu&euml; (ICA). La prise en charge pr&eacute;coce des syndromes coronariens aigus a permis d&rsquo;en am&eacute;liorer le pronostic. La dyspn&eacute;e est devenue un nouveau challenge diagnostique et th&eacute;rapeutique. Cette mise au point pr&eacute;sente la prise en charge de la dyspn&eacute;e aigu&euml; suspecte d&rsquo;ICA.<br /><strong>En pr&eacute;hospitalier </strong>: Un traitement inappropri&eacute; ou un mauvais diagnostic sont responsables d&rsquo;une surmortalit&eacute;. Les&nbsp; recommandations insistent sur la relation entre un diagnostic pr&eacute;coce, un traitement appropri&eacute; et le pronostic, avec le concept r&eacute;cent de time-to-therapy. Diff&eacute;rents outils sont disponibles dont l&rsquo;&eacute;chographie clinique, compos&eacute;e d&rsquo;une &eacute;chographie pulmonaire, d&rsquo;une coupe 4 cavit&eacute;s, et d&rsquo;une &eacute;chographie vasculaire.<br /><strong>Dans le service d&rsquo;accueil des urgences </strong>: La radiographie pulmonaire et les dosages biologiques sont recommand&eacute;s.<br />Le peptide natriur&eacute;tique de type B (brain natriuretic peptide [BNP]) permet d&rsquo;am&eacute;liorer la performance diagnostique,<br />mais sa valeur varie avec de nombreux facteurs. Il peut &ecirc;tre normal en cas d&rsquo;&oelig;d&egrave;me aigu du poumon flash.<br /><strong>Traitement et orientation </strong>: Le concept de time-to-therapy a un r&ocirc;le important dans la prise en charge de l&rsquo;ICA. L&rsquo;oxyg&egrave;ne, la ventilation non invasive, les vasodilatateurs et les diur&eacute;tiques sont recommand&eacute;s le plus t&ocirc;t possible. Toute premi&egrave;re pouss&eacute;e d&rsquo;ICA doit &ecirc;tre hospitalis&eacute;e, et tout patientpr&eacute;sentant une d&eacute;faillance organique doit &ecirc;tre admis en r&eacute;animation.<br /><strong>Conclusion </strong>: L&rsquo;&eacute;chographie pulmonaire associ&eacute;e au BNP sont des outils efficaces face &agrave; un patient dyspn&eacute;ique. La th&eacute;rapeutique doit &ecirc;tre initi&eacute;e le plus rapidement possible. L&rsquo;am&eacute;lioration du pronostic des patients insuffisants cardiaques repose sur une fili&egrave;re de prise en charge d&egrave;s le pr&eacute;hospitalier.<br /><br /><br /><br /><br /><br /></p>'
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    med_description => '<p><span><span>Le but de ce document est de fournir des lignes directrices pratiques et factuelles pour le diagnostic et le traitement de l'insuffisance cardiaque.</span></span></p>'
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    0 => 'http://bus.sfmu.org/medias/images/cms/vignette-media/170/2592__30.jpg'
    1 => 'http://bus.sfmu.org/medias/images/cms/vignette-media/170/2592__35.jpg'
    2 => 'http://bus.sfmu.org/medias/images/cms/vignette-media/170/2592__40.jpg'
    3 => 'http://bus.sfmu.org/medias/images/cms/vignette-media/170/2592__45.jpg'
    4 => 'http://bus.sfmu.org/medias/images/cms/vignette-media/170/2592__50.jpg'
    5 => 'http://bus.sfmu.org/medias/images/cms/vignette-media/170/2592__55.jpg'
    6 => 'http://bus.sfmu.org/medias/images/cms/vignette-media/170/2592__60.jpg'
    640 =>
    0 => 'http://bus.sfmu.org/medias/images/cms/vignette-media/640/2592__30.jpg'
    1 => 'http://bus.sfmu.org/medias/images/cms/vignette-media/640/2592__35.jpg'
    2 => 'http://bus.sfmu.org/medias/images/cms/vignette-media/640/2592__40.jpg'
    3 => 'http://bus.sfmu.org/medias/images/cms/vignette-media/640/2592__45.jpg'
    4 => 'http://bus.sfmu.org/medias/images/cms/vignette-media/640/2592__50.jpg'
    5 => 'http://bus.sfmu.org/medias/images/cms/vignette-media/640/2592__55.jpg'
    6 => 'http://bus.sfmu.org/medias/images/cms/vignette-media/640/2592__60.jpg'
    web_id => 2
    session =>
    dos_id => 50
    prof_id =>
    ses_actif => 1
    ses_date => '2017-12-15'
    ses_date_crea => '2017-12-22 19:21:27'
    ses_date_maj => NULL
    ses_description => ''
    ses_heure_debut => '00:00:00'
    ses_heure_fin => '00:00:00'
    ses_id => 648
    ses_medecin_only => 0
    ses_moderateurs => ''
    ses_poubelle => 0
    ses_rang => NULL
    ses_ref_import => NULL
    ses_titre => 'Pour aller plus loin...'
    ses_titre2 => ''
    tpro_actif => NULL
    tpro_date_crea => NULL
    tpro_date_maj => NULL
    tpro_id => NULL
    tpro_label => NULL
    tpro_poubelle => NULL
    tses_actif => NULL
    tses_date_crea => NULL
    tses_date_maj => NULL
    tses_id => NULL
    tses_label => NULL
    tses_poubelle => NULL
    moduleActif => 'dossier'
    moduleActifName => 'Dossier'
    response => Zend_Controller_Response_Http Object()
    session => Zend_Session_Namespace Object()
    urlParams =>
    action => 'voir-mois'
    controller => 'index'
    dos_id => 50
    module => 'dossier'
    url_rewriting => 'dossier-thematique-novembre-2017-syndromes-d-insuffisance-cardiaque-aigue'
    viewMessenger =>

    Request parameters

    action => 'voir-mois'
    controller => 'index'
    dos_id => 50
    module => 'dossier'
    url_rewriting => 'dossier-thematique-novembre-2017-syndromes-d-insuffisance-cardiaque-aigue'

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    Zend_View_Helper_Placeholder_Registry => Zend_View_Helper_Placeholder_Registry Object()
    busApi => Myeo_Api_Caller Object()
    configSite => Zend_Config_Ini Object()

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