HOTARARE nr. 155 din 23 februarie 2011
pentru aprobarea criteriilor si normelor de diagnostic clinic, diagnostic functional si de evaluare a capacitatii de munca pe baza carora se face incadrarea in gradele I, II si III de invaliditate
EMITENT:     GUVERNUL
PUBLICAT IN: MONITORUL OFICIAL nr. 224 din 31 martie 2011
Data intrarii in vigoare : 31 martie 2011

    In temeiul art. 108 din Constitutia Romaniei, republicata, si al art. 70 din Legea nr. 263/2010 privind sistemul unitar de pensii publice, cu modificarile si completarile ulterioare,

    Guvernul Romaniei adopta prezenta hotarare.

    ART. 1
    Se aproba criteriile si normele de diagnostic clinic, diagnostic functional si de evaluare a capacitatii de munca pe baza carora se face incadrarea in gradele I, II si III de invaliditate, prevazute in anexa*) care face parte integranta din prezenta hotarare.
-----
    *) Anexa se publica in Monitorul Oficial al Romaniei, Partea I, nr. 224 bis, care se poate achizitiona de la Centrul pentru relatii cu publicul al Regiei Autonome "Monitorul Oficial", Bucuresti, sos. Panduri nr. 1.

    ART. 2
    La data intrarii in vigoare a prezentei hotarari se abroga Hotararea Guvernului nr. 400/2001 pentru aprobarea criteriilor si normelor de diagnostic clinic, diagnostic functional si de evaluare a capacitatii de munca pe baza carora se face incadrarea in gradele I, II si III de invaliditate, publicata in Monitorul Oficial al Romaniei, Partea I, nr. 251 din 16 mai 2001.

                                 PRIM-MINISTRU
                                    EMIL BOC

                                Contrasemneaza:
                           Ministrul muncii, familiei
                             si protectiei sociale,
                                Ioan Nelu Botis

                              Ministrul sanatatii,
                                  Cseke Attila

    Bucuresti, 23 februarie 2011.
    Nr. 155.

    ANEXA

                        INTRODUCERE

    Expertiza medicala a capacitatii de munca este o forma de asistenta medico-sociala care evalueaza, prin metode si tehnici specifice, capacitatea de munca a persoanelor cu diferite tulburari morfologice si functionale, in vederea prestatiilor de asigurari sociale (medicina de asigurari sociale).
    Demersurile specifice acestei activitati sunt centrate pe profilaxia invaliditatii si pe recuperarea capacitatii de munca, cu finalitate in reinsertia socio-profesionala a asiguratilor afectati prin boli sau accidente.
    Particularitatile de ordin medical si socio-profesional care intervin frecvent in evaluare fac uneori greu de aplicat standarde foarte precis definite. In acest sens, medicului expert al asigurarilor sociale, care realizeaza evaluarea, i se permite o anumita distantare fata de baremele stabilite, fara a incalca insa principiile si spiritul acestora. In aceste situatii, se impune expunerea cu claritate a motivelor care au condus la abordarea individualizata a cazului.
    (1) Diagnosticul functional se bazeaza pe elemente clinice si pe rezultatele investigatiilor de laborator. Exprima severitatea tulburarilor functionale si mecanismele prin care acestea se produc. Permite evaluarea restantului functional si a mecanismelor functionale care pot interveni compensator.
    (2) Deficienta functionala este consecinta unor tulburari morfologice sau functionale variate (boli, accidente, anomalii genetice); este cuantificabila prin evaluari clinice si functionale standard si se regaseste in formularea diagnosticului functional. Se coreleaza cu incapacitatea adaptativa si cu gradul de invaliditate.
    (3) Incapacitatea adaptativa este generata de tulburari morfologice si functionale diverse si exprima limitele persoanei in efortul de a se adapta la mediul natural si social. Se exprima procentual in cadrul unui sistem cuantificat din capacitatea adaptativa normala.
    (4) Capacitatea de munca se defineste prin posibilitatea desfasurarii unei activitati organizate, prin care persoana isi asigura intretinerea sa si a familiei. Capacitatea de munca se exprima ca un raport intre posibilitatile biologice individuale (evaluate strict din punct de vedere medical) si solicitarea profesionala (ca element medico-social). Este determinata de abilitatile fizice si intelectuale, determinate genetic, si de nivelul de integrare socio-profesionala, care tine de pregatire si de experienta.
    (5) Invaliditatea este o notiune medico-juridica care exprima statutul particular al unei persoane asigurate in sistemul public de pensii si alte drepturi de asigurari sociale, care beneficiaza de drepturi conform legii.

    Invaliditatea este cuantificata in raport cu posibilitatea desfasurarii activitatilor legate de viata cotidiana si/sau profesionala, astfel:
    1. invaliditate de gradul I, caracterizata prin pierderea totala a capacitatii de munca, a capacitatii de autoservire (autoingrijire, activitati gospodaresti etc.), necesitand asistenta permanenta din partea altei persoane;
    2. invaliditate de gradul II, caracterizata prin pierderea totala a capacitatii de munca, dar cu conservarea capacitatii de autoservire (autoingrijire, activitati gospodaresti etc.);
    3. invaliditate de gradul III, caracterizata prin pierderea a cel putin jumatate din capacitatea de munca, acest statut fiind compatibil cu prestarea unei activitati profesionale cu program redus si in conditii adecvate de solicitare.

    Relatia "deficienta functionala - inacapacitate adaptativa - grad de invaliditate" este reprezentata pe o scala negativa, care exprima pierderea functionala cu repercusiuni asupra indeplinirii rolului adecvat conform varstei, gradului de instruire si factorilor socio-culturali existenti.

*T*
 +----------------------------------------------------------------------------+
 ¦ Diagnosticul functional¦Incapacitatea adaptativa ¦ Gradul de invaliditate  ¦
 +------------------------+-------------------------+-------------------------¦
 ¦Fara deficienta         ¦           0-19%         ¦nu determina invaliditate¦
 ¦functionala             ¦                         ¦                         ¦
 +------------------------+-------------------------+-------------------------¦
 ¦Deficienta usoara       ¦          20-49%         ¦nu determina invaliditate¦
 +------------------------+-------------------------+-------------------------¦
 ¦Deficienta medie        ¦          50-69%         ¦           III           ¦
 +------------------------+-------------------------+-------------------------¦
 ¦Deficienta accentuata   ¦          70-89%         ¦            II           ¦
 +------------------------+-------------------------+-------------------------¦
 ¦Deficienta grava        ¦          90-100%        ¦             I           ¦
 +----------------------------------------------------------------------------+
*ST*

    * fara deficienta functionala (incapacitatea adaptativa 0-19%) - exprima limitele largi ale normalului:
    * deficienta usoara (incapacitatea adaptativa 20-49%) - afecteaza nesemnificativ activitatile cotidiene si profesionale; pot aparea contraindicatii privind activitatea profesionala/recomandari privind schimbarea locului de munca; capacitatea de munca este pastrata;
    * deficienta medie (incapacitatea adaptativa 50-69%) - limiteaza capacitatea adaptativa la mediul profesional in privinta programului sau a locului de munca; capacitatea de munca este redusa cu cel putin jumatate fata de standard;
    * deficienta accentuata (incapacitatea adaptativa 70-90%) - impiedica desfasurarea unei activitati profesionale in sistemul organizat de munca; capacitatea de munca este pierduta in totalitate;
    * deficienta grava (incapacitatea adaptativa 90-100%) - pierde, pe langa capacitatea de munca, si pe cea de autoservire.

    (6) in evaluarea capacitatii de munca se va avea in vedere tratamentul complex (farmacologic activ, chirurgical, recuperator etc.) si efectele acestuia.
    (7) Criteriile de diagnostic functional, incapacitate adaptativa si de evaluare a capacitatii de munca sunt reactualizate si imbunatatite periodic, pentru a fi aliniate la eventualele precizari si reglementari in domeniul medical care apar pe parcurs.
    (8) Pentru bolile rare, pentru care nu exista criterii specifice de apreciere a deficientei functionale si a capacitatii de munca, se vor urmari elementele clinice, evolutia, complicatiile si deficienta functionala determinata, aplicandu-se criteriile existente.

                   1. AFECTIUNI ALE APARATULUI CARDIOVASCULAR

               CRITERII DE DIAGNOSTIC FUNCTIONAL SI DE EVALUARE A
             CAPACITATII DE MUNCA IN BOALA CARDIACA ISCHEMICA (BCI)

    In boala cardiaca ischemica, deficienta functionala se stabileste in functie de:

    1. Simptome: caracterul durerii toracice, frecventa crizelor anginoase si nivelul de efort la care apar, raspunsul la tratamentul specific, prezenta si complexitatea aritmiilor, prezenta semnelor de insuficienta cardiaca.
    2. Severitatea ischemiei miocardice/stenozelor coronariene apreciate prin: EKG, TEF, ecografie cardiaca si coronarografie.
    3. Severitatea disfunctiei sistolice a ventriculului stang: ecografic.

    Criterii de evaluare a deficientei functionale, IA, a capacitatii de munca in BCI stabila
*T*
 +----------------------------------------------------------------------------+
 ¦Afectiunea.  ¦Deficienta functionala ¦Incapacitatea¦Capacitatea¦Gradul de   ¦
 ¦Forma clinica¦                       ¦adaptativa   ¦de munca   ¦invaliditate¦
 +-------------+-----------------------+-------------+-----------+------------¦
 ¦Angina       ¦Fara deficienta        ¦    0-19%    ¦Pastrata   ¦Nu se       ¦
 ¦pectorala    ¦functionala            ¦             ¦           ¦incadreaza  ¦
 ¦stabila      ¦- crizele anginoase    ¦             ¦           ¦            ¦
 ¦(AP)         ¦apar numai la efort    ¦             ¦           ¦            ¦
 ¦             ¦fizic de intensitate   ¦             ¦           ¦            ¦
 ¦             ¦foarte mare (eforturi  ¦             ¦           ¦            ¦
 ¦             ¦exhaustive > 8 METs    ¦             ¦           ¦            ¦
 ¦             ¦- cedeaza prompt la NTG¦             ¦           ¦            ¦
 ¦             ¦sau repaus             ¦             ¦           ¦            ¦
 ¦             ¦- fara simptome        ¦             ¦           ¦            ¦
 ¦             ¦anginoase si modificari¦             ¦           ¦            ¦
 ¦             ¦electrice (EKG)        ¦             ¦           ¦            ¦
 ¦             ¦interaccesual          ¦             ¦           ¦            ¦
 ¦             ¦- functie sistolica VS ¦             ¦           ¦            ¦
 ¦             ¦normala (FE > 55%)     ¦             ¦           ¦            ¦
 +-------------+-----------------------+-------------+-----------+------------¦
 ¦AP clasa I   ¦Deficienta functionala ¦   20-49%    ¦Pastrata   ¦Nu se       ¦
 ¦             ¦usoara                 ¦             ¦           ¦incadreaza  ¦
 ¦             ¦- crizele anginoase    ¦             ¦           ¦            ¦
 ¦             ¦apar la eforturi fizice¦             ¦           ¦            ¦
 ¦             ¦mari (7-8 METs)        ¦             ¦           ¦            ¦
 ¦             ¦- cedeaza rapid la     ¦             ¦           ¦            ¦
 ¦             ¦administrarea de       ¦             ¦           ¦            ¦
 ¦             ¦nitrocompusi si la     ¦             ¦           ¦            ¦
 ¦             ¦repaus                 ¦             ¦           ¦            ¦
 ¦             ¦- fara simptome        ¦             ¦           ¦            ¦
 ¦             ¦anginoase sau          ¦             ¦           ¦            ¦
 ¦             ¦modificari electrice   ¦             ¦           ¦            ¦
 ¦             ¦(EKG) interaccesuale   ¦             ¦           ¦            ¦
 ¦             ¦- disfunctie sistolica ¦             ¦           ¦            ¦
 ¦             ¦VS usoara (FE = 54-45%)¦             ¦           ¦            ¦
 ¦             ¦- insuficienta cardiaca¦             ¦           ¦            ¦
 ¦             ¦NYHAI                  ¦             ¦           ¦            ¦
 +-------------+-----------------------+-------------+-----------+------------¦
 ¦AP clasa II  ¦Deficienta functionala ¦   50-69%    ¦Pierduta   ¦ Gradul III ¦
 ¦             ¦medie                  ¦             ¦cel putin  ¦            ¦
 ¦             ¦- crizele anginoase    ¦             ¦jumatate   ¦            ¦
 ¦             ¦apar la eforturi mari  ¦             ¦           ¦            ¦
 ¦             ¦si medii (5-6 METs)    ¦             ¦           ¦            ¦
 ¦             ¦- cedeaza usor la      ¦             ¦           ¦            ¦
 ¦             ¦repaus si la           ¦             ¦           ¦            ¦
 ¦             ¦administrarea de       ¦             ¦           ¦            ¦
 ¦             ¦nitrocompusi           ¦             ¦           ¦            ¦
 ¦             ¦- modificari minoreEKG*¦             ¦           ¦            ¦
 ¦             ¦- TEF*** releva        ¦             ¦           ¦            ¦
 ¦             ¦modificari electrice cu¦             ¦           ¦            ¦
 ¦             ¦pattern ischemic la o  ¦             ¦           ¦            ¦
 ¦             ¦intensitate > de 80%   ¦             ¦           ¦            ¦
 ¦             ¦din nivelul maxim      ¦             ¦           ¦            ¦
 ¦             ¦teoretic individual    ¦             ¦           ¦            ¦
 ¦             ¦- disfunctie sistolica ¦             ¦           ¦            ¦
 ¦             ¦moderata (FE = 44-40%) ¦             ¦           ¦            ¦
 ¦             ¦- insuficienta cardiaca¦             ¦           ¦            ¦
 ¦             ¦NYHA II                ¦             ¦           ¦            ¦
 +-------------+-----------------------+-------------+-----------+------------¦
 ¦AP clasa III ¦Deficienta functionala ¦    70-89%   ¦Pierduta in¦  Gradul II ¦
 ¦             ¦accentuata             ¦             ¦totalitate ¦            ¦
 ¦             ¦- crizele anginoase    ¦             ¦           ¦            ¦
 ¦             ¦apar la eforturi de    ¦             ¦           ¦            ¦
 ¦             ¦intensitate mica,      ¦             ¦           ¦            ¦
 ¦             ¦uneori si in repaus    ¦             ¦           ¦            ¦
 ¦             ¦3-4 METs)              ¦             ¦           ¦            ¦
 ¦             ¦- cedeaza greu la      ¦             ¦           ¦            ¦
 ¦             ¦administrarea de       ¦             ¦           ¦            ¦
 ¦             ¦nitrocompusi           ¦             ¦           ¦            ¦
 ¦             ¦- modificari importante¦             ¦           ¦            ¦
 ¦             ¦EKG** accesuale si     ¦             ¦           ¦            ¦
 ¦             ¦interaccesuale         ¦             ¦           ¦            ¦
 ¦             ¦- disfunctie sistolica ¦             ¦           ¦            ¦
 ¦             ¦VS moderata            ¦             ¦           ¦            ¦
 ¦             ¦FE = 39-30%)           ¦             ¦           ¦            ¦
 ¦             ¦- insuficienta         ¦             ¦           ¦            ¦
 ¦             ¦cardiaca NYHA III      ¦             ¦           ¦            ¦
 ¦             ¦- toleranta mica la    ¦             ¦           ¦            ¦
 ¦             ¦efort - permite        ¦             ¦           ¦            ¦
 ¦             ¦activitatea de         ¦             ¦           ¦            ¦
 ¦             ¦autoingrijire          ¦             ¦           ¦            ¦
 +-------------+-----------------------+-------------+-----------+------------¦
 ¦AP clasa IV  ¦Deficienta functionala ¦   90-100%   ¦Capacitate ¦  Gradul I  ¦
 ¦             ¦grava                  ¦             ¦de munca si¦            ¦
 ¦             ¦- crizele anginoase    ¦             ¦autoservire¦            ¦
 ¦             ¦apar in repaus         ¦             ¦pierduta in¦            ¦
 ¦             ¦(1-2 METs) si sunt     ¦             ¦totalitate ¦            ¦
 ¦             ¦obiectivate de         ¦             ¦           ¦            ¦
 ¦             ¦modificari EKG**       ¦             ¦           ¦            ¦
 ¦             ¦- disfunctie sistolica ¦             ¦           ¦            ¦
 ¦             ¦grava VS(FE < 30%)     ¦             ¦           ¦            ¦
 ¦             ¦- insuficienta         ¦             ¦           ¦            ¦
 ¦             ¦cardiaca NYHA IV       ¦             ¦           ¦            ¦
 ¦             ¦- bolnavii isi pierd   ¦             ¦           ¦            ¦
 ¦             ¦capacitatea de         ¦             ¦           ¦            ¦
 ¦             ¦autoingrijire          ¦             ¦           ¦            ¦
 +----------------------------------------------------------------------------+
*ST*

    INFARCTUL MIOCARDIC

    Pentru bolnavii cu IM vechi, deficienta functionala se stabileste in functie de: extinderea zonei de necroza, severitatea disfunctiei sistolice a VS, complexitatea tulburarilor de ritm si de conducere asociate, intensitatea simptomelor reziduale - toleranta la efort, eficacitatea tratamentului.

    Tabelul de mai jos reda criteriile de apreciere a deficientei functionale, IA si a capacitatii de munca in IM vechi.
*T*
 +----------------------------------------------------------------------------+
 ¦Afectiunea.  ¦Deficienta functionala ¦Incapacitatea¦Capacitatea¦Gradul de   ¦
 ¦Forma clinica¦                       ¦adaptativa   ¦de munca   ¦invaliditate¦
 +-------------+-----------------------+-------------+-----------+------------¦
 ¦Infarctul    ¦Deficienta functionala ¦    20-49%   ¦Pastrata   ¦Nu se       ¦
 ¦miocardic    ¦usoara                 ¦             ¦           ¦incadreaza  ¦
 ¦vechi        ¦- bolnav asimptomatic  ¦             ¦           ¦            ¦
 ¦(Fara supra- ¦sau cu simptomatologia ¦             ¦           ¦            ¦
 ¦denivelare de¦dureroasa (angina      ¦             ¦           ¦            ¦
 ¦ST, fara unda¦pectorala), care apare ¦             ¦           ¦            ¦
 ¦Q sau cu su- ¦la eforturi fizice mari¦             ¦           ¦            ¦
 ¦pradenivelare¦(7-8METs)              ¦             ¦           ¦            ¦
 ¦de ST, cu    ¦- EKG releva sechela   ¦             ¦           ¦            ¦
 ¦unda Q)      ¦electrica a IM fara    ¦             ¦           ¦            ¦
 ¦             ¦alte  modificari.      ¦             ¦           ¦            ¦
 ¦             ¦- disfunctia sistolica ¦             ¦           ¦            ¦
 ¦             ¦usoara VS (FE = 45-54%)¦             ¦           ¦            ¦
 ¦             ¦- insuficienta cardiaca¦             ¦           ¦            ¦
 ¦             ¦NYHA I                 ¦             ¦           ¦            ¦
 ¦             +-----------------------+-------------+-----------+------------¦
 ¦             ¦Deficienta functionala ¦    50-69%   ¦Pierduta   ¦Gradul III  ¦
 ¦             ¦medie                  ¦             ¦cel putin  ¦            ¦
 ¦             ¦- bolnavul prezinta la ¦             ¦jumatate   ¦            ¦
 ¦             ¦eforturi mari/medii    ¦             ¦           ¦            ¦
 ¦             ¦(5-6METs) dureri       ¦             ¦           ¦            ¦
 ¦             ¦anginoase, dispnee,    ¦             ¦           ¦            ¦
 ¦             ¦palpitatii             ¦             ¦           ¦            ¦
 ¦             ¦- EKG de repaus releva ¦             ¦           ¦            ¦
 ¦             ¦sechela electrica de IM¦             ¦           ¦            ¦
 ¦             ¦si posibile modificari ¦             ¦           ¦            ¦
 ¦             ¦minore* de faza        ¦             ¦           ¦            ¦
 ¦             ¦terminala, posibile    ¦             ¦           ¦            ¦
 ¦             ¦aritmii benigne        ¦             ¦           ¦            ¦
 ¦             ¦- TEF*** obiectiveaza  ¦             ¦           ¦            ¦
 ¦             ¦modificari electrice cu¦             ¦           ¦            ¦
 ¦             ¦pattern ischemic la o  ¦             ¦           ¦            ¦
 ¦             ¦intensitate > 80% din  ¦             ¦           ¦            ¦
 ¦             ¦efortul teoretic maxim ¦             ¦           ¦            ¦
 ¦             ¦individual             ¦             ¦           ¦            ¦
 ¦             ¦- disfunctie sistolica ¦             ¦           ¦            ¦
 ¦             ¦moderata (FE = 44-40%),¦             ¦           ¦            ¦
 ¦             ¦eventual HVS           ¦             ¦           ¦            ¦
 ¦             ¦- insuficienta cardiaca¦             ¦           ¦            ¦
 ¦             ¦NYHA II                ¦             ¦           ¦            ¦
 ¦             +-----------------------+-------------+-----------+------------¦
 ¦             ¦Deficienta functionala ¦   70-89%    ¦Pierduta in¦Gradul II   ¦
 ¦             ¦accentuata             ¦             ¦totalitate ¦            ¦
 ¦             ¦- bolnavii prezinta    ¦             ¦           ¦            ¦
 ¦             ¦dureri anginoase la    ¦             ¦           ¦            ¦
 ¦             ¦eforturi mici sau medii¦             ¦           ¦            ¦
 ¦             ¦(3-4 METs), dispnee,   ¦             ¦           ¦            ¦
 ¦             ¦palpitatii             ¦             ¦           ¦            ¦
 ¦             ¦- EKG de repaus releva,¦             ¦           ¦            ¦
 ¦             ¦pe langa sechela de IM,¦             ¦           ¦            ¦
 ¦             ¦modificari de faza     ¦             ¦           ¦            ¦
 ¦             ¦terminala** si/sau alte¦             ¦           ¦            ¦
 ¦             ¦modificari electrice   ¦             ¦           ¦            ¦
 ¦             ¦severe (aritmii,       ¦             ¦           ¦            ¦
 ¦             ¦tulburari de conducere)¦             ¦           ¦            ¦
 ¦             ¦- disfunctie sistolica ¦             ¦           ¦            ¦
 ¦             ¦moderata (FE = 39-30%) ¦             ¦           ¦            ¦
 ¦             ¦- insuficienta cardiaca¦             ¦           ¦            ¦
 ¦             ¦NYHA III               ¦             ¦           ¦            ¦
 ¦             ¦- toleranta la efort   ¦             ¦           ¦            ¦
 ¦             ¦mica - permite         ¦             ¦           ¦            ¦
 ¦             ¦activitati de          ¦             ¦           ¦            ¦
 ¦             ¦autoingrijire          ¦             ¦           ¦            ¦
 ¦             +-----------------------+-------------+-----------+------------¦
 ¦             ¦Deficienta functionala ¦   90-100 %  ¦Capacitate ¦Gradul I    ¦
 ¦             ¦grava                  ¦             ¦de munca si¦            ¦
 ¦             ¦- tulburari de ritm si ¦             ¦autoservire¦            ¦
 ¦             ¦de conducere severe    ¦             ¦pierduta in¦            ¦
 ¦             ¦- edeme pulmonare acute¦             ¦totalitate ¦            ¦
 ¦             ¦repetitive             ¦             ¦           ¦            ¦
 ¦             ¦- insuficienta cardiaca¦             ¦           ¦            ¦
 ¦             ¦NYHA IV                ¦             ¦           ¦            ¦
 ¦             ¦- disfunctie sistolica ¦             ¦           ¦            ¦
 ¦             ¦VS grava (FE = < 30%)  ¦             ¦           ¦            ¦
 ¦             ¦- bolnavii au          ¦             ¦           ¦            ¦
 ¦             ¦capacitatea de         ¦             ¦           ¦            ¦
 ¦             ¦autoingrijire limitata ¦             ¦           ¦            ¦
 +----------------------------------------------------------------------------+
*ST*
-----
    * Subdenivelare ST < 1 mm, T aplatizat, difazic, usor negativ.
    ** Subdenivelare ST > 1 mm, descendenta, orizontala, T negativ, simetric, ascutit.
    *** Daca modificarile electrice cu pattern ischemic apar la o intensitate de efort < 80% din efortul maxim teoretic individual, deficienta functionala poate fi accentuata. Modificarile vor fi coroborate cu alte date obiective ale bolnavului.

    O mentiune aparte trebuie facuta pentru BCI nedureroasa, in care, semnele subiective fiind absente sau atipice, diagnosticul clinic si functional poate fi pus numai pe investigatii paraclinice (vezi baremul de investigatii). In functie de severitatea modificarilor oferite de investigatiile cardiovasculare, de gradul insuficientei cardiace (NYHA), se va face o apreciere corespunzatoare a statusului functional si a capacitatii de munca utilizand criteriile de la angina pectorala stabila.

    Observatii:
    1. Clasificarea Canadiana (Canadian CardiacSociety, CCS) a anginei pectorale stabile
    CLASA I - angina pectorala la efort intens, rapid prelungit; efortul obisnuit nu prezinta angina; corespunde unui consum energetic de 7-8 METs (METs = echivalente de consum de O(2) la efort).
    CLASA II - angina de efort mediu, care limiteaza usor activitatea pacientului (5-6 METs).
    CLASA III - angina la activitati uzuale, eforturi mici, cu limitarea activitatilor zilnice; corespunde unui consum energetic de 3-4 METs.
    CLASA IV - angina pectorala ce apare in repaus, pacientul fiind sever inabilitat (capacitatea de efort pierduta, sub 1-2 METs).
    2. Caracterizarea diferitelor activitati in functie de consumul energetic

                        CHESTIONARUL DE ACTIVITATE (VA)
                     (VETERANS ADMINISTRATION QUESTIONNAIRE)

    Se cere pacientului sa sublinieze activitatile pe care le poate indeplini fara sa prezinte dispnee, durere precordiala, oboseala.
*T*
 +----------------------------------------------------------------------------+
 ¦1 MET             ¦mananca, se imbraca, lucreaza la birou                   ¦
 +------------------+---------------------------------------------------------¦
 ¦2 METs            ¦face dus, coboara 8 trepte                               ¦
 +------------------+---------------------------------------------------------¦
 ¦3 METs            ¦se plimba incet pe o suprafata de aproximativ 2 blocuri  ¦
 +------------------+---------------------------------------------------------¦
 ¦4 METs            ¦munca usoara (strans frunze, vopsit sau tamplarit usor)  ¦
 +------------------+---------------------------------------------------------¦
 ¦5 METs            ¦plimbare 4 mph, dans, spalat masina                      ¦
 +------------------+---------------------------------------------------------¦
 ¦6 METs            ¦tamplarie grea                                           ¦
 +------------------+---------------------------------------------------------¦
 ¦7 METs            ¦munca grea: sapat, joc tenis, carat 30 kg                ¦
 +------------------+---------------------------------------------------------¦
 ¦8 METs            ¦impins mobile grele, jogging, carat 10 kg pe scari       ¦
 +------------------+---------------------------------------------------------¦
 ¦9 METs            ¦bicicleta moderat, sarit coarda                          ¦
 +------------------+---------------------------------------------------------¦
 ¦10 METs           ¦inot, bicicleta la deal, mers repede la deal             ¦
 +------------------+---------------------------------------------------------¦
 ¦11 METs           ¦schi fond, baschet meci intreg                           ¦
 +------------------+---------------------------------------------------------¦
 ¦12 METs           ¦alergare 8 mph                                           ¦
 +------------------+---------------------------------------------------------¦
 ¦13 METs           ¦orice activitate competitionala                          ¦
 +----------------------------------------------------------------------------+
*ST*

    3. Clasificarea disfunctiei sistolice a VS, conform datelor din literatura de specialitate (Braunwald Heart Disease - eight edition), este urmatoarea:
    - functie sistolica normala - EF > 55%;
    - disfunctie sistolica usoara - FE = 45-54%;
    - disfunctie sistolica moderata - FE = 30-44%;
    - disfunctie sistolica grava - FE < 30%.
    4. La bolnavii care au fost investigati invaziv, datele coronarografice vor constitui elemente functionale (numarul de vase afectate, severitatea stenozelor) si vor fi coroborate cu simptomele, disfunctia sistolica etc.

    I. HIPERTENSIUNEA ARTERIALA ESENTIALA
    Pentru stabilirea deficientei functionale in HTA, se vor identifica urmatoarele elemente functionale: forma clinica (clasificarea HTA in functie de valori), semne de afectare a principalelor organe "tinta", prezenta diferitelor conditii clinice, pentru care HTA constituie un factor de agravare al patologiei respective sau aceasta patologie reprezinta o complicatie a HTA.

    Tabelul de mai jos prezinta criteriile de evaluare a deficientei functionale, IA si a capacitatii de munca in HTA pe baza asocierii formelor clinice de HTA (clasificarea ESC-2009) cu elementele mentionate.

*T*
 +----------------------------------------------------------------------------+
 ¦    Forma clinica     ¦  Deficienta  ¦Incapacitatea¦Capacitatea¦Gradul de   ¦
 ¦                      ¦  functionala ¦adaptativa   ¦de munca   ¦invaliditate¦
 +----------------------------------------------------------------------------¦
 ¦HTA - forma clinica, fara afectarea organelor "tinta"(AOT), fara boala      ¦
 ¦      vasculara asociata                                                    ¦
 +----------------------------------------------------------------------------¦
 ¦HTA usoara (gr. I)*           ¦  usoara  ¦  20-49%  ¦  Pastrata ¦Nu se      ¦
 ¦TAS= 140-159 mmHg             ¦          ¦          ¦           ¦incadreaza ¦
 ¦TAD = 90-99 mmHg              ¦          ¦          ¦           ¦           ¦
 ¦HTA moderata**(gr. II)        ¦          ¦          ¦           ¦           ¦
 ¦TAS = 160-179 mmHg            ¦          ¦          ¦           ¦           ¦
 ¦TAD= 100-109 mmHg             ¦          ¦          ¦           ¦           ¦
 ¦HTA severa***(gr. III)        ¦          ¦          ¦           ¦           ¦
 ¦TAS >180, mmHgTAD > 110 mmHg  ¦          ¦          ¦           ¦           ¦
 +----------------------------------------------------------------------------¦
 ¦HTA - forma clinica asociata cu afectarea organelor "tinta" (AOT)           ¦
 +----------------------------------------------------------------------------¦
 ¦HTA usoara*   ¦- HVS          ¦  medie   ¦  50-69%  ¦Pierduta   ¦ Gradul III¦
 ¦HTA moderata**¦determinata    ¦          ¦          ¦cel putin  ¦           ¦
 ¦HTA severa*** ¦ecografic:     ¦          ¦          ¦jumatate   ¦           ¦
 ¦              ¦SIV/PPVS>=15mm ¦          ¦          ¦           ¦           ¦
 ¦              ¦si/sau         ¦          ¦          ¦           ¦           ¦
 ¦              ¦- creatinina   ¦          ¦          ¦           ¦           ¦
 ¦              ¦sanguina       ¦          ¦          ¦           ¦           ¦
 ¦              ¦>1,5mg/dl,     ¦          ¦          ¦           ¦           ¦
 ¦              ¦clearance      ¦          ¦          ¦           ¦           ¦
 ¦              ¦cr.<60ml/min   ¦          ¦          ¦           ¦           ¦
 ¦              +---------------+----------+----------+-----------+-----------¦
 ¦              ¦- microalbumi- ¦  usoara  ¦  20-49%  ¦Pastrata   ¦Nu se      ¦
 ¦              ¦nurie          ¦          ¦          ¦           ¦incadreaza ¦
 ¦              ¦- placi        ¦          ¦          ¦           ¦           ¦
 ¦              ¦aterosc.       ¦          ¦          ¦           ¦           ¦
 ¦              ¦carotidiene,   ¦          ¦          ¦           ¦           ¦
 ¦              ¦aortice        ¦          ¦          ¦           ¦           ¦
 +----------------------------------------------------------------------------¦
 ¦HTA - forma clinica asociata cu boala vasculara clinic manifestata          ¦
 +----------------------------------------------------------------------------¦
 ¦HTA usoara*   ¦- boala        ¦In functi ¦In concor-¦In concor- ¦Corespunza-¦
 ¦HTA moderata**¦coronariana    ¦de seve-  ¦danta cu  ¦danta cu   ¦tor redu-  ¦
 ¦HTA grava***  ¦ischemica, IM, ¦ritatea   ¦deficienta¦deficienta ¦cerii capa-¦
 ¦              ¦revasculari-   ¦conditiei ¦functio-  ¦functionala¦citatii de ¦
 ¦              ¦zare           ¦clinice   ¦nala      ¦si incapa- ¦munca      ¦
 ¦              ¦miocardica,    ¦asociate  ¦          ¦citatea    ¦           ¦
 ¦              ¦IC;            ¦          ¦          ¦adapatativa¦           ¦
 ¦              ¦- boala        ¦          ¦          ¦           ¦           ¦
 ¦              ¦vasculara      ¦          ¦          ¦           ¦           ¦
 ¦              ¦cerebrala,     ¦          ¦          ¦           ¦           ¦
 ¦              ¦AVC: ischemic, ¦          ¦          ¦           ¦           ¦
 ¦              ¦tranzitor,     ¦          ¦          ¦           ¦           ¦
 ¦              ¦hemoragic;     ¦          ¦          ¦           ¦           ¦
 ¦              ¦- boala        ¦          ¦          ¦           ¦           ¦
 ¦              ¦vasculara      ¦          ¦          ¦           ¦           ¦
 ¦              ¦periferica;    ¦          ¦          ¦           ¦           ¦
 ¦              ¦- afectare     ¦          ¦          ¦           ¦           ¦
 ¦              ¦renala:        ¦          ¦          ¦           ¦           ¦
 ¦              ¦insuficienta   ¦          ¦          ¦           ¦           ¦
 ¦              ¦renala,        ¦          ¦          ¦           ¦           ¦
 ¦              ¦proteinurie;   ¦          ¦          ¦           ¦           ¦
 ¦              ¦- retinopatie  ¦          ¦          ¦           ¦           ¦
 ¦              ¦avansata:      ¦          ¦          ¦           ¦           ¦
 ¦              ¦hemoragii,     ¦          ¦          ¦           ¦           ¦
 ¦              ¦exudate, edem. ¦          ¦          ¦           ¦           ¦
 +----------------------------------------------------------------------------¦
 ¦HTA maligna                                                                 ¦
 +----------------------------------------------------------------------------¦
 ¦HTA cu evolutie accelerata,   ¦Deficienta¦  70-100% ¦Capacitatea¦Gradul I   ¦
 ¦maligna;                      ¦functiona-¦          ¦de munca si¦sau II de  ¦
 ¦Definitia OMS: TAD > 130 mmHg,¦la accen- ¦          ¦(eventual) ¦invalidi-  ¦
 ¦FO cu exsudate hemoragice,    ¦tuata/    ¦          ¦de         ¦tate       ¦
 ¦IR progresiva, rezistenta la  ¦grava in  ¦          ¦autoservire¦           ¦
 ¦tratament.                    ¦functie de¦          ¦pierduta in¦           ¦
 ¦                              ¦severita- ¦          ¦totalitate ¦           ¦
 ¦                              ¦tea       ¦          ¦           ¦           ¦
 ¦                              ¦complica- ¦          ¦           ¦           ¦
 ¦                              ¦tiilor si ¦          ¦           ¦           ¦
 ¦                              ¦raspunsul ¦          ¦           ¦           ¦
 ¦                              ¦la trata- ¦          ¦           ¦           ¦
 ¦                              ¦ment      ¦          ¦           ¦           ¦
 +----------------------------------------------------------------------------+
*ST*

    II. HIPERTENSIUNEA SECUNDARA
    Aprecierea deficientei functionale, a incapacitatii adaptative si a capacitatii de munca se va face dupa criteriile de evaluare a HTA primara (esentiala).

    AFECTIUNI CONGENITALE NECIANOGENE
*T*
 +----------------------------------------------------------------------------+
 ¦Afectiunea.  ¦      Deficienta       ¦Incapacitatea¦Capacitatea¦Gradul de   ¦
 ¦Forma clinica¦      functionala      ¦adaptativa   ¦de munca   ¦invaliditate¦
 +-------------+-----------------------+-------------+-----------+------------¦
 ¦Defectul     ¦Deficienta functionala ¦   20-49%    ¦Pastrata   ¦Nu se       ¦
 ¦septal       ¦usoara                 ¦             ¦           ¦incadreaza  ¦
 ¦atrial (DSA) ¦DSA cu sunt            ¦             ¦           ¦            ¦
 ¦             ¦stanga-dreapta         ¦             ¦           ¦            ¦
 ¦             ¦nesemnificativ, cu     ¦             ¦           ¦            ¦
 ¦             ¦cord compensat, fara   ¦             ¦           ¦            ¦
 ¦             ¦semne de marire a      ¦             ¦           ¦            ¦
 ¦             ¦cordului drept         ¦             ¦           ¦            ¦
 ¦             +-----------------------+-------------+-----------+------------¦
 ¦             ¦Deficienta functionala ¦   50-69%    ¦Pierduta   ¦Gradul III  ¦
 ¦             ¦medie                  ¦             ¦cel putin  ¦            ¦
 ¦             ¦DSA cu sunt            ¦             ¦jumatate   ¦            ¦
 ¦             ¦stanga-dreapta moderat ¦             ¦           ¦            ¦
 ¦             ¦cu semne de            ¦             ¦           ¦            ¦
 ¦             ¦supraincarcare a inimii¦             ¦           ¦            ¦
 ¦             ¦drepte cu tulburari    ¦             ¦           ¦            ¦
 ¦             ¦functionale            ¦             ¦           ¦            ¦
 ¦             ¦(dispnee la eforturi   ¦             ¦           ¦            ¦
 ¦             ¦mari si medii)         ¦             ¦           ¦            ¦
 ¦             +-----------------------+-------------+-----------+------------¦
 ¦             ¦Deficienta functionala ¦    70-89%   ¦Pierduta in¦Gradul II   ¦
 ¦             ¦accentuata             ¦             ¦totalitate ¦            ¦
 ¦             ¦DSA cu sunt            ¦             ¦           ¦            ¦
 ¦             ¦stanga-dreapta         ¦             ¦           ¦            ¦
 ¦             ¦semnificativ (raport   ¦             ¦           ¦            ¦
 ¦             ¦flux pulmonar/flux     ¦             ¦           ¦            ¦
 ¦             ¦sistemic peste 1,5/l)  ¦             ¦           ¦            ¦
 ¦             ¦si HTP; DSA cu         ¦             ¦           ¦            ¦
 ¦             ¦cardiomegalie          ¦             ¦           ¦            ¦
 ¦             ¦importanta sau cu      ¦             ¦           ¦            ¦
 ¦             ¦tulburari de ritm      ¦             ¦           ¦            ¦
 ¦             ¦persistente sau        ¦             ¦           ¦            ¦
 ¦             ¦frecvent repetitive,   ¦             ¦           ¦            ¦
 ¦             ¦cu dispnee la eforturi ¦             ¦           ¦            ¦
 ¦             ¦minore                 ¦             ¦           ¦            ¦
 +-------------+-----------------------+-------------+-----------+------------¦
 ¦DSA operat   ¦Deficienta functionala ¦    20-49%   ¦Pastrata   ¦Nu se       ¦
 ¦Aprecierea se¦usoara                 ¦             ¦           ¦incadreaza  ¦
 ¦va face la 6 ¦DSA mic operat cu      ¦             ¦           ¦            ¦
 ¦luni de la   ¦restitutio ad inteerum ¦             ¦           ¦            ¦
 ¦interventie  ¦cu dispnee numai la    ¦             ¦           ¦            ¦
 ¦             ¦eforturi mari          ¦             ¦           ¦            ¦
 ¦             +-----------------------+-------------+-----------+------------¦
 ¦             ¦Deficienta functionala ¦    50-69%   ¦Pierduta   ¦Gradul III  ¦
 ¦             ¦medie                  ¦             ¦cel putin  ¦            ¦
 ¦             ¦DSA operat cu dilatare ¦             ¦jumatate   ¦            ¦
 ¦             ¦mica a cordului,       ¦             ¦           ¦            ¦
 ¦             ¦presiune pulmonara     ¦             ¦           ¦            ¦
 ¦             ¦sistolica normala,     ¦             ¦           ¦            ¦
 ¦             ¦dispnee la eforturi    ¦             ¦           ¦            ¦
 ¦             ¦mari si medii          ¦             ¦           ¦            ¦
 ¦             +-----------------------+-------------+-----------+------------¦
 ¦             ¦Deficienta functionala ¦   70-89%    ¦Pierduta in¦  Gradul II ¦
 ¦             ¦accentuata             ¦             ¦totalitate ¦            ¦
 ¦             ¦DSA operat cu          ¦             ¦           ¦            ¦
 ¦             ¦persistenta            ¦             ¦           ¦            ¦
 ¦             ¦cardiomegaliei, a HTP, ¦             ¦           ¦            ¦
 ¦             ¦a tulburarilor de ritm ¦             ¦           ¦            ¦
 +-------------+-----------------------+-------------+-----------+------------¦
 ¦Defectul     ¦Tulburarile functionale¦             ¦           ¦            ¦
 ¦septal       ¦in DVS sunt dependente ¦             ¦           ¦            ¦
 ¦interventri- ¦de marimea comunicarii ¦             ¦           ¦            ¦
 ¦cular (DSV)  ¦si starea patului      ¦             ¦           ¦            ¦
 ¦             ¦vascular pulmonar      ¦             ¦           ¦            ¦
 ¦             +-----------------------+-------------+-----------+------------¦
 ¦             ¦Deficienta functionala ¦    20-49%   ¦Pastrata   ¦Nu se       ¦
 ¦             ¦usoara                 ¦             ¦           ¦incadreaza  ¦
 ¦             ¦DSV mic (0,5cm?/m?) cu ¦             ¦           ¦            ¦
 ¦             ¦sunt stanga-dreapta    ¦             ¦           ¦            ¦
 ¦             ¦modest, cu raport flux ¦             ¦           ¦            ¦
 ¦             ¦pulmonar/flux sistemic ¦             ¦           ¦            ¦
 ¦             ¦(QP/QS) sub 1,5.       ¦             ¦           ¦            ¦
 ¦             ¦VD nu este dilatat sau ¦             ¦           ¦            ¦
 ¦             ¦hipertrofiat.          ¦             ¦           ¦            ¦
 ¦             ¦Pacienti asimptomatici.¦             ¦           ¦            ¦
 ¦             ¦Prezinta dispnee doar  ¦             ¦           ¦            ¦
 ¦             ¦la eforturi mari       ¦             ¦           ¦            ¦
 ¦             +-----------------------+-------------+-----------+------------¦
 ¦             ¦Deficienta functionala ¦   50-69%    ¦Pierduta   ¦Gradul III  ¦
 ¦             ¦medie                  ¦             ¦cel putin  ¦            ¦
 ¦             ¦DSV moderat            ¦             ¦jumatate   ¦            ¦
 ¦             ¦(0,5-1cm?/m?), raport  ¦             ¦           ¦            ¦
 ¦             ¦QP/QS de 1,5-2 prin    ¦             ¦           ¦            ¦
 ¦             ¦sunt stanga-dreapta    ¦             ¦           ¦            ¦
 ¦             ¦semnificativ. In efort ¦             ¦           ¦            ¦
 ¦             ¦mare sau mediu,        ¦             ¦           ¦            ¦
 ¦             ¦pacientii prezinta     ¦             ¦           ¦            ¦
 ¦             ¦dispnee. Examenele     ¦             ¦           ¦            ¦
 ¦             ¦paraclinice (eco, EKG, ¦             ¦           ¦            ¦
 ¦             ¦Rx. cord pulmonar)     ¦             ¦           ¦            ¦
 ¦             ¦arata cardiomegalie    ¦             ¦           ¦            ¦
 ¦             ¦usoara/moderata, HVD,  ¦             ¦           ¦            ¦
 ¦             ¦HTP moderata,          ¦             ¦           ¦            ¦
 ¦             ¦insuficienta cardiaca  ¦             ¦           ¦            ¦
 ¦             ¦NYHA II                ¦             ¦           ¦            ¦
 ¦             +-----------------------+-------------+-----------+------------¦
 ¦             ¦Deficienta functionala ¦   70-89%    ¦Pierduta in¦Gradul II   ¦
 ¦             ¦accentuata             ¦             ¦totalitate ¦            ¦
 ¦             ¦Bolnav cu DSV mare     ¦             ¦           ¦            ¦
 ¦             ¦( > 1 cm?/m?) cu raport¦             ¦           ¦            ¦
 ¦             ¦QP/QS mai mare de 2.   ¦             ¦           ¦            ¦
 ¦             ¦Prezinta dispnee la    ¦             ¦           ¦            ¦
 ¦             ¦eforturi mici sau chiar¦             ¦           ¦            ¦
 ¦             ¦in repaus, infectii    ¦             ¦           ¦            ¦
 ¦             ¦pulmonare. Obiectiv    ¦             ¦           ¦            ¦
 ¦             ¦HTP arteriala grava,   ¦             ¦           ¦            ¦
 ¦             ¦cardiomegalie cu       ¦             ¦           ¦            ¦
 ¦             ¦hipertrofie            ¦             ¦           ¦            ¦
 ¦             ¦biventriculara, semne  ¦             ¦           ¦            ¦
 ¦             ¦de insuficienta        ¦             ¦           ¦            ¦
 ¦             ¦cardiaca NYHA III sau  ¦             ¦           ¦            ¦
 ¦             ¦III/IV, aritmii        ¦             ¦           ¦            ¦
 ¦             ¦ventriculare           ¦             ¦           ¦            ¦
 ¦             +-----------------------+-------------+-----------+------------¦
 ¦             ¦Deficienta functionala ¦   90-100%   ¦Capacitatea¦Gradul I    ¦
 ¦             ¦grava                  ¦             ¦de munca si¦            ¦
 ¦             ¦DSV cu insuficienta    ¦             ¦autoservire¦            ¦
 ¦             ¦cardiaca grava         ¦             ¦pierduta in¦            ¦
 ¦             ¦ireductibila sau       ¦             ¦totalitate ¦            ¦
 ¦             ¦aritmii ventriculare   ¦             ¦           ¦            ¦
 ¦             ¦grave cu risc de       ¦             ¦           ¦            ¦
 ¦             ¦moarte subita,         ¦             ¦           ¦            ¦
 ¦             ¦conducand la           ¦             ¦           ¦            ¦
 ¦             ¦pierderea capacitatii  ¦             ¦           ¦            ¦
 ¦             ¦de autoservire         ¦             ¦           ¦            ¦
 +-------------+-----------------------+-------------+-----------+------------¦
 ¦DSV operat   ¦Deficienta functionala ¦   20-49%    ¦Pastrata   ¦Nu se       ¦
 ¦Aprecierea   ¦usoara                 ¦             ¦           ¦incadreaza  ¦
 ¦tulburarilor ¦DSV operat fara sunt   ¦             ¦           ¦            ¦
 ¦functionale  ¦rezidual               ¦             ¦           ¦            ¦
 ¦se face la 6 +-----------------------+-------------+-----------+------------¦
 ¦luni de la   ¦Deficienta functionala ¦   50-69%    ¦Pierduta   ¦Gradul III  ¦
 ¦interventie. ¦medie                  ¦             ¦cel putin  ¦            ¦
 ¦Pentru       ¦DSV operat cu sunt     ¦             ¦jumatate   ¦            ¦
 ¦bolnavii cu  ¦rezidual moderat si    ¦             ¦           ¦            ¦
 ¦HTP          ¦HTP moderata           ¦             ¦           ¦            ¦
 ¦preoperator  +-----------------------+-------------+-----------+------------¦
 ¦sau cu semne ¦Deficienta functionala ¦   70-89%    ¦Pierduta in¦Gradul II   ¦
 ¦clinice de   ¦accentuata             ¦             ¦totalitate ¦            ¦
 ¦DSV rezidual ¦DSV operat cu sunt     ¦             ¦           ¦            ¦
 ¦se efectueaza¦mare, HTP persistenta, ¦             ¦           ¦            ¦
 ¦cateterism   ¦dispnee la eforturi    ¦             ¦           ¦            ¦
 ¦cardiac.     ¦mici si repaus         ¦             ¦           ¦            ¦
 +-------------+-----------------------+-------------+-----------+------------¦
 ¦Persistenta  ¦PCA determina un sunt  ¦             ¦           ¦            ¦
 ¦de canal     ¦stanga-dreapta a carui ¦             ¦           ¦            ¦
 ¦arterial     ¦marime depinde de      ¦             ¦           ¦            ¦
 ¦(PCA)        ¦calibrul canalului si  ¦             ¦           ¦            ¦
 ¦             ¦de relatiile dintre    ¦             ¦           ¦            ¦
 ¦             ¦rezistenta vasculara   ¦             ¦           ¦            ¦
 ¦             ¦sistemica si cea       ¦             ¦           ¦            ¦
 ¦             ¦pulmonara              ¦             ¦           ¦            ¦
 ¦             +-----------------------+-------------+-----------+------------¦
 ¦             ¦Fara deficienta        ¦    0-19%    ¦Pastrata   ¦Nu se       ¦
 ¦             ¦functionala            ¦             ¦           ¦incadreaza  ¦
 ¦             ¦PCA mic, cu sunt       ¦             ¦           ¦            ¦
 ¦             ¦nesemnificativ         ¦             ¦           ¦            ¦
 ¦             ¦hemodinamic, bolnavi   ¦             ¦           ¦            ¦
 ¦             ¦asimptomatici          ¦             ¦           ¦            ¦
 ¦             +-----------------------+-------------+-----------+------------¦
 ¦             ¦Deficienta functionala ¦    20-49%   ¦Pastrata   ¦Nu se       ¦
 ¦             ¦usoara                 ¦             ¦           ¦incadreaza  ¦
 ¦             ¦PCA mic/moderat cu sunt¦             ¦           ¦            ¦
 ¦             ¦redus, fara            ¦             ¦           ¦            ¦
 ¦             ¦cardiomegalie, cu      ¦             ¦           ¦            ¦
 ¦             ¦tulburari functionale  ¦             ¦           ¦            ¦
 ¦             ¦(dispnee) la eforturi  ¦             ¦           ¦            ¦
 ¦             ¦foarte mari            ¦             ¦           ¦            ¦
 ¦             +-----------------------+-------------+-----------+------------¦
 ¦             ¦Deficienta functionala ¦    50-69%   ¦Pierduta   ¦Gradul III  ¦
 ¦             ¦medie                  ¦             ¦cel putin  ¦            ¦
 ¦             ¦PCA moderat cu elemente¦             ¦jumatate   ¦            ¦
 ¦             ¦de HVS sau hipertrofie ¦             ¦           ¦            ¦
 ¦             ¦biventriculara si de   ¦             ¦           ¦            ¦
 ¦             ¦incarcare pulmonara    ¦             ¦           ¦            ¦
 ¦             ¦(HTP).                 ¦             ¦           ¦            ¦
 ¦             ¦Dispnee la eforturi    ¦             ¦           ¦            ¦
 ¦             ¦mari si medii          ¦             ¦           ¦            ¦
 ¦             +-----------------------+-------------+-----------+------------¦
 ¦             ¦Deficienta functionala ¦    70-89%   ¦Pierduta in¦Gradul II   ¦
 ¦             ¦accentuata             ¦             ¦totalitate ¦            ¦
 ¦             ¦PCA cu HTP grava, cu   ¦             ¦           ¦            ¦
 ¦             ¦suflu continuu tipic la¦             ¦           ¦            ¦
 ¦             ¦care se asociaza       ¦             ¦           ¦            ¦
 ¦             ¦rulment de flux        ¦             ¦           ¦            ¦
 ¦             ¦diastolic apical,      ¦             ¦           ¦            ¦
 ¦             ¦cardiomegalie, dispnee ¦             ¦           ¦            ¦
 ¦             ¦la efort mic si chiar  ¦             ¦           ¦            ¦
 ¦             ¦de repaus, insuficienta¦             ¦           ¦            ¦
 ¦             ¦cardiaca               ¦             ¦           ¦            ¦
 +-------------+-----------------------+-------------+-----------+------------¦
 ¦PCA operat   ¦Deficienta functionala ¦    20-49%   ¦Pastrata   ¦Nu se       ¦
 ¦Aprecierea   ¦usoara                 ¦             ¦           ¦incadreaza  ¦
 ¦se face      ¦Bolnavi asimptomatici  ¦             ¦           ¦            ¦
 ¦dupa 6 luni  ¦cu examen fizic cardiac¦             ¦           ¦            ¦
 ¦             ¦Rgr. si EKG normale    ¦             ¦           ¦            ¦
 ¦             +-----------------------+-------------+-----------+------------¦
 ¦             ¦Deficienta functionala ¦    50-69%   ¦Pierduta   ¦Gradul III  ¦
 ¦             ¦medie                  ¦             ¦cel putin  ¦            ¦
 ¦             ¦Daca persista o HTP    ¦             ¦jumatate   ¦            ¦
 ¦             ¦reziduala (prin        ¦             ¦           ¦            ¦
 ¦             ¦cateterism cardiac si  ¦             ¦           ¦            ¦
 ¦             ¦sunt simptomatici)     ¦             ¦           ¦            ¦
 +-------------+-----------------------+-------------+-----------+------------¦
 ¦Coarctatia   ¦Fara deficienta        ¦     0-19%   ¦Pastrata   ¦Nu se       ¦
 ¦aortica (CoA)¦functionala            ¦             ¦           ¦incadreaza  ¦
 ¦             ¦Bolnavi asimptomatici. ¦             ¦           ¦            ¦
 ¦             ¦Tensiunea arteriala    ¦             ¦           ¦            ¦
 ¦             ¦normala, suflu sistolic¦             ¦           ¦            ¦
 ¦             ¦moderat in sp. II IC   ¦             ¦           ¦            ¦
 ¦             ¦stg., fara semne de HVS¦             ¦           ¦            ¦
 ¦             ¦si circulatie          ¦             ¦           ¦            ¦
 ¦             ¦colaterala, test de    ¦             ¦           ¦            ¦
 ¦             ¦efort normal.          ¦             ¦           ¦            ¦
 ¦             +-----------------------+-------------+-----------+------------¦
 ¦             ¦Deficienta functionala ¦    20-49%   ¦Pastrata   ¦Nu se       ¦
 ¦             ¦usoara                 ¦             ¦           ¦incadreaza  ¦
 ¦             ¦Bolnavi pauci          ¦             ¦           ¦            ¦
 ¦             ¦simptomatici, eventual ¦             ¦           ¦            ¦
 ¦             ¦cefalee, ameteli,      ¦             ¦           ¦            ¦
 ¦             ¦pulsatii craniene.     ¦             ¦           ¦            ¦
 ¦             ¦S.S. SP. II IC STG.,   ¦             ¦           ¦            ¦
 ¦             ¦toleranta buna la      ¦             ¦           ¦            ¦
 ¦             ¦efort. HVS usoara      ¦             ¦           ¦            ¦
 ¦             ¦(EKG, eco,             ¦             ¦           ¦            ¦
 ¦             ¦radiologice)           ¦             ¦           ¦            ¦
 ¦             +-----------------------+-------------+-----------+------------¦
 ¦             ¦Deficienta functionala ¦    50-69%   ¦Pierduta   ¦Gradul III  ¦
 ¦             ¦medie                  ¦             ¦cel putin  ¦            ¦
 ¦             ¦Bolnavii prezinta      ¦             ¦jumatate   ¦            ¦
 ¦             ¦simptomatologia unei   ¦             ¦           ¦            ¦
 ¦             ¦HTA (cefalee,          ¦             ¦           ¦            ¦
 ¦             ¦epistaxis, tinitus,    ¦             ¦           ¦            ¦
 ¦             ¦scotoame, congestie    ¦             ¦           ¦            ¦
 ¦             ¦cefalica), angina,     ¦             ¦           ¦            ¦
 ¦             ¦dispnee - asociate     ¦             ¦           ¦            ¦
 ¦             ¦senzatiei de raceala   ¦             ¦           ¦            ¦
 ¦             ¦in membrele pelvine,   ¦             ¦           ¦            ¦
 ¦             ¦chiar claudicatie      ¦             ¦           ¦            ¦
 ¦             ¦intermitenta sau       ¦             ¦           ¦            ¦
 ¦             ¦dureri abdominale.     ¦             ¦           ¦            ¦
 ¦             ¦Obiectiv, diferenta    ¦             ¦           ¦            ¦
 ¦             ¦dintre TA brahiala si  ¦             ¦           ¦            ¦
 ¦             ¦poplitee este de       ¦             ¦           ¦            ¦
 ¦             ¦10 mmHg. Circulatia    ¦             ¦           ¦            ¦
 ¦             ¦colaterala moderat     ¦             ¦           ¦            ¦
 ¦             ¦dezvoltata. HVS        ¦             ¦           ¦            ¦
 ¦             ¦moderat/severa, dar cu ¦             ¦           ¦            ¦
 ¦             ¦functie ventriculara   ¦             ¦           ¦            ¦
 ¦             ¦normala                ¦             ¦           ¦            ¦
 ¦             +-----------------------+-------------+-----------+------------¦
 ¦             ¦Deficienta functionala ¦    70-89%   ¦Pierduta in¦Gradul II   ¦
 ¦             ¦accentuata             ¦             ¦totalitate ¦            ¦
 ¦             ¦Co.A. semnificativa:   ¦             ¦           ¦            ¦
 ¦             ¦gradient maxim de      ¦             ¦           ¦            ¦
 ¦             ¦20 mmHg, cu flux       ¦             ¦           ¦            ¦
 ¦             ¦continuu in timpul     ¦             ¦           ¦            ¦
 ¦             ¦diastolei in Ao        ¦             ¦           ¦            ¦
 ¦             ¦descendenta.           ¦             ¦           ¦            ¦
 ¦             ¦Circulatia colaterala  ¦             ¦           ¦            ¦
 ¦             ¦dezvoltata,            ¦             ¦           ¦            ¦
 ¦             ¦cardiomegalie,         ¦             ¦           ¦            ¦
 ¦             ¦insuficienta cardiaca  ¦             ¦           ¦            ¦
 ¦             ¦NYHA III, III/IV,      ¦             ¦           ¦            ¦
 ¦             ¦tulburari de ritm cu   ¦             ¦           ¦            ¦
 ¦             ¦sincope, crize         ¦             ¦           ¦            ¦
 ¦             ¦anginoase, accidente   ¦             ¦           ¦            ¦
 ¦             ¦vasculare cerebrale.   ¦             ¦           ¦            ¦
 ¦             ¦Pot avea alte          ¦             ¦           ¦            ¦
 ¦             ¦cardiopatii            ¦             ¦           ¦            ¦
 ¦             ¦congenitale asociate   ¦             ¦           ¦            ¦
 ¦             +-----------------------+-------------+-----------+------------¦
 ¦             ¦Deficienta functionala ¦   90-100%   ¦Capacitate ¦            ¦
 ¦             ¦grava                  ¦             ¦de munca si¦            ¦
 ¦             ¦Bolnavi cu insuficienta¦             ¦autoservire¦            ¦
 ¦             ¦cardiaca grava         ¦             ¦pierduta in¦            ¦
 ¦             ¦ireductibila sau       ¦             ¦totalitate ¦            ¦
 ¦             ¦sechele dupa accidente ¦             ¦           ¦            ¦
 ¦             ¦vasculare cerebrale    ¦             ¦           ¦            ¦
 ¦             ¦care fac imposibila    ¦             ¦           ¦            ¦
 ¦             ¦autoservirea           ¦             ¦           ¦            ¦
 +-------------+-----------------------+-------------+-----------+------------¦
 ¦Coarctatia   ¦Tulburarile functionale¦             ¦           ¦            ¦
 ¦aortica      ¦vor fi apreciate in    ¦             ¦           ¦            ¦
 ¦operata      ¦raport de: prezenta sau¦             ¦           ¦            ¦
 ¦sau dupa     ¦disparitia gradientului¦             ¦           ¦            ¦
 ¦angioplastie ¦la nivelul coarctatiei;¦             ¦           ¦            ¦
 ¦percutana cu ¦scaderea TA pana la    ¦             ¦           ¦            ¦
 ¦balon        ¦normalizarea valorilor;¦             ¦           ¦            ¦
 ¦             ¦disparitia fenomenelor ¦             ¦           ¦            ¦
 ¦             ¦subiective, a tulbura- ¦             ¦           ¦            ¦
 ¦             ¦rilor de ritm, a       ¦             ¦           ¦            ¦
 ¦             ¦crizelor anginoase     ¦             ¦           ¦            ¦
 ¦             +-----------------------+-------------+-----------+------------¦
 ¦             ¦Deficienta functionala ¦    20-49%   ¦Pastrata   ¦Nu se       ¦
 ¦             ¦usoara                 ¦             ¦           ¦incadreaza  ¦
 ¦             ¦In situatia realizarii ¦             ¦           ¦            ¦
 ¦             ¦dezideratelor mai sus  ¦             ¦           ¦            ¦
 ¦             ¦enuntate               ¦             ¦           ¦            ¦
 ¦             +-----------------------+-------------+-----------+------------¦
 ¦             ¦Deficienta functionala ¦    50-69%   ¦Pierduta   ¦Gradul III  ¦
 ¦             ¦medie                  ¦             ¦cel putin  ¦            ¦
 ¦             ¦In situatia mentinerii ¦             ¦           ¦            ¦
 ¦             ¦gradientului la nivelul¦             ¦           ¦            ¦
 ¦             ¦coarctatiei, cu valori ¦             ¦           ¦            ¦
 ¦             ¦TA crescute (dominant  ¦             ¦           ¦            ¦
 ¦             ¦sistolice) la nivelul  ¦             ¦           ¦            ¦
 ¦             ¦membrelor toracale, cu ¦             ¦           ¦            ¦
 ¦             ¦semne subiective       ¦             ¦           ¦            ¦
 ¦             ¦jumatate de HTA, cu    ¦             ¦           ¦            ¦
 ¦             ¦tulburari functionale  ¦             ¦           ¦            ¦
 ¦             ¦la eforturi mari si    ¦             ¦           ¦            ¦
 ¦             ¦medii                  ¦             ¦           ¦            ¦
 ¦             +-----------------------+-------------+-----------+------------¦
 ¦             ¦Deficienta functionala ¦    70-89%   ¦Pierduta in¦Gradul II   ¦
 ¦             ¦accentuata             ¦             ¦totalitate ¦            ¦
 ¦             ¦Bolnavii la care       ¦             ¦           ¦            ¦
 ¦             ¦interventia nu a dat   ¦             ¦           ¦            ¦
 ¦             ¦rezultate sau au aparut¦             ¦           ¦            ¦
 ¦             ¦complicatii post       ¦             ¦           ¦            ¦
 ¦             ¦operatorii (disectie   ¦             ¦           ¦            ¦
 ¦             ¦de aorta, anevrism Ao) ¦             ¦           ¦            ¦
 ¦             ¦au deficienta          ¦             ¦           ¦            ¦
 ¦             ¦functionala accentuata ¦             ¦           ¦            ¦
 ¦             ¦prin intensitatea      ¦             ¦           ¦            ¦
 ¦             ¦tulburarilor si        ¦             ¦           ¦            ¦
 ¦             ¦prognostic nefavorabil ¦             ¦           ¦            ¦
 +-------------+-----------------------+-------------+-----------+------------¦
 ¦Stenoza      ¦Deficienta functionala ¦   20-49%    ¦Pastrata   ¦Nu se       ¦
 ¦aortica      ¦usoara                 ¦             ¦           ¦incadreaza  ¦
 ¦congenitala  ¦Aria orificiului       ¦             ¦           ¦            ¦
 ¦(SAo)        ¦valvular 1,5-2,5 cm?,  ¦             ¦           ¦            ¦
 ¦Sunt 3 forme ¦gradient mediu <       ¦             ¦           ¦            ¦
 ¦principale de¦20 mmHg, gradient      ¦             ¦           ¦            ¦
 ¦SAo:         ¦maxim 16-36 mmHg;      ¦             ¦           ¦            ¦
 ¦- valvulara; ¦bolnavii asimptomatici ¦             ¦           ¦            ¦
 ¦- supraval-  ¦sau pauci simptomatici ¦             ¦           ¦            ¦
 ¦vulara       ¦numai la eforturi mari ¦             ¦           ¦            ¦
 ¦- subvalvu-  ¦(dispnee, ameteli),    ¦             ¦           ¦            ¦
 ¦lara         ¦absenta HVS, test de   ¦             ¦           ¦            ¦
 ¦(cazul       ¦toleranta la efort     ¦             ¦           ¦            ¦
 ¦bolnavilor   ¦normal; insuficienta   ¦             ¦           ¦            ¦
 ¦care ating   ¦cardiaca NYHA I        ¦             ¦           ¦            ¦
 ¦varsta       +-----------------------+-------------+-----------+------------¦
 ¦adulta).     ¦Deficienta functionala ¦   50-69%    ¦Pierduta   ¦Gradul III  ¦
 ¦             ¦medie                  ¦             ¦cel putin  ¦            ¦
 ¦             ¦Bolnavii cu SAo        ¦             ¦jumatate   ¦            ¦
 ¦             ¦moderata: aria         ¦             ¦           ¦            ¦
 ¦             ¦orificiului valvular   ¦             ¦           ¦            ¦
 ¦             ¦0,75-1,5 cm? (gradient ¦             ¦           ¦            ¦
 ¦             ¦mediu 20-50 mmHg,      ¦             ¦           ¦            ¦
 ¦             ¦gradient maxim         ¦             ¦           ¦            ¦
 ¦             ¦36-80 mmHg la Eco      ¦             ¦           ¦            ¦
 ¦             ¦Doppler), dispnee la   ¦             ¦           ¦            ¦
 ¦             ¦efort mare si mediu,   ¦             ¦           ¦            ¦
 ¦             ¦HVS usoara/moderata,   ¦             ¦           ¦            ¦
 ¦             ¦capacitate functionala ¦             ¦           ¦            ¦
 ¦             ¦normala sau usor       ¦             ¦           ¦            ¦
 ¦             ¦redusa, insuficienta   ¦             ¦           ¦            ¦
 ¦             ¦cardiaca NYHA II;      ¦             ¦           ¦            ¦
 ¦             +-----------------------+-------------+-----------+------------¦
 ¦             ¦Deficienta functionala ¦    70-89%   ¦Pierduta in¦Gradul II   ¦
 ¦             ¦accentuata             ¦             ¦totalitate ¦            ¦
 ¦             ¦Bolnavii cu SAo grava: ¦             ¦           ¦            ¦
 ¦             ¦aria orificiului       ¦             ¦           ¦            ¦
 ¦             ¦valvular  < 0,75,      ¦             ¦           ¦            ¦
 ¦             ¦gradient mediu >       ¦             ¦           ¦            ¦
 ¦             ¦50 mmHg, gradient      ¦             ¦           ¦            ¦
 ¦             ¦maxim > 80 mmHg, crize ¦             ¦           ¦            ¦
 ¦             ¦de angina pectorala,   ¦             ¦           ¦            ¦
 ¦             ¦sincope repetate,      ¦             ¦           ¦            ¦
 ¦             ¦tulburari de ritm si   ¦             ¦           ¦            ¦
 ¦             ¦conducere in repaus sau¦             ¦           ¦            ¦
 ¦             ¦la efort,              ¦             ¦           ¦            ¦
 ¦             ¦cardiomegalie, HVS,    ¦             ¦           ¦            ¦
 ¦             ¦insuficienta cardiaca  ¦             ¦           ¦            ¦
 ¦             ¦NYHA III               ¦             ¦           ¦            ¦
 ¦             +-----------------------+-------------+-----------+------------¦
 ¦             ¦Deficienta functionala ¦   90-100%   ¦Capacitate ¦Gradul I    ¦
 ¦             ¦grava                  ¦             ¦de munca si¦            ¦
 ¦             ¦Bolnavii cu SAo cu     ¦             ¦autoservire¦            ¦
 ¦             ¦insuficienta cardiaca  ¦             ¦pierduta in¦            ¦
 ¦             ¦NYHA IV, ireductibila, ¦             ¦totalitate ¦            ¦
 ¦             ¦cu pierderea           ¦             ¦           ¦            ¦
 ¦             ¦posibilitatii de       ¦             ¦           ¦            ¦
 ¦             ¦autoservire            ¦             ¦           ¦            ¦
 +-------------+-----------------------+-------------+-----------+------------¦
 ¦Stenoza      ¦Fara deficienta        ¦    0-19%    ¦Pastrata   ¦Nu se       ¦
 ¦pulmonara    ¦functionala            ¦             ¦           ¦            ¦
 ¦valvulara:   ¦Stenoza pulmonara      ¦             ¦           ¦            ¦
 ¦Severitatea  ¦valvulara minima fara  ¦             ¦           ¦            ¦
 ¦stenozei este¦semne subiective si    ¦             ¦           ¦            ¦
 ¦in functie de¦fara repercusiuni      ¦             ¦           ¦            ¦
 ¦gradientul   ¦hemodinamice           ¦             ¦           ¦            ¦
 ¦transvalvular+-----------------------+-------------+-----------+------------¦
 ¦maxim        ¦Deficienta functionala ¦    20-49%   ¦Pastrata   ¦Nu se       ¦
 ¦apreciat prin¦usoara                 ¦             ¦           ¦incadreaza  ¦
 ¦examen       ¦Stenoza pulmonara      ¦             ¦           ¦            ¦
 ¦Eco-Doppler, ¦valvulara usoara, cu   ¦             ¦           ¦            ¦
 ¦astfel:      ¦absenta HVD (EKG, Rgr  ¦             ¦           ¦            ¦
 ¦- discreta   ¦si eco); Doppler arata ¦             ¦           ¦            ¦
 ¦- grad.      ¦gradient redus, iar    ¦             ¦           ¦            ¦
 ¦<25 mmHg     ¦Rdg. o dilatare        ¦             ¦           ¦            ¦
 ¦- usoara     ¦post-stenotica a       ¦             ¦           ¦            ¦
 ¦- grad.      ¦arterei pulmonare      ¦             ¦           ¦            ¦
 ¦25-49 mmHg   ¦Bolnavi asimptomatici  ¦             ¦           ¦            ¦
 ¦- moderata   ¦in repaus, cu dispnee  ¦             ¦           ¦            ¦
 ¦- grad.      ¦la eforturi mari       ¦             ¦           ¦            ¦
 ¦50-79 mmHg   +-----------------------+-------------+-----------+------------¦
 ¦- grava -    ¦Deficienta functionala ¦   50-69%    ¦Pierduta   ¦Gradul III  ¦
 ¦> 80 mmHg    ¦medie                  ¦             ¦cel putin  ¦            ¦
 ¦La gradient  ¦Stenoza pulmonara      ¦             ¦           ¦            ¦
 ¦> 80 mmHg    ¦moderata, cu tulburari ¦             ¦           ¦            ¦
 ¦apar         ¦functionale la eforturi¦             ¦           ¦            ¦
 ¦HVD marcata  ¦mari si medii.         ¦             ¦           ¦            ¦
 ¦si fenomene  ¦Cateterismul cardiac si¦             ¦           ¦            ¦
 ¦de insufi-   ¦Eco Doppler arata      ¦             ¦           ¦            ¦
 ¦cienta       ¦gradient jumatate      ¦             ¦           ¦            ¦
 ¦tricuspida   ¦transvalvular de       ¦             ¦           ¦            ¦
 ¦             ¦50 mmHg sau >, cu unele¦             ¦           ¦            ¦
 ¦             ¦semne de disfunctie de ¦             ¦           ¦            ¦
 ¦             ¦VD                     ¦             ¦           ¦            ¦
 ¦             +-----------------------+-------------+-----------+------------¦
 ¦             ¦Deficienta functionala ¦   70-89%    ¦Pierduta in¦Gradul II   ¦
 ¦             ¦accentuata             ¦             ¦totalitate ¦            ¦
 ¦             ¦Stenoza pulmonara      ¦             ¦           ¦            ¦
 ¦             ¦valvulara grava cu HVD ¦             ¦           ¦            ¦
 ¦             ¦marcata cu insuficienta¦             ¦           ¦            ¦
 ¦             ¦cardiaca dreapta, cu   ¦             ¦           ¦            ¦
 ¦             ¦tulburari de ritm,     ¦             ¦           ¦            ¦
 ¦             ¦sincope, crize         ¦             ¦           ¦            ¦
 ¦             ¦anginoase, dispnee de  ¦             ¦           ¦            ¦
 ¦             ¦repaus si la eforturi  ¦             ¦           ¦            ¦
 ¦             ¦mici                   ¦             ¦           ¦            ¦
 ¦             +-----------------------+-------------+-----------+------------¦
 ¦             ¦Deficienta functionala ¦   90-100%   ¦Capacitate ¦Gradul I    ¦
 ¦             ¦grava                  ¦             ¦de munca si¦            ¦
 ¦             ¦Gradient transvalvular ¦             ¦autoservire¦            ¦
 ¦             ¦maxim > 80 mmHg,       ¦             ¦pierduta in¦            ¦
 ¦             ¦Insuficienta cardiaca  ¦             ¦totalitate ¦            ¦
 ¦             ¦ireductibila, sincope  ¦             ¦           ¦            ¦
 ¦             ¦frecvent repetitive, cu¦             ¦           ¦            ¦
 ¦             ¦pierderea autoservirii ¦             ¦           ¦            ¦
 +-------------+-----------------------+-------------+-----------+------------¦
 ¦Stenoza      ¦Deficienta functionala ¦   20-49%    ¦  Pastrata ¦Nu se       ¦
 ¦pulmonara    ¦usoara                 ¦             ¦           ¦incadreaza  ¦
 ¦operata -    ¦Asimptomatici, functie ¦             ¦           ¦            ¦
 ¦aprecierea se¦ventriculara dreapta   ¦             ¦           ¦            ¦
 ¦va face la 6 ¦normala                ¦             ¦           ¦            ¦
 ¦luni dupa    +-----------------------+-------------+-----------+------------¦
 ¦interventie  ¦Deficienta functionala ¦   50-69%    ¦Pierduta   ¦Gradul III  ¦
 ¦             ¦medie                  ¦             ¦cel putin  ¦            ¦
 ¦             ¦Persista unele semne de¦             ¦           ¦            ¦
 ¦             ¦disfunctie de VD si    ¦             ¦           ¦            ¦
 ¦             ¦tulburari functionale  ¦             ¦           ¦            ¦
 ¦             ¦la efort mare si mediu ¦             ¦           ¦            ¦
 +-------------+-----------------------+-------------+-----------+------------¦
 ¦Sindromul    ¦Deficienta functionala ¦    70-89%   ¦Pierduta in¦Gradul II   ¦
 ¦Eisenmenger- ¦accentuata             ¦             ¦totalitate ¦            ¦
 ¦boala        ¦Dispnee in repaus,     ¦             ¦           ¦            ¦
 ¦vasculara    ¦intensificata la       ¦             ¦           ¦            ¦
 ¦obstructiva  ¦eforturi minime,       ¦             ¦           ¦            ¦
 ¦pulmonara    ¦insuficienta cardiaca  ¦             ¦           ¦            ¦
 ¦secundara    ¦NYHA III sau IV,       ¦             ¦           ¦            ¦
 ¦unui sunt    ¦tulburari de ritm      ¦             ¦           ¦            ¦
 ¦larg         ¦severe                 ¦             ¦           ¦            ¦
 ¦stanga-      +-----------------------+-------------+-----------+------------¦
 ¦dreapta, cu  ¦Deficienta functionala ¦   90-100%   ¦Capacitate ¦Gradul I    ¦
 ¦o cresterea  ¦grava                  ¦             ¦de munca si¦            ¦
 ¦PAP ce poate ¦Insuficienta cardiaca  ¦             ¦autoservire¦            ¦
 ¦egala PAS si ¦NYHA IV, ireductibila, ¦             ¦pierduta in¦            ¦
 ¦inversa      ¦aritmii ventriculare   ¦             ¦totalitate ¦            ¦
 ¦suntul.      ¦grave, cu pierderea    ¦             ¦           ¦            ¦
 ¦             ¦capacitatii de         ¦             ¦           ¦            ¦
 ¦             ¦autoservire            ¦             ¦           ¦            ¦
 +----------------------------------------------------------------------------+
*ST*

    VALVULOPATII
    In aprecierea diagnosticului functional intr-o valvulopatie, se va tine seama de:
    - sediul leziunilor;
    - existenta unor leziuni multiple;
    - volume ventriculare, arii valvulare, gradiente intraventriculare;
    - functia sistolica globala;
    - existenta factorilor care indica un proces inflamator activ (reumatism articular acut, endocardite, miocardite, pericardite);
    - existenta complicatiilor;
    - posibilitatea si rezultatele tratamentului chirurgical specific.

    Valvulopatii mitrale
*T*
 +----------------------------------------------------------------------------+
 ¦Afectiunea.  ¦      Deficienta       ¦Incapacitatea¦Capacitatea¦Gradul de   ¦
 ¦Forma clinica¦      functionala      ¦adaptativa   ¦de munca   ¦invaliditate¦
 +-------------+-----------------------+-------------+-----------+------------¦
 ¦Insuficienta ¦Fara deficienta        ¦    0-19%    ¦Pastrata   ¦Nu se       ¦
 ¦mitrala (IM) ¦functionala            ¦             ¦           ¦incadreaza  ¦
 ¦(reumatismala¦IM cu semne clinice    ¦             ¦           ¦            ¦
 ¦sau prin alt ¦minime (suflu sistolic ¦             ¦           ¦            ¦
 ¦mecanism     ¦I sau II) fara         ¦             ¦           ¦            ¦
 ¦valvular)    ¦tulburari functionale. ¦             ¦           ¦            ¦
 ¦             ¦Functie sistolica      ¦             ¦           ¦            ¦
 ¦             ¦ventriculara stanga    ¦             ¦           ¦            ¦
 ¦             ¦normala:               ¦             ¦           ¦            ¦
 ¦             ¦FE >55%, DTSVS < 45 mm ¦             ¦           ¦            ¦
 ¦             +-----------------------+-------------+-----------+------------¦
 ¦             ¦Deficienta functionala ¦   20-49%    ¦Pastrata   ¦Nu se       ¦
 ¦             ¦usoara                 ¦             ¦           ¦incadreaza  ¦
 ¦             ¦IM cu suflu sistolic   ¦             ¦           ¦            ¦
 ¦             ¦gr. II sau III, fara   ¦             ¦           ¦            ¦
 ¦             ¦tulburari de ritm,     ¦             ¦           ¦            ¦
 ¦             ¦fara tulburari         ¦             ¦           ¦            ¦
 ¦             ¦functionale in repaus  ¦             ¦           ¦            ¦
 ¦             ¦si la eforturi medii,  ¦             ¦           ¦            ¦
 ¦             ¦dar cu dispnee,        ¦             ¦           ¦            ¦
 ¦             ¦palpitatii la eforturi ¦             ¦           ¦            ¦
 ¦             ¦mari (> 6 METs), cu    ¦             ¦           ¦            ¦
 ¦             ¦disfunctie sistolica   ¦             ¦           ¦            ¦
 ¦             ¦VS usoara:             ¦             ¦           ¦            ¦
 ¦             ¦FE = 54-45%,           ¦             ¦           ¦            ¦
 ¦             ¦DTSVS 45-50 mm         ¦             ¦           ¦            ¦
 ¦             +-----------------------+-------------+-----------+------------¦
 ¦             ¦Deficienta functionala ¦    50-69%   ¦Pierduta   ¦Gradul III  ¦
 ¦             ¦medie                  ¦             ¦cel putin  ¦            ¦
 ¦             ¦IM cu suflu sistolic   ¦             ¦jumatate   ¦            ¦
 ¦             ¦gr. III cu semne de HVS¦             ¦           ¦            ¦
 ¦             ¦clinice, radiologice,  ¦             ¦           ¦            ¦
 ¦             ¦ecocardiografice si    ¦             ¦           ¦            ¦
 ¦             ¦EKG, cu tulburari      ¦             ¦           ¦            ¦
 ¦             ¦functionale la eforturi¦             ¦           ¦            ¦
 ¦             ¦medii si mari          ¦             ¦           ¦            ¦
 ¦             ¦(5-6METs).             ¦             ¦           ¦            ¦
 ¦             ¦Disfunctie sistolica   ¦             ¦           ¦            ¦
 ¦             ¦VS moderata:           ¦             ¦           ¦            ¦
 ¦             ¦FE = 40-44%,           ¦             ¦           ¦            ¦
 ¦             ¦DTSVS50-55 mm.         ¦             ¦           ¦            ¦
 ¦             +-----------------------+-------------+-----------+------------¦
 ¦             ¦Deficienta functionala ¦    70-89%   ¦Pierduta in¦Gradul II   ¦
 ¦             ¦accentuata             ¦             ¦totalitate ¦            ¦
 ¦             ¦IM cu S.S. gr. III/IV, ¦             ¦           ¦            ¦
 ¦             ¦cu sincope frecvente,  ¦             ¦           ¦            ¦
 ¦             ¦cu tulburari de ritm   ¦             ¦           ¦            ¦
 ¦             ¦sau de conducere grave,¦             ¦           ¦            ¦
 ¦             ¦cu semne de            ¦             ¦           ¦            ¦
 ¦             ¦insuficienta cardiaca  ¦             ¦           ¦            ¦
 ¦             ¦NYHA III. Disfunctie   ¦             ¦           ¦            ¦
 ¦             ¦sistolica VS moderata: ¦             ¦           ¦            ¦
 ¦             ¦FE = 39 = 30%,         ¦             ¦           ¦            ¦
 ¦             ¦DTSVS > 55mm.          ¦             ¦           ¦            ¦
 ¦             +-----------------------+-------------+-----------+------------¦
 ¦             ¦Deficienta functionala ¦   90-100%   ¦Capacitate ¦Gradul I    ¦
 ¦             ¦grava                  ¦             ¦de munca si¦            ¦
 ¦             ¦IM cu insuficienta     ¦             ¦autoservire¦            ¦
 ¦             ¦cardiaca NYHA IV,      ¦             ¦pierduta in¦            ¦
 ¦             ¦ireductibila, cu       ¦             ¦totalitate ¦            ¦
 ¦             ¦tulburari functionale  ¦             ¦           ¦            ¦
 ¦             ¦importante in repaus,  ¦             ¦           ¦            ¦
 ¦             ¦care limiteaza mult    ¦             ¦           ¦            ¦
 ¦             ¦sau duc la pierderea   ¦             ¦           ¦            ¦
 ¦             ¦totala a capacitatii   ¦             ¦           ¦            ¦
 ¦             ¦de autoservire,        ¦             ¦           ¦            ¦
 ¦             ¦disfunctie sistolica   ¦             ¦           ¦            ¦
 ¦             ¦grava FE < 30%         ¦             ¦           ¦            ¦
 +-------------+-----------------------+-------------+-----------+------------¦
 ¦Stenoza      ¦Fara deficienta        ¦    0-19%    ¦Pastrata   ¦Nu se       ¦
 ¦mitrala      ¦functionala            ¦             ¦           ¦incadreaza  ¦
 ¦(SM)         ¦SM larga               ¦             ¦           ¦            ¦
 ¦             ¦(AOM 1,5-2,5 cm?), cu  ¦             ¦           ¦            ¦
 ¦             ¦semne minime clinice   ¦             ¦           ¦            ¦
 ¦             ¦radiologice,           ¦             ¦           ¦            ¦
 ¦             ¦ecografice, EKG, fara  ¦             ¦           ¦            ¦
 ¦             ¦tulburari functionale  ¦             ¦           ¦            ¦
 ¦             ¦(dispnee) la efort     ¦             ¦           ¦            ¦
 ¦             +-----------------------+-------------+-----------+------------¦
 ¦             ¦Deficienta functionala ¦    20-49%   ¦Pastrata   ¦Nu se       ¦
 ¦             ¦usoara                 ¦             ¦           ¦incadreaza  ¦
 ¦             ¦SM larga               ¦             ¦           ¦            ¦
 ¦             ¦(AOM.1,5-2,5 cm?),     ¦             ¦           ¦            ¦
 ¦             ¦gradient mediu <       ¦             ¦           ¦            ¦
 ¦             ¦6 mmHg, PAP normala sau¦             ¦           ¦            ¦
 ¦             ¦HTP usoara, cu         ¦             ¦           ¦            ¦
 ¦             ¦tulburari functionale  ¦             ¦           ¦            ¦
 ¦             ¦(dispnee) numai la     ¦             ¦           ¦            ¦
 ¦             ¦eforturi mari (> 6METs)¦             ¦           ¦            ¦
 ¦             +-----------------------+-------------+-----------+------------¦
 ¦             ¦Deficienta functionala ¦    50-69%   ¦Pierduta   ¦Gradul III  ¦
 ¦             ¦medie                  ¦             ¦cel putin  ¦            ¦
 ¦             ¦SM medie (AOM 1-1,5cm?,¦             ¦jumatate   ¦            ¦
 ¦             ¦gradient mediu         ¦             ¦           ¦            ¦
 ¦             ¦6-12 mmHg), cu HTP     ¦             ¦           ¦            ¦
 ¦             ¦moderata, tulburari    ¦             ¦           ¦            ¦
 ¦             ¦functionale (dispnee)  ¦             ¦           ¦            ¦
 ¦             ¦la eforturi medii      ¦             ¦           ¦            ¦
 ¦             ¦(5-6METs)              ¦             ¦           ¦            ¦
 ¦             +-----------------------+-------------+-----------+------------¦
 ¦             ¦Deficienta functionala ¦   70-89%    ¦Capacitate ¦Gradul II   ¦
 ¦             ¦accentuata             ¦             ¦de munca   ¦            ¦
 ¦             ¦SM stransa (AOM < 1cm?,¦             ¦pierduta in¦            ¦
 ¦             ¦gradient mediu >       ¦             ¦totalitate ¦            ¦
 ¦             ¦12 mmHg), HTP moderat/ ¦             ¦           ¦            ¦
 ¦             ¦grava si/sau tulburari ¦             ¦           ¦            ¦
 ¦             ¦de ritm, si/sau edem   ¦             ¦           ¦            ¦
 ¦             ¦pulmonar acut in       ¦             ¦           ¦            ¦
 ¦             ¦antecedente,           ¦             ¦           ¦            ¦
 ¦             ¦insuficienta cardiaca  ¦             ¦           ¦            ¦
 ¦             ¦dreapta                ¦             ¦           ¦            ¦
 ¦             +-----------------------+-------------+-----------+------------¦
 ¦             ¦Deficienta functionala ¦   90-100%   ¦Capacitate ¦Gradul I    ¦
 ¦             ¦grava                  ¦             ¦de munca si¦            ¦
 ¦             ¦SM complicata cu       ¦             ¦autoservire¦            ¦
 ¦             ¦insuficienta cardiaca  ¦             ¦pierduta in¦            ¦
 ¦             ¦(NYHA IV) ireductibila,¦             ¦totalitate ¦            ¦
 ¦             ¦cu EPA frecvent        ¦             ¦           ¦            ¦
 ¦             ¦repetitiv, cu infarcte ¦             ¦           ¦            ¦
 ¦             ¦pulmonare sau cu       ¦             ¦           ¦            ¦
 ¦             ¦accidente embolice care¦             ¦           ¦            ¦
 ¦             ¦conduc la tulburari    ¦             ¦           ¦            ¦
 ¦             ¦motorii grave.         ¦             ¦           ¦            ¦
 ¦             ¦Posibilitatea          ¦             ¦           ¦            ¦
 ¦             ¦subiectilor de a se    ¦             ¦           ¦            ¦
 ¦             ¦ingriji singuri este   ¦             ¦           ¦            ¦
 ¦             ¦mult diminuata, pana   ¦             ¦           ¦            ¦
 ¦             ¦la pierderea           ¦             ¦           ¦            ¦
 ¦             ¦capacitatii de         ¦             ¦           ¦            ¦
 ¦             ¦autoservire            ¦             ¦           ¦            ¦
 +-------------+-----------------------+-------------+-----------+------------¦
 ¦Boala mitrala¦Aprecierea se va face  ¦             ¦           ¦            ¦
 ¦Asocierea SM ¦in raport cu gravitatea¦             ¦           ¦            ¦
 ¦cu IM cu     ¦tulburarilor           ¦             ¦           ¦            ¦
 ¦semnele      ¦functionale, conform   ¦             ¦           ¦            ¦
 ¦insumate ale ¦datelor enuntate la    ¦             ¦           ¦            ¦
 ¦celor doua   ¦stenoza mitrala si     ¦             ¦           ¦            ¦
 ¦afectiuni    ¦insuficienta mitrala   ¦             ¦           ¦            ¦
 +-------------+-----------------------+-------------+-----------+------------¦
 ¦Afectiunile  ¦Sunt mult mai rare, de ¦             ¦           ¦            ¦
 ¦tricuspidiene¦obicei asociate        ¦             ¦           ¦            ¦
 ¦             ¦leziunilor mitrale.    ¦             ¦           ¦            ¦
 ¦             ¦Aprecierea             ¦             ¦           ¦            ¦
 ¦             ¦incapacitatii se va    ¦             ¦           ¦            ¦
 ¦             ¦face conform cu        ¦             ¦           ¦            ¦
 ¦             ¦normele stabilite in   ¦             ¦           ¦            ¦
 ¦             ¦afectiunile valvulare  ¦             ¦           ¦            ¦
 ¦             ¦mitrale                ¦             ¦           ¦            ¦
 +----------------------------------------------------------------------------+
*ST*

    Valvulopatii aortice
*T*
 +----------------------------------------------------------------------------+
 ¦Afectiunea.  ¦      Deficienta       ¦Incapacitatea¦Capacitatea¦Gradul de   ¦
 ¦Forma clinica¦      functionala      ¦adaptativa   ¦de munca   ¦invaliditate¦
 +-------------+-----------------------+-------------+-----------+------------¦
 ¦Insuficienta ¦Fara deficienta        ¦    0-19%    ¦Pastrata   ¦Nu se       ¦
 ¦aortica      ¦functionala            ¦             ¦           ¦incadreaza  ¦
 ¦             ¦Afectiune de grad usor,¦             ¦           ¦            ¦
 ¦             ¦fara tulburari         ¦             ¦           ¦            ¦
 ¦             ¦functionale, cu semne  ¦             ¦           ¦            ¦
 ¦             ¦clinice minime,        ¦             ¦           ¦            ¦
 ¦             ¦functie sistolica VS   ¦             ¦           ¦            ¦
 ¦             ¦normala (FE > 55%,     ¦             ¦           ¦            ¦
 ¦             ¦DTSVS < 45 mm)         ¦             ¦           ¦            ¦
 +-------------+-----------------------+-------------+-----------+------------¦
 ¦             ¦Deficienta functionala ¦   20-49%    ¦Pastrata   ¦Nu se       ¦
 ¦             ¦usoara                 ¦             ¦           ¦incadreaza  ¦
 ¦             ¦Afectiune aortica de   ¦             ¦           ¦            ¦
 ¦             ¦grad usor, cu semne    ¦             ¦           ¦            ¦
 ¦             ¦clinice minore, cu     ¦             ¦           ¦            ¦
 ¦             ¦tulburari functionale  ¦             ¦           ¦            ¦
 ¦             ¦(dispnee, ameteli,     ¦             ¦           ¦            ¦
 ¦             ¦palpitatii) numai la   ¦             ¦           ¦            ¦
 ¦             ¦eforturi mari, cedand  ¦             ¦           ¦            ¦
 ¦             ¦rapid la repaus,       ¦             ¦           ¦            ¦
 ¦             ¦disfunctie sistolica   ¦             ¦           ¦            ¦
 ¦             ¦VS usoara              ¦             ¦           ¦            ¦
 ¦             ¦(FE = 54-45%,          ¦             ¦           ¦            ¦
 ¦             ¦DTSVS = 45-50 mm)      ¦             ¦           ¦            ¦
 +-------------+-----------------------+-------------+-----------+------------¦
 ¦             ¦Deficienta functionala ¦   50-69%    ¦Pierduta   ¦Gradul III  ¦
 ¦             ¦medie                  ¦             ¦cel putin  ¦            ¦
 ¦             ¦Afectiune Ao medie la  ¦             ¦jumatate   ¦            ¦
 ¦             ¦care tulburarile       ¦             ¦           ¦            ¦
 ¦             ¦functionale (dispnee,  ¦             ¦           ¦            ¦
 ¦             ¦crize anginoase,       ¦             ¦           ¦            ¦
 ¦             ¦tulburari de ritm) apar¦             ¦           ¦            ¦
 ¦             ¦la eforturi fizice de  ¦             ¦           ¦            ¦
 ¦             ¦intensitate medie,     ¦             ¦           ¦            ¦
 ¦             ¦insuficienta cardiaca  ¦             ¦           ¦            ¦
 ¦             ¦NYHA II, disfunctie    ¦             ¦           ¦            ¦
 ¦             ¦sistolica VS moderata  ¦             ¦           ¦            ¦
 ¦             ¦(FE = 40-44%;          ¦             ¦           ¦            ¦
 ¦             ¦DTSVS = 50-55 mm)      ¦             ¦           ¦            ¦
 +-------------+-----------------------+-------------+-----------+------------¦
 ¦             ¦Deficienta functionala ¦   70-89%    ¦Pierduta in¦Gradul II   ¦
 ¦             ¦accentuata             ¦             ¦totalitate ¦            ¦
 ¦             ¦Afectiune Ao grava, in ¦             ¦           ¦            ¦
 ¦             ¦care tulburarile       ¦             ¦           ¦            ¦
 ¦             ¦functionale sunt       ¦             ¦           ¦            ¦
 ¦             ¦intense (dispnee la    ¦             ¦           ¦            ¦
 ¦             ¦efort dar si de repaus,¦             ¦           ¦            ¦
 ¦             ¦crize anginoase        ¦             ¦           ¦            ¦
 ¦             ¦repetate, stari        ¦             ¦           ¦            ¦
 ¦             ¦sincopale, tulburari de¦             ¦           ¦            ¦
 ¦             ¦ritm sau conducere,    ¦             ¦           ¦            ¦
 ¦             ¦insuficienta cardiaca  ¦             ¦           ¦            ¦
 ¦             ¦NYHA III sau III/IV,   ¦             ¦           ¦            ¦
 ¦             ¦disfunctie sistolica VS¦             ¦           ¦            ¦
 ¦             ¦moderata (FE 39-30%,   ¦             ¦           ¦            ¦
 ¦             ¦DTSVS > 55 mm)         ¦             ¦           ¦            ¦
 +-------------+-----------------------+-------------+-----------+------------¦
 ¦             ¦Deficienta functionala ¦   90-100%   ¦Capacitate ¦Gradul I    ¦
 ¦             ¦grava                  ¦             ¦de munca si¦            ¦
 ¦             ¦Afectiune Ao cu        ¦             ¦autoservire¦            ¦
 ¦             ¦insuficienta cardiaca  ¦             ¦pierduta in¦            ¦
 ¦             ¦NYHA IV, ireductibila, ¦             ¦totalitate ¦            ¦
 ¦             ¦cu tulburari           ¦             ¦           ¦            ¦
 ¦             ¦functionale grave care ¦             ¦           ¦            ¦
 ¦             ¦impiedica autoservirea.¦             ¦           ¦            ¦
 ¦             ¦Disfunctie sistolica VS¦             ¦           ¦            ¦
 ¦             ¦grava FE < 30%.        ¦             ¦           ¦            ¦
 +-------------+-----------------------+-------------+-----------+------------¦
 ¦Stenoza      ¦Fara deficienta        ¦    0-19%    ¦Pastrata   ¦Nu se       ¦
 ¦aortica      ¦functionala            ¦             ¦           ¦incadreaza  ¦
 ¦             ¦Stenoza aortica usoara,¦             ¦           ¦            ¦
 ¦             ¦fara tulburari         ¦             ¦           ¦            ¦
 ¦             ¦functionale, cu semne  ¦             ¦           ¦            ¦
 ¦             ¦clinice minime         ¦             ¦           ¦            ¦
 ¦             +-----------------------+-------------+-----------+------------¦
 ¦             ¦Deficienta functionala ¦    20-49%   ¦Pastrata   ¦Nu se       ¦
 ¦             ¦usoara                 ¦             ¦           ¦incadreaza  ¦
 ¦             ¦Stenoza aortica usoara:¦             ¦           ¦            ¦
 ¦             ¦AOA> 1,5 cm?           ¦             ¦           ¦            ¦
 ¦             ¦Gradient medim <       ¦             ¦           ¦            ¦
 ¦             ¦20 mmHg                ¦             ¦           ¦            ¦
 ¦             ¦Gradient maxim:        ¦             ¦           ¦            ¦
 ¦             ¦16-36 mmHg             ¦             ¦           ¦            ¦
 ¦             ¦Angina, dispnee,       ¦             ¦           ¦            ¦
 ¦             ¦palpitatii numai la    ¦             ¦           ¦            ¦
 ¦             ¦eforturi mari (7-8METs)¦             ¦           ¦            ¦
 ¦             +-----------------------+-------------+-----------+------------¦
 ¦             ¦Deicienta functionala  ¦    50-69%   ¦Pierduta   ¦Gradul III  ¦
 ¦             ¦medie                  ¦             ¦cel putin  ¦            ¦
 ¦             ¦Stenoza aortica medie: ¦             ¦jumatate   ¦            ¦
 ¦             ¦AOA =0,75-1,5 cm?      ¦             ¦           ¦            ¦
 ¦             ¦Gradient mediu         ¦             ¦           ¦            ¦
 ¦             ¦20-50 mmHg             ¦             ¦           ¦            ¦
 ¦             ¦Gradient maxim         ¦             ¦           ¦            ¦
 ¦             ¦36-80 mmHg             ¦             ¦           ¦            ¦
 ¦             ¦Angina, dispnee,       ¦             ¦           ¦            ¦
 ¦             ¦palpitatii apar la     ¦             ¦           ¦            ¦
 ¦             ¦eforturi  de           ¦             ¦           ¦            ¦
 ¦             ¦intensitate medie      ¦             ¦           ¦            ¦
 ¦             ¦(5-6METs),             ¦             ¦           ¦            ¦
 ¦             ¦insuficienta cardiaca  ¦             ¦           ¦            ¦
 ¦             ¦NYHA II                ¦             ¦           ¦            ¦
 ¦             +-----------------------+-------------+-----------+------------¦
 ¦             ¦Deficienta functionala ¦   70-89%    ¦Pierduta in¦Gradul II   ¦
 ¦             ¦accentuata             ¦             ¦totalitate ¦            ¦
 ¦             ¦Stenoza aortica grava: ¦             ¦           ¦            ¦
 ¦             ¦AOA < 0,75 cm?         ¦             ¦           ¦            ¦
 ¦             ¦Gradient mediu >       ¦             ¦           ¦            ¦
 ¦             ¦50 mmHg                ¦             ¦           ¦            ¦
 ¦             ¦Gradient maxim >       ¦             ¦           ¦            ¦
 ¦             ¦80 mmHg                ¦             ¦           ¦            ¦
 ¦             ¦Crize anginoase        ¦             ¦           ¦            ¦
 ¦             ¦repetate, stari        ¦             ¦           ¦            ¦
 ¦             ¦sincopale, tulburari   ¦             ¦           ¦            ¦
 ¦             ¦de ritm si conducere,  ¦             ¦           ¦            ¦
 ¦             ¦insuficienta cardiaca  ¦             ¦           ¦            ¦
 ¦             ¦NYHA III sau           ¦             ¦           ¦            ¦
 ¦             ¦NYHA III/IV            ¦             ¦           ¦            ¦
 ¦             +-----------------------+-------------+-----------+------------¦
 ¦             ¦Deficienta functionala ¦   90-100%   ¦Capacitate ¦Gradul I    ¦
 ¦             ¦grava                  ¦             ¦de munca si¦            ¦
 ¦             ¦Stenoza aortica grava  ¦             ¦autoservire¦            ¦
 ¦             ¦cu insuficienta        ¦             ¦pierduta in¦            ¦
 ¦             ¦cardiaca ireductibila, ¦             ¦totalitate ¦            ¦
 ¦             ¦NYHA IV, cu tulburari  ¦             ¦           ¦            ¦
 ¦             ¦functionale grave, care¦             ¦           ¦            ¦
 ¦             ¦impiedica autoservirea ¦             ¦           ¦            ¦
 +----------------------------------------------------------------------------+
*ST*

    Deficienta functionala in boala aortica va fi apreciata dupa criteriile functionale prezentate la cele doua entitati. Afectiunile aortice, asociate cu afectiunile mitrale, vor fi apreciate in raport cu datele functionale prezentate la capitolul despre afectiunea aortica si afectiunea mitrala.

    Valvulopatii pulmonare

    Stenoza pulmonara castigata este foarte rara. Pentru evaluare functionala, se vor aplica criteriile de la stenoza pulmonara congenitala.
    Insuficienta valvulara pulmonara apare mai frecvent secundar hipertensiunii pulmonare de orice etiologie sau secundar dilatatiei arterei pulmonare (idiopatica). Insuficienta pulmonara organica este, de asemenea, rara; poate fi congenitala (asociata frecvent cu alte malformatii) sau castigata. Evaluarea functionala se va face in functie de severitatea simptomelor (dispnee) si a hipertensiunii pulmonare.

    Valvulopatii post-interventii chirurgicale
    (comisurotomii, proteze valvulare)
*T*
 +----------------------------------------------------------------------------+
 ¦Afectiunea.  ¦      Deficienta       ¦Incapacitatea¦Capacitatea¦Gradul de   ¦
 ¦Forma clinica¦      functionala      ¦adaptativa   ¦de munca   ¦invaliditate¦
 +-------------+-----------------------+-------------+-----------+------------¦
 ¦Valvulari    ¦Deficienta functionala ¦   20-49%    ¦Pastrata   ¦Nu se       ¦
 ¦operati      ¦usoara                 ¦             ¦           ¦incadreaza  ¦
 ¦pentru       ¦Postoperator, persista ¦             ¦           ¦            ¦
 ¦corectarea   ¦dispnee la eforturi    ¦             ¦           ¦            ¦
 ¦viciului     ¦mari, in absenta altor ¦             ¦           ¦            ¦
 ¦valvular     ¦fenomene patologice    ¦             ¦           ¦            ¦
 ¦             +-----------------------+-------------+-----------+------------¦
 ¦             ¦Deficienta functionala ¦   50-69%    ¦Pierduta   ¦Gradul III  ¦
 ¦             ¦medie                  ¦             ¦cel putin  ¦            ¦
 ¦             ¦Postoperator, prezinta ¦             ¦jumatate   ¦            ¦
 ¦             ¦dispnee la eforturi    ¦             ¦           ¦            ¦
 ¦             ¦mari, tulburari de ritm¦             ¦           ¦            ¦
 ¦             ¦trecatoare, tulburari  ¦             ¦           ¦            ¦
 ¦             ¦de conducere, dureri   ¦             ¦           ¦            ¦
 ¦             ¦anginoase la eforturi  ¦             ¦           ¦            ¦
 ¦             ¦mari                   ¦             ¦           ¦            ¦
 ¦             +-----------------------+-------------+-----------+------------¦
 ¦             ¦Deficienta functionala ¦   70-89%    ¦Pierduta in¦Gradul II   ¦
 ¦             ¦accentuata             ¦             ¦totalitate ¦            ¦
 ¦             ¦Postoperator, dispnee  ¦             ¦           ¦            ¦
 ¦             ¦la eforturi medii,     ¦             ¦           ¦            ¦
 ¦             ¦tulburari de ritm, de  ¦             ¦           ¦            ¦
 ¦             ¦conducere, dureri      ¦             ¦           ¦            ¦
 ¦             ¦anginoase. Sunt        ¦             ¦           ¦            ¦
 ¦             ¦prezente semne de      ¦             ¦           ¦            ¦
 ¦             ¦restenozare,           ¦             ¦           ¦            ¦
 ¦             ¦disfunctii ale         ¦             ¦           ¦            ¦
 ¦             ¦protezei, procese      ¦             ¦           ¦            ¦
 ¦             ¦endocarditice,         ¦             ¦           ¦            ¦
 ¦             ¦colmatari, embolii     ¦             ¦           ¦            ¦
 ¦             +-----------------------+-------------+-----------+------------¦
 ¦             ¦Deficienta functionala ¦   90-100%   ¦Capacitate ¦Gradul I    ¦
 ¦             ¦grava                  ¦             ¦de munca si¦            ¦
 ¦             ¦Postoperator,          ¦             ¦autoservire¦            ¦
 ¦             ¦restenozare, accidente ¦             ¦pierduta in¦            ¦
 ¦             ¦embolice cu sechele    ¦             ¦totalitate ¦            ¦
 ¦             ¦neurologice importante,¦             ¦           ¦            ¦
 ¦             ¦insuficienta cardiaca  ¦             ¦           ¦            ¦
 ¦             ¦grava, ireductibila,   ¦             ¦           ¦            ¦
 ¦             ¦care impiedica         ¦             ¦           ¦            ¦
 ¦             ¦posibilitatea de       ¦             ¦           ¦            ¦
 ¦             ¦autoservire            ¦             ¦           ¦            ¦
 +----------------------------------------------------------------------------+
*ST*

    TULBURARI DE RITM SI CONDUCERE CARDIACA
*T*
 +----------------------------------------------------------------------------+
 ¦             ¦                       ¦             ¦           ¦            ¦
 ¦Afectiunea.  ¦      Deficienta       ¦Incapacitatea¦Capacitatea¦Gradul de   ¦
 ¦Forma clinica¦      functionala      ¦adaptativa   ¦de munca   ¦invaliditate¦
 +-------------+-----------------------+-------------+-----------+------------¦
 ¦Tulburari de ¦Pentru stabilirea      ¦             ¦           ¦            ¦
 ¦ritm cardiac ¦deficientei functionale¦             ¦           ¦            ¦
 ¦             ¦se vor lua in          ¦             ¦           ¦            ¦
 ¦             ¦considerare:           ¦             ¦           ¦            ¦
 ¦             ¦- etiologia aritmiei   ¦             ¦           ¦            ¦
 ¦             ¦(BCI, valvulopatii,    ¦             ¦           ¦            ¦
 ¦             ¦cardio-miopatii, boli  ¦             ¦           ¦            ¦
 ¦             ¦endocrine etc.)        ¦             ¦           ¦            ¦
 ¦             ¦- simptomatologia      ¦             ¦           ¦            ¦
 ¦             ¦produsa                ¦             ¦           ¦            ¦
 ¦             ¦- frecventa episoadelor¦             ¦           ¦            ¦
 ¦             ¦aritmice               ¦             ¦           ¦            ¦
 ¦             ¦- existenta disfunctiei¦             ¦           ¦            ¦
 ¦             ¦sistolice ventriculare ¦             ¦           ¦            ¦
 ¦             ¦stangi si/sau a        ¦             ¦           ¦            ¦
 ¦             ¦tulburarilor           ¦             ¦           ¦            ¦
 ¦             ¦hemodinamice           ¦             ¦           ¦            ¦
 ¦             ¦- raspunsul la         ¦             ¦           ¦            ¦
 ¦             ¦tratament              ¦             ¦           ¦            ¦
 ¦             ¦- prezenta             ¦             ¦           ¦            ¦
 ¦             ¦complicatiilor induse  ¦             ¦           ¦            ¦
 ¦             ¦de aritmie             ¦             ¦           ¦            ¦
 ¦             ¦- tipul tulburarilor de¦             ¦           ¦            ¦
 ¦             ¦ritm                   ¦             ¦           ¦            ¦
 ¦             ¦- tulburari de irigatie¦             ¦           ¦            ¦
 ¦             ¦coronariana sau        ¦             ¦           ¦            ¦
 ¦             ¦cerebrala produse sau  ¦             ¦           ¦            ¦
 ¦             ¦intensificate de       ¦             ¦           ¦            ¦
 ¦             ¦aritmie                ¦             ¦           ¦            ¦
 +-------------+-----------------------+-------------+-----------+------------¦
 ¦Aritmii      ¦Fara/deficienta usoara ¦    0-49%    ¦Pastrata   ¦Nu se       ¦
 ¦sinusale     ¦- tulburarile de ritm  ¦             ¦           ¦incadreaza  ¦
 ¦(tahicardii, ¦sinusale, controlate   ¦             ¦           ¦            ¦
 ¦bradicardii  ¦terapeutic, care nu    ¦             ¦           ¦            ¦
 ¦aritmii      ¦afecteaza capacitatea  ¦             ¦           ¦            ¦
 ¦sinusale)    ¦de efort.              ¦             ¦           ¦            ¦
 ¦             +-----------------------+-------------+-----------+------------¦
 ¦             ¦Deficienta medie (o    ¦    50-69%   ¦Pierduta   ¦Gradul III  ¦
 ¦             ¦perioada limitata      ¦             ¦cel putin  ¦            ¦
 ¦             ¦pentru controlul       ¦             ¦jumatate   ¦            ¦
 ¦             ¦aritmiei si al         ¦             ¦           ¦            ¦
 ¦             ¦simptomelor) pentru    ¦             ¦           ¦            ¦
 ¦             ¦tahicardia sinusala    ¦             ¦           ¦            ¦
 ¦             ¦inapropiata (cresterea ¦             ¦           ¦            ¦
 ¦             ¦persistenta, neadecvata¦             ¦           ¦            ¦
 ¦             ¦a FC in raport cu      ¦             ¦           ¦            ¦
 ¦             ¦efortul fizic,         ¦             ¦           ¦            ¦
 ¦             ¦emotiile, starile      ¦             ¦           ¦            ¦
 ¦             ¦patologice la care este¦             ¦           ¦            ¦
 ¦             ¦supus bolnavul) sau    ¦             ¦           ¦            ¦
 ¦             ¦bradicardia sinusala   ¦             ¦           ¦            ¦
 ¦             ¦simptomatica, care     ¦             ¦           ¦            ¦
 ¦             ¦limiteaza capacitatea  ¦             ¦           ¦            ¦
 ¦             ¦de efort.              ¦             ¦           ¦            ¦
 +-------------+-----------------------+-------------+-----------+------------¦
 ¦Aritmii      ¦Aprecierea deficientei ¦             ¦           ¦            ¦
 ¦extrasis-    ¦functionale in aritmia ¦             ¦           ¦            ¦
 ¦tolice       ¦extra-sistolica se     ¦             ¦           ¦            ¦
 ¦- Supraven-  ¦face tinand seama de:  ¦             ¦           ¦            ¦
 ¦triculare    ¦- originea             ¦             ¦           ¦            ¦
 ¦(ESSV)       ¦extrasistolei          ¦             ¦           ¦            ¦
 ¦- Ventricu-  ¦- precizarea mono- sau ¦             ¦           ¦            ¦
 ¦lare (EV)    ¦plurifocalitatii       ¦             ¦           ¦            ¦
 ¦             ¦extrasistolei          ¦             ¦           ¦            ¦
 ¦             ¦- tipul morfologic     ¦             ¦           ¦            ¦
 ¦             ¦(mono- sau polimorf)   ¦             ¦           ¦            ¦
 ¦             ¦- frecventa            ¦             ¦           ¦            ¦
 ¦             ¦- sistematizarea       ¦             ¦           ¦            ¦
 ¦             ¦- modificari ale undei ¦             ¦           ¦            ¦
 ¦             ¦T la complexul         ¦             ¦           ¦            ¦
 ¦             ¦post-extra-sistolic;   ¦             ¦           ¦            ¦
 ¦             ¦- substratul patogenic ¦             ¦           ¦            ¦
 ¦             ¦- relatia cu efortul;  ¦             ¦           ¦            ¦
 ¦             ¦Pentru EV se va lua in ¦             ¦           ¦            ¦
 ¦             ¦considerare            ¦             ¦           ¦            ¦
 ¦             ¦complexitatea          ¦             ¦           ¦            ¦
 ¦             ¦acestora -             ¦             ¦           ¦            ¦
 ¦             ¦clasificarea Lown:     ¦             ¦           ¦            ¦
 ¦             ¦- clasa 0-EV absente   ¦             ¦           ¦            ¦
 ¦             ¦- clasa I-EV rare,     ¦             ¦           ¦            ¦
 ¦             ¦izolate (< 1 EV/min.)  ¦             ¦           ¦            ¦
 ¦             ¦- clasa II-EV frecvente¦             ¦           ¦            ¦
 ¦             ¦(> 1 EV /min.)         ¦             ¦           ¦            ¦
 ¦             ¦- clasa III-EV         ¦             ¦           ¦            ¦
 ¦             ¦polimorfe, bigeminate  ¦             ¦           ¦            ¦
 ¦             ¦- clasa IV-EV cuplate, ¦             ¦           ¦            ¦
 ¦             ¦in salva               ¦             ¦           ¦            ¦
 ¦             ¦- clasa V-EV cu fenomen¦             ¦           ¦            ¦
 ¦             ¦R/Tcu index de         ¦             ¦           ¦            ¦
 ¦             ¦precocitate >0,05      ¦             ¦           ¦            ¦
 ¦             +-----------------------+-------------+-----------+------------¦
 ¦             ¦Fara deficienta        ¦    0-19%    ¦Pastrata   ¦Nu se       ¦
 ¦             ¦functionala            ¦             ¦           ¦incadreaza  ¦
 ¦             ¦ESSV rare, izolate sau ¦             ¦           ¦            ¦
 ¦             ¦EV clasa I (Lown), ce  ¦             ¦           ¦            ¦
 ¦             ¦apar fara legatura cu  ¦             ¦           ¦            ¦
 ¦             ¦efortul, sunt foarte   ¦             ¦           ¦            ¦
 ¦             ¦rare, nu produc        ¦             ¦           ¦            ¦
 ¦             ¦tulburari subiective,  ¦             ¦           ¦            ¦
 ¦             ¦nu apar pe un fond     ¦             ¦           ¦            ¦
 ¦             ¦patologic organic      ¦             ¦           ¦            ¦
 ¦             +-----------------------+-------------+-----------+------------¦
 ¦             ¦Deficienta functionala ¦    20-49%   ¦Pastrata   ¦Nu se       ¦
 ¦             ¦usoara                 ¦             ¦           ¦incadreaza  ¦
 ¦             ¦EV clasa II (Lown) la  ¦             ¦           ¦            ¦
 ¦             ¦care nu se evidentiaza ¦             ¦           ¦            ¦
 ¦             ¦un fond patogenic      ¦             ¦           ¦            ¦
 ¦             ¦cardiovascular, nu au  ¦             ¦           ¦            ¦
 ¦             ¦relatie cu efortul, nu ¦             ¦           ¦            ¦
 ¦             ¦au consecinte          ¦             ¦           ¦            ¦
 ¦             ¦hemodinamice, raspund  ¦             ¦           ¦            ¦
 ¦             ¦prompt, favorabil la   ¦             ¦           ¦            ¦
 ¦             ¦medicatie antiaritmica ¦             ¦           ¦            ¦
 ¦             +-----------------------+-------------+-----------+------------¦
 ¦             ¦Deficienta functionala ¦   50-69%    ¦Pierduta   ¦Gradul III  ¦
 ¦             ¦medie                  ¦             ¦cel putin  ¦            ¦
 ¦             ¦ESSV repetitive        ¦             ¦jumatate   ¦            ¦
 ¦             ¦frecvente sau EV clasa ¦             ¦           ¦            ¦
 ¦             ¦III ce apar in cadrul  ¦             ¦           ¦            ¦
 ¦             ¦unor afectiuni         ¦             ¦           ¦            ¦
 ¦             ¦cardiovasculare si care¦             ¦           ¦            ¦
 ¦             ¦produc unele consecinte¦             ¦           ¦            ¦
 ¦             ¦hemodinamice care      ¦             ¦           ¦            ¦
 ¦             ¦impiedica efectuarea   ¦             ¦           ¦            ¦
 ¦             ¦eforturilor mari si    ¦             ¦           ¦            ¦
 ¦             ¦medii; aritmiile sunt  ¦             ¦           ¦            ¦
 ¦             ¦controlate             ¦             ¦           ¦            ¦
 ¦             ¦nesatisfacator prin    ¦             ¦           ¦            ¦
 ¦             ¦tratament antiaritmic  ¦             ¦           ¦            ¦
 ¦             +-----------------------+-------------+-----------+------------¦
 ¦             ¦Deficienta functionala ¦    70-89%   ¦Pierduta in¦Gradul II   ¦
 ¦             ¦accentuata             ¦             ¦totalitate ¦            ¦
 ¦             ¦EV (Lown III sau IV) ce¦             ¦           ¦            ¦
 ¦             ¦nu pot fi controlate   ¦             ¦           ¦            ¦
 ¦             ¦corespunzator prin     ¦             ¦           ¦            ¦
 ¦             ¦tratament, apar pe un  ¦             ¦           ¦            ¦
 ¦             ¦fond de boala organica ¦             ¦           ¦            ¦
 ¦             ¦cardiaca certa, aritmii¦             ¦           ¦            ¦
 ¦             ¦EV cu fenomen R/T      ¦             ¦           ¦            ¦
 ¦             ¦(Lown V) sau QT        ¦             ¦           ¦            ¦
 ¦             ¦prelungit sau cu       ¦             ¦           ¦            ¦
 ¦             ¦lambouri de TPV, care  ¦             ¦           ¦            ¦
 ¦             ¦induc tulburari        ¦             ¦           ¦            ¦
 ¦             ¦hemodinamice manifeste;¦             ¦           ¦            ¦
 ¦             ¦toleranta redusa la    ¦             ¦           ¦            ¦
 ¦             ¦efort de intensitate   ¦             ¦           ¦            ¦
 ¦             ¦mica                   ¦             ¦           ¦            ¦
 +-------------+-----------------------+-------------+-----------+------------¦
 ¦Tahicardii   ¦Aprecierea deficientei ¦             ¦           ¦            ¦
 ¦paroxistice  ¦functionale in TPSV    ¦             ¦           ¦            ¦
 ¦Supraven-    ¦trebuie sa ia in       ¦             ¦           ¦            ¦
 ¦triculare    ¦considerare:           ¦             ¦           ¦            ¦
 ¦(TPSV)       ¦- tipul aritmiei in    ¦             ¦           ¦            ¦
 ¦             ¦functie de mecanismul  ¦             ¦           ¦            ¦
 ¦             ¦electrofiziologic;     ¦             ¦           ¦            ¦
 ¦             ¦- fondul etiopatogenic ¦             ¦           ¦            ¦
 ¦             ¦(tulburari             ¦             ¦           ¦            ¦
 ¦             ¦neurovegetative, BCI,  ¦             ¦           ¦            ¦
 ¦             ¦valvulopatii,          ¦             ¦           ¦            ¦
 ¦             ¦cardiomiopatii, HTA,   ¦             ¦           ¦            ¦
 ¦             ¦WPW, hipertiroidii     ¦             ¦           ¦            ¦
 ¦             ¦etc.);                 ¦             ¦           ¦            ¦
 ¦             ¦- categoria de         ¦             ¦           ¦            ¦
 ¦             ¦tahicardie             ¦             ¦           ¦            ¦
 ¦             ¦supraventriculara in   ¦             ¦           ¦            ¦
 ¦             ¦relatie cu durata      ¦             ¦           ¦            ¦
 ¦             ¦(1. paroxistice        ¦             ¦           ¦            ¦
 ¦             ¦recurente - durata:    ¦             ¦           ¦            ¦
 ¦             ¦secunde, ore);         ¦             ¦           ¦            ¦
 ¦             ¦2. persistente - zile, ¦             ¦           ¦            ¦
 ¦             ¦saptamani, recurente;  ¦             ¦           ¦            ¦
 ¦             ¦3. cronice);           ¦             ¦           ¦            ¦
 ¦             ¦- simptomatologia      ¦             ¦           ¦            ¦
 ¦             ¦determinata (in        ¦             ¦           ¦            ¦
 ¦             ¦raport cu frecventa,   ¦             ¦           ¦            ¦
 ¦             ¦durata, bolile         ¦             ¦           ¦            ¦
 ¦             ¦asociale): angina,     ¦             ¦           ¦            ¦
 ¦             ¦dispnee, lipotimii,    ¦             ¦           ¦            ¦
 ¦             ¦sincope;               ¦             ¦           ¦            ¦
 ¦             ¦- riscul letal.        ¦             ¦           ¦            ¦
 ¦             +-----------------------+-------------+-----------+------------¦
 ¦             ¦Fara deficienta        ¦    0-19%    ¦Pastrata   ¦Nu se       ¦
 ¦             ¦functionala            ¦             ¦           ¦incadreaza  ¦
 ¦             ¦TPSV unice sau care    ¦             ¦           ¦            ¦
 ¦             ¦apar la intervale      ¦             ¦           ¦            ¦
 ¦             ¦foarte mari de timp,   ¦             ¦           ¦            ¦
 ¦             ¦fiind produse in       ¦             ¦           ¦            ¦
 ¦             ¦anumite conditii       ¦             ¦           ¦            ¦
 ¦             ¦specifice (exces       ¦             ¦           ¦            ¦
 ¦             ¦nicotinic sau cofeina, ¦             ¦           ¦            ¦
 ¦             ¦stres etc.); nu        ¦             ¦           ¦            ¦
 ¦             ¦altereaza, in afara    ¦             ¦           ¦            ¦
 ¦             ¦crizelor, posibilitatea¦             ¦           ¦            ¦
 ¦             ¦de efort fizic, sunt   ¦             ¦           ¦            ¦
 ¦             ¦autolimitate sau       ¦             ¦           ¦            ¦
 ¦             ¦raspund la manevre     ¦             ¦           ¦            ¦
 ¦             ¦vagale                 ¦             ¦           ¦            ¦
 ¦             +-----------------------+-------------+-----------+------------¦
 ¦             ¦Deficienta functionala ¦    20-49%   ¦Pastrata   ¦Nu se       ¦
 ¦             ¦usoara                 ¦             ¦           ¦incadreaza  ¦
 ¦             ¦In TPSV cu recurente   ¦             ¦           ¦            ¦
 ¦             ¦rare, care raspund     ¦             ¦           ¦            ¦
 ¦             ¦favorabil la tratament,¦             ¦           ¦            ¦
 ¦             ¦cand nu sunt semne de  ¦             ¦           ¦            ¦
 ¦             ¦afectare organica a    ¦             ¦           ¦            ¦
 ¦             ¦cordului si fondul     ¦             ¦           ¦            ¦
 ¦             ¦patogenic al tulburarii¦             ¦           ¦            ¦
 ¦             ¦de ritm este           ¦             ¦           ¦            ¦
 ¦             ¦neuro-vegetativ sau    ¦             ¦           ¦            ¦
 ¦             ¦dismetabolic, cand     ¦             ¦           ¦            ¦
 ¦             ¦toleranta la efort     ¦             ¦           ¦            ¦
 ¦             ¦intercritica este      ¦             ¦           ¦            ¦
 ¦             ¦buna                   ¦             ¦           ¦            ¦
 ¦             +-----------------------+-------------+-----------+------------¦
 ¦             ¦Deficienta functionala ¦    50-69%   ¦Pierduta   ¦Gradul III  ¦
 ¦             ¦medie                  ¦             ¦cel putin  ¦            ¦
 ¦             ¦TPSV cu recurente      ¦             ¦jumatate   ¦            ¦
 ¦             ¦frecvente,             ¦             ¦           ¦            ¦
 ¦             ¦asimptomatica          ¦             ¦           ¦            ¦
 ¦             ¦intercritic, necesita  ¦             ¦           ¦            ¦
 ¦             ¦tratament antiaritmic  ¦             ¦           ¦            ¦
 ¦             ¦cronic, toleranta la   ¦             ¦           ¦            ¦
 ¦             ¦efort poate fi         ¦             ¦           ¦            ¦
 ¦             ¦limitata de aparitia   ¦             ¦           ¦            ¦
 ¦             ¦tulburarilor de ritm si¦             ¦           ¦            ¦
 ¦             ¦a tulburarilor         ¦             ¦           ¦            ¦
 ¦             ¦functionale            ¦             ¦           ¦            ¦
 ¦             ¦(palpitatii, dispnee,  ¦             ¦           ¦            ¦
 ¦             ¦ameteli) la eforturi de¦             ¦           ¦            ¦
 ¦             ¦intensitate mare si    ¦             ¦           ¦            ¦
 ¦             ¦medie;                 ¦             ¦           ¦            ¦
 ¦             ¦TPSV recurente         ¦             ¦           ¦            ¦
 ¦             ¦frecvente, la persoane ¦             ¦           ¦            ¦
 ¦             ¦asimptomatice, cu      ¦             ¦           ¦            ¦
 ¦             ¦sindrom WPW            ¦             ¦           ¦            ¦
 ¦             ¦intermitent;           ¦             ¦           ¦            ¦
 ¦             +-----------------------+-------------+-----------+------------¦
 ¦             ¦Deficienta functionala ¦    70-89%   ¦Pierduta in¦Gradul II   ¦
 ¦             ¦accentuata             ¦             ¦totalitate ¦            ¦
 ¦             ¦TPSV persistenta,      ¦             ¦           ¦            ¦
 ¦             ¦simptomatica, partial  ¦             ¦           ¦            ¦
 ¦             ¦controlata de medicatia¦             ¦           ¦            ¦
 ¦             ¦specifica; toleranta   ¦             ¦           ¦            ¦
 ¦             ¦redusa la efort de     ¦             ¦           ¦            ¦
 ¦             ¦intensitate mica;      ¦             ¦           ¦            ¦
 ¦             ¦TPSV paroxistica sau   ¦             ¦           ¦            ¦
 ¦             ¦persistenta recurenta, ¦             ¦           ¦            ¦
 ¦             ¦a carei etiologie este ¦             ¦           ¦            ¦
 ¦             ¦sindromul WPW permanent¦             ¦           ¦            ¦
 ¦             ¦(risc crescut de moarte¦             ¦           ¦            ¦
 ¦             ¦subita);               ¦             ¦           ¦            ¦
 +-------------+-----------------------+-------------+-----------+------------¦
 ¦             ¦N.B. Subiectii cu WPW, ¦             ¦           ¦            ¦
 ¦             ¦care beneficiaza de    ¦             ¦           ¦            ¦
 ¦             ¦tratament prin cateter ¦             ¦           ¦            ¦
 ¦             ¦ablatie a fasciculului ¦             ¦           ¦            ¦
 ¦             ¦accesor, la care       ¦             ¦           ¦            ¦
 ¦             ¦procedura a fost       ¦             ¦           ¦            ¦
 ¦             ¦eficienta si a decurs  ¦             ¦           ¦            ¦
 ¦             ¦fara complicatii vor fi¦             ¦           ¦            ¦
 ¦             ¦reevaluati             ¦             ¦           ¦            ¦
 ¦             ¦post-procedural,       ¦             ¦           ¦            ¦
 ¦             ¦urmarindu-se           ¦             ¦           ¦            ¦
 ¦             ¦principalele elemente  ¦             ¦           ¦            ¦
 ¦             ¦functionale necesare   ¦             ¦           ¦            ¦
 ¦             ¦stabilirii             ¦             ¦           ¦            ¦
 ¦             ¦diagnosticului         ¦             ¦           ¦            ¦
 ¦             ¦functional.            ¦             ¦           ¦            ¦
 +-------------+-----------------------+-------------+-----------+------------¦
 ¦Tahicardii   ¦Deficienta functionala ¦    50-69%   ¦Pierduta   ¦Gradul III  ¦
 ¦ventriculare ¦medie                  ¦             ¦cel putin  ¦            ¦
 ¦             ¦TV cu crize la         ¦             ¦jumatate   ¦            ¦
 ¦             ¦intervale mari,        ¦             ¦           ¦            ¦
 ¦             ¦controlate terapeutic  ¦             ¦           ¦            ¦
 ¦             ¦Tulburarile de ritm si ¦             ¦           ¦            ¦
 ¦             ¦cele functionale apar  ¦             ¦           ¦            ¦
 ¦             ¦la eforturi de         ¦             ¦           ¦            ¦
 ¦             ¦intensitate mare/medie ¦             ¦           ¦            ¦
 ¦             +-----------------------+-------------+-----------+------------¦
 ¦             ¦Deficienta functionala ¦    70-89%   ¦Pierduta in¦Gradul II   ¦
 ¦             ¦accentuata             ¦             ¦totalitate ¦            ¦
 ¦             ¦Tahicardie ventriculara¦             ¦           ¦            ¦
 ¦             ¦bidirectionala, torsada¦             ¦           ¦            ¦
 ¦             ¦varfului si ritmul     ¦             ¦           ¦            ¦
 ¦             ¦idio-ventricular       ¦             ¦           ¦            ¦
 ¦             ¦accelerat, necontrolate¦             ¦           ¦            ¦
 ¦             ¦suficient prin         ¦             ¦           ¦            ¦
 ¦             ¦tratament. De asemenea,¦             ¦           ¦            ¦
 ¦             ¦in TV insotite de      ¦             ¦           ¦            ¦
 ¦             ¦insuficienta cardiaca, ¦             ¦           ¦            ¦
 ¦             ¦fenomene de ischemie   ¦             ¦           ¦            ¦
 ¦             ¦cerebrala, sincope,    ¦             ¦           ¦            ¦
 ¦             ¦ischemie miocardica si ¦             ¦           ¦            ¦
 ¦             ¦tulburari hemodinamice.¦             ¦           ¦            ¦
 ¦             ¦Prin substratul lor, de¦             ¦           ¦            ¦
 ¦             ¦cele mai multe ori     ¦             ¦           ¦            ¦
 ¦             ¦fiind afectiuni        ¦             ¦           ¦            ¦
 ¦             ¦cardiace grave,        ¦             ¦           ¦            ¦
 ¦             ¦tulburarile de ritm    ¦             ¦           ¦            ¦
 ¦             ¦ventricular determina o¦             ¦           ¦            ¦
 ¦             ¦deficienta functionala ¦             ¦           ¦            ¦
 ¦             ¦accentuata             ¦             ¦           ¦            ¦
 +-------------+-----------------------+-------------+-----------+------------¦
 ¦Fibrilatia   ¦In FA si flutter,      ¦             ¦           ¦            ¦
 ¦atriala,     ¦deficienta functionala ¦             ¦           ¦            ¦
 ¦flutter-ul   ¦se va aprecia in raport¦             ¦           ¦            ¦
 ¦atrial       ¦de substratul          ¦             ¦           ¦            ¦
 ¦             ¦etiopatogenic, de      ¦             ¦           ¦            ¦
 ¦             ¦caracterul permanent   ¦             ¦           ¦            ¦
 ¦             ¦sau paroxistic (in     ¦             ¦           ¦            ¦
 ¦             ¦acest caz se va lua in ¦             ¦           ¦            ¦
 ¦             ¦considerare frecventa  ¦             ¦           ¦            ¦
 ¦             ¦si durata episoadelor  ¦             ¦           ¦            ¦
 ¦             ¦paroxistice) de alura  ¦             ¦           ¦            ¦
 ¦             ¦ventriculara, de       ¦             ¦           ¦            ¦
 ¦             ¦existenta semnelor de  ¦             ¦           ¦            ¦
 ¦             ¦insuficienta           ¦             ¦           ¦            ¦
 ¦             ¦cardio-circulatorie si ¦             ¦           ¦            ¦
 ¦             ¦de toleranta la efort  ¦             ¦           ¦            ¦
 ¦             ¦(in principiu, mult    ¦             ¦           ¦            ¦
 ¦             ¦redusa).               ¦             ¦           ¦            ¦
 ¦             +-----------------------+-------------+-----------+------------¦
 ¦             ¦Deficienta functionala ¦    20-49%   ¦Pastrata   ¦Nu se       ¦
 ¦             ¦usoara                 ¦             ¦           ¦incadreaza  ¦
 ¦             ¦Episod de FA           ¦             ¦           ¦            ¦
 ¦             ¦paroxistica unic sau   ¦             ¦           ¦            ¦
 ¦             ¦episoade rare ce apar  ¦             ¦           ¦            ¦
 ¦             ¦la intervale mari de   ¦             ¦           ¦            ¦
 ¦             ¦timp, declansate de    ¦             ¦           ¦            ¦
 ¦             ¦factori extracardiaci, ¦             ¦           ¦            ¦
 ¦             ¦autolimitate, sau      ¦             ¦           ¦            ¦
 ¦             ¦controlate de medicatia¦             ¦           ¦            ¦
 ¦             ¦specifica; intercritic,¦             ¦           ¦            ¦
 ¦             ¦capacitatea de efort   ¦             ¦           ¦            ¦
 ¦             ¦fizic nu este alterata.¦             ¦           ¦            ¦
 ¦             +-----------------------+-------------+-----------+------------¦
 ¦             ¦Deficienta functionala ¦    50-69%   ¦Pierduta   ¦Gradul III  ¦
 ¦             ¦medie                  ¦             ¦cel putin  ¦            ¦
 ¦             ¦FA paroxistica,        ¦             ¦jumatate   ¦            ¦
 ¦             ¦recurenta, indusa de   ¦             ¦           ¦            ¦
 ¦             ¦prezenta bolii         ¦             ¦           ¦            ¦
 ¦             ¦structurale            ¦             ¦           ¦            ¦
 ¦             ¦cardiovasculare sau de ¦             ¦           ¦            ¦
 ¦             ¦factori extracardiaci  ¦             ¦           ¦            ¦
 ¦             ¦(afectiuni pulmonare,  ¦             ¦           ¦            ¦
 ¦             ¦hipertiroidism,        ¦             ¦           ¦            ¦
 ¦             ¦idiopatica) etc.       ¦             ¦           ¦            ¦
 ¦             +-----------------------+-------------+-----------+------------¦
 ¦             ¦Flutter atrial         ¦    50-69%   ¦Pierduta   ¦Gradul III  ¦
 ¦             ¦paroxistic, recurent,  ¦             ¦cel putin  ¦            ¦
 ¦             ¦indus de prezenta      ¦             ¦jumatate   ¦            ¦
 ¦             ¦bolii structurale      ¦             ¦           ¦            ¦
 ¦             ¦cardiovasculare sau de ¦             ¦           ¦            ¦
 ¦             ¦factori extracardiaci  ¦             ¦           ¦            ¦
 ¦             ¦(afectiuni pulmonare,  ¦             ¦           ¦            ¦
 ¦             ¦hipertiroidism,        ¦             ¦           ¦            ¦
 ¦             ¦idiopatica) etc.       ¦             ¦           ¦            ¦
 +-------------+-----------------------+-------------+-----------+------------¦
 ¦             ¦FA permanenta, cu AV   ¦    50-69%   ¦Pierduta   ¦Gradul III  ¦
 ¦             ¦medie controlata       ¦             ¦cel putin  ¦            ¦
 ¦             ¦medicamentos, fara     ¦             ¦jumatate   ¦            ¦
 ¦             ¦semne clinice de       ¦             ¦           ¦            ¦
 ¦             ¦insuficienta cardiaca, ¦             ¦           ¦            ¦
 ¦             ¦cu toleranta buna la   ¦             ¦           ¦            ¦
 ¦             ¦eforturi cu solicitari ¦             ¦           ¦            ¦
 ¦             ¦energetice medii.      ¦             ¦           ¦            ¦
 ¦             +-----------------------+-------------+-----------+------------¦
 ¦             ¦Deficienta functionala ¦    70-89%   ¦Pierduta in¦Gradul II   ¦
 ¦             ¦accentuata             ¦             ¦totalitate ¦            ¦
 ¦             ¦Flutter-ul atrial      ¦             ¦           ¦            ¦
 ¦             ¦cronic (mai rar),      ¦             ¦           ¦            ¦
 ¦             ¦indiferent de etiologie¦             ¦           ¦            ¦
 ¦             ¦FA persistenta sau     ¦             ¦           ¦            ¦
 ¦             ¦permanenta,            ¦             ¦           ¦            ¦
 ¦             ¦simptomatica           ¦             ¦           ¦            ¦
 ¦             ¦(palpitatii, angina,   ¦             ¦           ¦            ¦
 ¦             ¦dispnee) cu tendinta de¦             ¦           ¦            ¦
 ¦             ¦agravare a bolii de    ¦             ¦           ¦            ¦
 ¦             ¦baza, risc             ¦             ¦           ¦            ¦
 ¦             ¦tromboembolic crescut, ¦             ¦           ¦            ¦
 ¦             ¦risc de cardiomiopatie ¦             ¦           ¦            ¦
 ¦             ¦aritmogena             ¦             ¦           ¦            ¦
 ¦             +-----------------------+-------------+-----------+------------¦
 ¦             ¦Deficienta functionala ¦   90-100%   ¦Capacitatea¦Gradul I    ¦
 ¦             ¦grava                  ¦             ¦de munca si¦            ¦
 ¦             ¦In situatia            ¦             ¦autoservire¦            ¦
 ¦             ¦tulburarilor produse   ¦             ¦pierduta in¦            ¦
 ¦             ¦prin accidente         ¦             ¦totalitate ¦            ¦
 ¦             ¦tromboembolice cu      ¦             ¦           ¦            ¦
 ¦             ¦sechele neurologice    ¦             ¦           ¦            ¦
 ¦             ¦care impiedica         ¦             ¦           ¦            ¦
 ¦             ¦autoservirea.          ¦             ¦           ¦            ¦
 +----------------------------------------------------------------------------+
*ST*

    TULBURARI CRONICE DE CONDUCERE
*T*
 +----------------------------------------------------------------------------+
 ¦Afectiunea.  ¦         Deficienta         ¦Incapa- ¦Capacitatea¦Gradul de   ¦
 ¦             ¦         functionala        ¦citatea ¦de munca   ¦invaliditate¦
 ¦             ¦                            ¦adapta- ¦           ¦            ¦
 ¦             ¦                            ¦tiva    ¦           ¦            ¦
 +-------------+----------------------------+--------+-----------+------------¦
 ¦Blocurile    ¦Se va considera fondul      ¦        ¦           ¦            ¦
 ¦atrioventri- ¦etiopatogenic al tulburarii,¦        ¦           ¦            ¦
 ¦culare       ¦caracterul permanent sau    ¦        ¦           ¦            ¦
 ¦             ¦tranzitoriu, existenta      ¦        ¦           ¦            ¦
 ¦             ¦simptomatologiei (lipotimii,¦        ¦           ¦            ¦
 ¦             ¦sincope, angina pectorala,  ¦        ¦           ¦            ¦
 ¦             ¦dispnee, crize Adams Stokes,¦        ¦           ¦            ¦
 ¦             ¦pierderi de cunostinta),    ¦        ¦           ¦            ¦
 ¦             ¦raspunsul la tratament si   ¦        ¦           ¦            ¦
 ¦             ¦posibilitatea implantarii   ¦        ¦           ¦            ¦
 ¦             ¦unui stimulator. De asemenea¦        ¦           ¦            ¦
 ¦             ¦se vor lua in considerare si¦        ¦           ¦            ¦
 ¦             ¦alte modificari patologice  ¦        ¦           ¦            ¦
 ¦             ¦EKG concomitente cu blocul. ¦        ¦           ¦            ¦
 ¦             +----------------------------+--------+-----------+------------¦
 ¦             ¦Deficienta functionala      ¦ 20-49% ¦Pastrata   ¦Nu se       ¦
 ¦             ¦usoara                      ¦        ¦           ¦incadreaza  ¦
 ¦             ¦BAV gr. I sau gr. II tip 1  ¦        ¦           ¦            ¦
 ¦             +----------------------------+--------+-----------+------------¦
 ¦             ¦Deficienta functionala      ¦ 50-69% ¦Pierduta   ¦Gradul III  ¦
 ¦             ¦medie                       ¦        ¦cel putin  ¦            ¦
 ¦             ¦BAV gr. II (cu substrat     ¦        ¦jumatate   ¦            ¦
 ¦             ¦organic) sau unele forme de ¦        ¦           ¦            ¦
 ¦             ¦BAV gr. III (ex: congenital)¦        ¦           ¦            ¦
 ¦             ¦in care exista o toleranta  ¦        ¦           ¦            ¦
 ¦             ¦la eforturi mici/medii      ¦        ¦           ¦            ¦
 ¦             ¦satisfacatoare,             ¦        ¦           ¦            ¦
 ¦             ¦simptomatologia clinica este¦        ¦           ¦            ¦
 ¦             ¦redusa si nu se evidentiaza ¦        ¦           ¦            ¦
 ¦             ¦alte modificari patologice  ¦        ¦           ¦            ¦
 ¦             ¦EKG in afara blocului A-V.  ¦        ¦           ¦            ¦
 ¦             +----------------------------+--------+-----------+------------¦
 ¦             ¦Deficienta functionala      ¦ 70-89% ¦Pierduta in¦Gradul II   ¦
 ¦             ¦accentuata                  ¦        ¦totalitate ¦            ¦
 ¦             ¦BAV gr. II si III,          ¦        ¦           ¦            ¦
 ¦             ¦simptomatice, cu toleranta  ¦        ¦           ¦            ¦
 ¦             ¦redusa la eforturi de       ¦        ¦           ¦            ¦
 ¦             ¦intensitate mica            ¦        ¦           ¦            ¦
 +-------------+----------------------------+--------+-----------+------------¦
 ¦Blocurile    ¦Aprecierea functionala se va¦        ¦           ¦            ¦
 ¦intraventri- ¦face in raport de substratul¦        ¦           ¦            ¦
 ¦culare       ¦etiopatogenic al afectiunii,¦        ¦           ¦            ¦
 ¦             ¦de gradul de complexitate al¦        ¦           ¦            ¦
 ¦             ¦tulburarilor de conducere,  ¦        ¦           ¦            ¦
 ¦             ¦de simptomatologia pe care o¦        ¦           ¦            ¦
 ¦             ¦determina, de riscul vital  ¦        ¦           ¦            ¦
 ¦             ¦pe care-l presupune si de   ¦        ¦           ¦            ¦
 ¦             ¦raspunsul la tratamentul    ¦        ¦           ¦            ¦
 ¦             ¦specific.                   ¦        ¦           ¦            ¦
 ¦             +----------------------------+--------+-----------+------------¦
 ¦             ¦Deficienta functionala      ¦ 20-49% ¦Pastrata   ¦Nu se       ¦
 ¦             ¦usoara                      ¦        ¦           ¦incadreaza  ¦
 ¦             ¦BRD incomplet, BRD complet  ¦        ¦           ¦            ¦
 ¦             ¦congenital, BFAS, BFPI, fara¦        ¦           ¦            ¦
 ¦             ¦alte modificari             ¦        ¦           ¦            ¦
 ¦             ¦morfofunctionale ale inimii,¦        ¦           ¦            ¦
 ¦             ¦fara limitarea capacitatii  ¦        ¦           ¦            ¦
 ¦             ¦de efort                    ¦        ¦           ¦            ¦
 ¦             +----------------------------+--------+-----------+------------¦
 ¦             ¦Deficienta functionala medie¦ 50-69% ¦Pierduta   ¦Gradul III  ¦
 ¦             ¦BRD sau BRS major, asociate ¦        ¦cel putin  ¦            ¦
 ¦             ¦altor afectiuni cardiace, la¦        ¦jumatate   ¦            ¦
 ¦             ¦care bolnavii sunt          ¦        ¦           ¦            ¦
 ¦             ¦simptomatici la eforturi    ¦        ¦           ¦            ¦
 ¦             ¦mari si medii, dar au       ¦        ¦           ¦            ¦
 ¦             ¦conservata capacitatea de   ¦        ¦           ¦            ¦
 ¦             ¦prestatie fizica pentru     ¦        ¦           ¦            ¦
 ¦             ¦eforturi de mica intensitate¦        ¦           ¦            ¦
 ¦             +----------------------------+--------+-----------+------------¦
 ¦             ¦Deficienta functionala      ¦ 70-89% ¦Pierduta in¦Gradul II   ¦
 ¦             ¦accentuata                  ¦        ¦totalitate ¦            ¦
 ¦             ¦Blocuri bifasciculare (BRD  ¦        ¦           ¦            ¦
 ¦             ¦major + BFAS, BRD major +   ¦        ¦           ¦            ¦
 ¦             ¦BFPI, BRS major) si         ¦        ¦           ¦            ¦
 ¦             ¦trifasciculare (bloc        ¦        ¦           ¦            ¦
 ¦             ¦bifascicular + bloc AV) ce  ¦        ¦           ¦            ¦
 ¦             ¦apar in cadrul unei         ¦        ¦           ¦            ¦
 ¦             ¦cardiopatii cronice,        ¦        ¦           ¦            ¦
 ¦             ¦simptomatice la eforturi de ¦        ¦           ¦            ¦
 ¦             ¦mica intensitate si chiar in¦        ¦           ¦            ¦
 ¦             ¦repaus                      ¦        ¦           ¦            ¦
 +-------------+----------------------------+--------+-----------+------------¦
 ¦Boala nodului¦Aprecierea tulburarilor     ¦        ¦           ¦            ¦
 ¦sinusal (BNS)¦functionale se va face in   ¦        ¦           ¦            ¦
 ¦             ¦functie de complexitatea    ¦        ¦           ¦            ¦
 ¦             ¦disritmiei supraventriculare¦        ¦           ¦            ¦
 ¦             ¦asociata posibil cu         ¦        ¦           ¦            ¦
 ¦             ¦tulburari de conducere AV   ¦        ¦           ¦            ¦
 ¦             ¦sau chiar intraventriculare,¦        ¦           ¦            ¦
 ¦             ¦prezenta simptomatologiei:  ¦        ¦           ¦            ¦
 ¦             ¦palpitatii, angina, ameteli,¦        ¦           ¦            ¦
 ¦             ¦dispnee, sincope, chiar Adam¦        ¦           ¦            ¦
 ¦             ¦Stokes, precum si toleranta ¦        ¦           ¦            ¦
 ¦             ¦la efortul fizic. Se vor lua¦        ¦           ¦            ¦
 ¦             ¦de asemenea in discutie     ¦        ¦           ¦            ¦
 ¦             ¦indicatia implantarii de    ¦        ¦           ¦            ¦
 ¦             ¦stimulator cardiac, precum  ¦        ¦           ¦            ¦
 ¦             ¦si existenta altor          ¦        ¦           ¦            ¦
 ¦             ¦modificari structurale      ¦        ¦           ¦            ¦
 ¦             ¦cardiovasculare             ¦        ¦           ¦            ¦
 ¦             +----------------------------+--------+-----------+------------¦
 ¦             ¦Deficienta functionala      ¦ 20-49% ¦Pastrata   ¦Nu se       ¦
 ¦             ¦usoara                      ¦        ¦           ¦incadreaza  ¦
 ¦             ¦BNS cu bradicardie sinusala ¦        ¦           ¦            ¦
 ¦             ¦asimptomatica. Fara         ¦        ¦           ¦            ¦
 ¦             ¦afectarea capacitatii de    ¦        ¦           ¦            ¦
 ¦             ¦efort.                      ¦        ¦           ¦            ¦
 ¦             +----------------------------+--------+-----------+------------¦
 ¦             ¦Deficienta functionala medie¦ 50-69% ¦Pierduta   ¦Gradul III  ¦
 ¦             ¦BNS cu disritmii            ¦        ¦cel putin  ¦            ¦
 ¦             ¦supraventriculare           ¦        ¦jumatate   ¦            ¦
 ¦             ¦simptomatice; toleranta la  ¦        ¦           ¦            ¦
 ¦             ¦eforturi de intensitate     ¦        ¦           ¦            ¦
 ¦             ¦medie pastrata.             ¦        ¦           ¦            ¦
 ¦             +----------------------------+--------+-----------+------------¦
 ¦             ¦Deficienta functionala      ¦ 70-89% ¦Pierduta in¦Gradul II   ¦
 ¦             ¦accentuata                  ¦        ¦totalitate ¦            ¦
 ¦             ¦BNS simptomatica, cu        ¦        ¦           ¦            ¦
 ¦             ¦disritmii supraventriculare ¦        ¦           ¦            ¦
 ¦             ¦complexe, eventual asociate ¦        ¦           ¦            ¦
 ¦             ¦cu tulburari de conducere   ¦        ¦           ¦            ¦
 ¦             ¦AV, toleranta la efort      ¦        ¦           ¦            ¦
 ¦             ¦pastrata doar pentru        ¦        ¦           ¦            ¦
 ¦             ¦eforturi de intensitate mica¦        ¦           ¦            ¦
 +-------------+----------------------------+--------+-----------+------------¦
 ¦Bolnavi      ¦Se vor lua in considerare   ¦        ¦           ¦            ¦
 ¦purtatori de ¦urmatoarele elemente:       ¦        ¦           ¦            ¦
 ¦stimulator   ¦- disparitia, ameliorarea   ¦        ¦           ¦            ¦
 ¦cardiac      ¦sau persistenta             ¦        ¦           ¦            ¦
 ¦(pacemaker)  ¦simptomatologiei clinice    ¦        ¦           ¦            ¦
 ¦             ¦care a motivat interventia  ¦        ¦           ¦            ¦
 ¦             ¦(cu referire dominant la    ¦        ¦           ¦            ¦
 ¦             ¦starile lipotimice sau      ¦        ¦           ¦            ¦
 ¦             ¦sincopale);                 ¦        ¦           ¦            ¦
 ¦             ¦- prezenta unor anomalii de ¦        ¦           ¦            ¦
 ¦             ¦puls cauzate fie de         ¦        ¦           ¦            ¦
 ¦             ¦epuizarea sursei de energie,¦        ¦           ¦            ¦
 ¦             ¦fie de malfunctia de        ¦        ¦           ¦            ¦
 ¦             ¦stimulare si decelare a     ¦        ¦           ¦            ¦
 ¦             ¦eventualelor extrasistole;  ¦        ¦           ¦            ¦
 ¦             ¦- semne EKG ale eficacitatii¦        ¦           ¦            ¦
 ¦             ¦stimularii, precum si a     ¦        ¦           ¦            ¦
 ¦             ¦situatiei patologice care a ¦        ¦           ¦            ¦
 ¦             ¦necesitat pacingul;         ¦        ¦           ¦            ¦
 ¦             ¦- tipul de stimulator,      ¦        ¦           ¦            ¦
 ¦             ¦cardiopatia pacientului     ¦        ¦           ¦            ¦
 ¦             ¦purtator si vechimea        ¦        ¦           ¦            ¦
 ¦             ¦generatorului de puls       ¦        ¦           ¦            ¦
 ¦             ¦implantat;                  ¦        ¦           ¦            ¦
 ¦             ¦- eventuale complicatii     ¦        ¦           ¦            ¦
 ¦             +----------------------------+--------+-----------+------------¦
 ¦             ¦Deficienta functionala      ¦ 20-49% ¦Pastrata   ¦Nu se       ¦
 ¦             ¦usoara                      ¦        ¦Se pot     ¦incadreaza  ¦
 ¦             ¦In cardio-stimulare         ¦        ¦desfasura  ¦            ¦
 ¦             ¦eficienta, cu stare clinica ¦        ¦activitati ¦            ¦
 ¦             ¦functionala buna, fara alte ¦        ¦profesiona-¦            ¦
 ¦             ¦alterari ale functiei inimii¦        ¦le seden-  ¦            ¦
 ¦             ¦                            ¦        ¦tare/usoare¦            ¦
 ¦             ¦                            ¦        ¦in conditii¦            ¦
 ¦             ¦                            ¦        ¦optime de  ¦            ¦
 ¦             ¦                            ¦        ¦microclimat¦            ¦
 ¦             ¦                            ¦        ¦fara risc  ¦            ¦
 ¦             ¦                            ¦        ¦profesional¦            ¦
 ¦             +----------------------------+--------+-----------+------------¦
 ¦             ¦Deficienta functionala medie¦ 50-69% ¦Pierduta   ¦Gradul III  ¦
 ¦             ¦Pacientii prezinta unele    ¦        ¦cel putin  ¦            ¦
 ¦             ¦tulburari functionale, la   ¦        ¦jumatate   ¦            ¦
 ¦             ¦eforturi mari si medii,     ¦        ¦(cu        ¦            ¦
 ¦             ¦exista modificari patologice¦        ¦aceleasi   ¦            ¦
 ¦             ¦EKG in afara celor induse de¦        ¦recomandari¦            ¦
 ¦             ¦pacing                      ¦        ¦ca mai sus)¦            ¦
 ¦             +----------------------------+--------+-----------+------------¦
 ¦             ¦Deficienta functionala      ¦ 70-89% ¦Pierduta in¦Gradul II   ¦
 ¦             ¦accentuata                  ¦        ¦totalitate ¦            ¦
 ¦             ¦Pacienti cu afectiuni       ¦        ¦           ¦            ¦
 ¦             ¦cardiace organice severe, la¦        ¦           ¦            ¦
 ¦             ¦care implantarea            ¦        ¦           ¦            ¦
 ¦             ¦stimulatorului a permis doar¦        ¦           ¦            ¦
 ¦             ¦regularizarea ritmului      ¦        ¦           ¦            ¦
 ¦             ¦cardiac, dar care, prin     ¦        ¦           ¦            ¦
 ¦             ¦natura si amploarea modifi- ¦        ¦           ¦            ¦
 ¦             ¦carilor morfo-functionale   ¦        ¦           ¦            ¦
 ¦             ¦cardiovasculare, au capaci- ¦        ¦           ¦            ¦
 ¦             ¦tate functionala mult redu- ¦        ¦           ¦            ¦
 ¦             ¦sa, prezinta simptome la    ¦        ¦           ¦            ¦
 ¦             ¦eforturi mici si chiar in   ¦        ¦           ¦            ¦
 ¦             ¦repaus si au risc vital     ¦        ¦           ¦            ¦
 ¦             ¦crescut                     ¦        ¦           ¦            ¦
 +-------------+----------------------------+--------+-----------+------------¦
 ¦Bolnavi dupa ¦Aprecierea tulburarilor     ¦        ¦           ¦            ¦
 ¦By-pass      ¦functionale se va face in   ¦        ¦           ¦            ¦
 ¦coronarian   ¦raport cu:                  ¦        ¦           ¦            ¦
 ¦sau          ¦- evolutia simptomatologiei ¦        ¦           ¦            ¦
 ¦angioplastie ¦(angina, palpitatii,        ¦        ¦           ¦            ¦
 ¦coronariana  ¦dispnee);                   ¦        ¦           ¦            ¦
 ¦             ¦- evolutia aspectului EKG:  ¦        ¦           ¦            ¦
 ¦             ¦modificari de faza terminala¦        ¦           ¦            ¦
 ¦             ¦aritmii, tulburari de       ¦        ¦           ¦            ¦
 ¦             ¦conducere;                  ¦        ¦           ¦            ¦
 ¦             ¦- tulburarile de kinetica   ¦        ¦           ¦            ¦
 ¦             ¦regionale si functia        ¦        ¦           ¦            ¦
 ¦             ¦sistolica globala a VS;     ¦        ¦           ¦            ¦
 ¦             ¦- existenta restenozarilor. ¦        ¦           ¦            ¦
 ¦             +----------------------------+--------+-----------+------------¦
 ¦             ¦Deficienta functionala      ¦ 20-49% ¦Pastrata   ¦Nu se       ¦
 ¦             ¦usoara                      ¦        ¦Pentru     ¦incadreaza  ¦
 ¦             ¦Fara simptome anginoase sau ¦        ¦activitatea¦            ¦
 ¦             ¦angina apare la intervale   ¦        ¦profesiona-¦            ¦
 ¦             ¦mari, aspect EKG normal sau ¦        ¦la cu      ¦            ¦
 ¦             ¦EKG releva modificari minore¦        ¦solicitari ¦            ¦
 ¦             ¦de faza terminala, aritmii  ¦        ¦energetice ¦            ¦
 ¦             ¦benigne; functie cardiaca   ¦        ¦mici, in   ¦            ¦
 ¦             ¦normala sau disfunctie      ¦        ¦conditii de¦            ¦
 ¦             ¦sistolica usoara            ¦        ¦microclimat¦            ¦
 ¦             ¦(FE = 50-45%)               ¦        ¦corespunza-¦            ¦
 ¦             ¦                            ¦        ¦tor, fara  ¦            ¦
 ¦             ¦                            ¦        ¦risc       ¦            ¦
 ¦             ¦                            ¦        ¦profesional¦            ¦
 ¦             +----------------------------+--------+-----------+------------¦
 ¦             ¦Deficienta functionala medie¦ 50-69% ¦Pierduta   ¦Gradul III  ¦
 ¦             ¦Revascularizare incompleta, ¦        ¦cel putin  ¦            ¦
 ¦             ¦cu persistenta anginei la   ¦        ¦jumatate   ¦            ¦
 ¦             ¦eforturi medii; disfunctie  ¦        ¦           ¦            ¦
 ¦             ¦sistolica moderata de VS    ¦        ¦           ¦            ¦
 ¦             ¦(FE = 40-44%; insuficienta  ¦        ¦           ¦            ¦
 ¦             ¦cardiaca NYHA II;           ¦        ¦           ¦            ¦
 ¦             +----------------------------+--------+-----------+------------¦
 ¦             ¦Deficienta functionala      ¦ 70-89% ¦Pierduta in¦Gradul II   ¦
 ¦             ¦accentuata in situatia in   ¦        ¦totalitate ¦            ¦
 ¦             ¦care simptomatologia si     ¦        ¦           ¦            ¦
 ¦             ¦tulburarile functionale     ¦        ¦           ¦            ¦
 ¦             ¦persista si dupa aceste     ¦        ¦           ¦            ¦
 ¦             ¦tehnici, sau daca s-au      ¦        ¦           ¦            ¦
 ¦             ¦produs restenozari sau      ¦        ¦           ¦            ¦
 ¦             ¦infarct miocardic acut post ¦        ¦           ¦            ¦
 ¦             ¦interventie; disfunctie     ¦        ¦           ¦            ¦
 ¦             ¦sistolica moderata          ¦        ¦           ¦            ¦
 ¦             ¦(FE = 39-30%); insuficienta ¦        ¦           ¦            ¦
 ¦             ¦cardiaca NYHA III.          ¦        ¦           ¦            ¦
 +-------------+----------------------------+--------+-----------+------------¦
 ¦Cardiomiopa- ¦Variabilitatea simptomelor  ¦        ¦           ¦            ¦
 ¦tia hipertro-¦care determina deficienta   ¦        ¦           ¦            ¦
 ¦fica (CMH)   ¦functionala este determinata¦        ¦           ¦            ¦
 ¦este o       ¦de interactiunea complexa   ¦        ¦           ¦            ¦
 ¦afectiune    ¦dintre HVS, gradientul      ¦        ¦           ¦            ¦
 ¦miocardica   ¦intraventricular, ischemia  ¦        ¦           ¦            ¦
 ¦primitiva,   ¦miocardica si disfunctia    ¦        ¦           ¦            ¦
 ¦caracterizata¦diastolica si sistolica.    ¦        ¦           ¦            ¦
 ¦prin         ¦Criteriile de apreciere a   ¦        ¦           ¦            ¦
 ¦hipertrofia  ¦deficientei functionale sunt¦        ¦           ¦            ¦
 ¦VS si/sau VD,¦rezultatul coroborarii      ¦        ¦           ¦            ¦
 ¦care         ¦datelor clinice: dispnee,   ¦        ¦           ¦            ¦
 ¦afecteaza    ¦angina pectorala,           ¦        ¦           ¦            ¦
 ¦predominent  ¦presincope, sincope;        ¦        ¦           ¦            ¦
 ¦septul inter-¦paraclinice:                ¦        ¦           ¦            ¦
 ¦ventricular. ¦ecocardiografice - metoda de¦        ¦           ¦            ¦
 ¦             ¦electie pentru determinarea ¦        ¦           ¦            ¦
 ¦Caracteris-  ¦severitatii HVS, localizarea¦        ¦           ¦            ¦
 ¦tici:        ¦si cuantificarea            ¦        ¦           ¦            ¦
 ¦VS nedilatat,¦gradientului                ¦        ¦           ¦            ¦
 ¦variabilita- ¦intraventricular, a         ¦        ¦           ¦            ¦
 ¦tea mare a   ¦disfunctiei cardiace;       ¦        ¦           ¦            ¦
 ¦gradului de  ¦electrice: HVS cu gradient  ¦        ¦           ¦            ¦
 ¦hipertrofie; ¦QRS-T alterat, unde Q       ¦        ¦           ¦            ¦
 ¦Pentru       ¦patologice, aritmii.        ¦        ¦           ¦            ¦
 ¦definirea    +----------------------------+--------+-----------+------------¦
 ¦CMH: grosimea¦Deficienta functionala      ¦ 20-49% ¦Pastrata   ¦Nu se       ¦
 ¦peretelui    ¦usoara                      ¦        ¦           ¦incadreaza  ¦
 ¦> 13 mm      ¦CMH asimptomatice cu        ¦        ¦           ¦            ¦
 ¦             ¦toleranta buna la eforturi  ¦        ¦           ¦            ¦
 ¦             ¦mari si medii. Hipertrofie  ¦        ¦           ¦            ¦
 ¦             ¦septala > 13 mm             ¦        ¦           ¦            ¦
 ¦             +----------------------------+--------+-----------+------------¦
 ¦             ¦Deficienta functionala medie¦ 50-69% ¦Pierduta   ¦Gradul III  ¦
 ¦             ¦Bolnavii paucisimptomatici  ¦        ¦cel putin  ¦            ¦
 ¦             ¦in repaus si la eforturi    ¦        ¦jumatate   ¦            ¦
 ¦             ¦mici, dar cu dispnee,       ¦        ¦           ¦            ¦
 ¦             ¦sincope la efort mediu si   ¦        ¦           ¦            ¦
 ¦             ¦mare, angina, palpitatii,   ¦        ¦           ¦            ¦
 ¦             ¦modificari EKG, hipertrofie ¦        ¦           ¦            ¦
 ¦             ¦septala avansata, SAM,      ¦        ¦           ¦            ¦
 ¦             ¦gradient intraventricular.  ¦        ¦           ¦            ¦
 ¦             ¦Insuficienta cardiaca       ¦        ¦           ¦            ¦
 ¦             ¦NYHA II                     ¦        ¦           ¦            ¦
 ¦             +----------------------------+--------+-----------+------------¦
 ¦             ¦Deficienta functionala      ¦ 70-89% ¦Pierduta in¦Gradul II   ¦
 ¦             ¦accentuata                  ¦        ¦totalitate ¦            ¦
 ¦             ¦Bolnavii simptomatici la    ¦        ¦           ¦            ¦
 ¦             ¦efort mic si repaus: angina,¦        ¦           ¦            ¦
 ¦             ¦palpitatii dispnee, SAM, cu ¦        ¦           ¦            ¦
 ¦             ¦obstructie importanta a caii¦        ¦           ¦            ¦
 ¦             ¦de iesire a VS (eco), cu    ¦        ¦           ¦            ¦
 ¦             ¦tulburari de ritm grave, cu ¦        ¦           ¦            ¦
 ¦             ¦sincope sau presincope in   ¦        ¦           ¦            ¦
 ¦             ¦antecedente (repetitive).   ¦        ¦           ¦            ¦
 ¦             ¦Insuficienta cardiaca       ¦        ¦           ¦            ¦
 ¦             ¦NYHA III                    ¦        ¦           ¦            ¦
 ¦             +----------------------------+--------+-----------+------------¦
 ¦             ¦Deficienta functionala grava¦ 90-100%¦Capacitate ¦Gradul I    ¦
 ¦             ¦CMH cu insuficienta cardiaca¦        ¦de munca si¦            ¦
 ¦             ¦NYHA IV, ireversibila,      ¦        ¦autoservire¦            ¦
 ¦             ¦tulburari grave de ritm si  ¦        ¦pierduta in¦            ¦
 ¦             ¦sincope frecvente care      ¦        ¦totalitate ¦            ¦
 ¦             ¦impiedica autoservirea      ¦        ¦           ¦            ¦
 +-------------+----------------------------+--------+-----------+------------¦
 ¦Cardiomiopa- ¦Elementele functionale sunt ¦        ¦           ¦            ¦
 ¦tia dilatati-¦consecinta reducerii        ¦        ¦           ¦            ¦
 ¦va (CMD):    ¦contractilitatii miocardice.¦        ¦           ¦            ¦
 ¦dilatatia VS ¦Pentru aprecierea           ¦        ¦           ¦            ¦
 ¦sau a ambilor¦deficientei functionale sunt¦        ¦           ¦            ¦
 ¦ventriculi,  ¦suficiente datele clinice:  ¦        ¦           ¦            ¦
 ¦conform      ¦dispnee, fatigabilitate,    ¦        ¦           ¦            ¦
 ¦criteriilor  ¦reducerea tolerantei la     ¦        ¦           ¦            ¦
 ¦de diagnostic¦efort; Paraclinic:          ¦        ¦           ¦            ¦
 ¦acceptate in ¦ecocardiografia este        ¦        ¦           ¦            ¦
 ¦prezent:     ¦investigatia esentiala,     ¦        ¦           ¦            ¦
 ¦D.T.DVS >    ¦care detecteaza dilatatia   ¦        ¦           ¦            ¦
 ¦2,7 cm/m?    ¦VS si disfunctia sistolica; ¦        ¦           ¦            ¦
 ¦FE < 45%     ¦EKG este intotdeauna        ¦        ¦           ¦            ¦
 ¦             ¦anormala, dar anomaliile    ¦        ¦           ¦            ¦
 ¦             ¦electrice sunt de cele mai  ¦        ¦           ¦            ¦
 ¦             ¦multe ori nespecifice: TS,  ¦        ¦           ¦            ¦
 ¦             ¦aplatizare T, subdenivelare ¦        ¦           ¦            ¦
 ¦             ¦ST, Q patologice, BRS etc.  ¦        ¦           ¦            ¦
 ¦             +----------------------------+--------+-----------+------------¦
 ¦             ¦CMD in faza initiala pot    ¦ 20-49% ¦Pastrata   ¦Ne se       ¦
 ¦             ¦avea deficienta functionala ¦        ¦           ¦incadreaza  ¦
 ¦             ¦usoara, daca au toleranta   ¦        ¦           ¦            ¦
 ¦             ¦buna la efort               ¦        ¦           ¦            ¦
 ¦             +----------------------------+--------+-----------+------------¦
 ¦             ¦Deficienta functionala medie¦ 50-69% ¦Pierduta   ¦Gradul III  ¦
 ¦             ¦CMD cu dispnee la efort mare¦        ¦cel putin  ¦            ¦
 ¦             ¦si mediu, crize anginoase   ¦        ¦jumatate   ¦            ¦
 ¦             ¦rare, tulburari de ritm     ¦        ¦           ¦            ¦
 ¦             ¦episodice. Disfunctie       ¦        ¦           ¦            ¦
 ¦             ¦sistolica VS moderata       ¦        ¦           ¦            ¦
 ¦             ¦(FE = 40-44%) Insuficienta  ¦        ¦           ¦            ¦
 ¦             ¦cardiaca NYHA II            ¦        ¦           ¦            ¦
 ¦             +----------------------------+--------+-----------+------------¦
 ¦             ¦Deficienta functionala      ¦ 70-89% ¦Pierduta in¦Gradul II   ¦
 ¦             ¦accentuata                  ¦        ¦totalitate ¦            ¦
 ¦             ¦Bolnavii cu insuficienta    ¦        ¦           ¦            ¦
 ¦             ¦cardiaca NYHA III, III/IV cu¦        ¦           ¦            ¦
 ¦             ¦tulburari severe de ritm    ¦        ¦           ¦            ¦
 ¦             ¦si/sau conducere cu tromboze¦        ¦           ¦            ¦
 ¦             ¦intracavitare               ¦        ¦           ¦            ¦
 ¦             ¦Disfunctie sistolica V.S.   ¦        ¦           ¦            ¦
 ¦             ¦moderata (FE = 39-30%)      ¦        ¦           ¦            ¦
 ¦             +----------------------------+--------+-----------+------------¦
 ¦             ¦Deficienta functionala grava¦ 90-100%¦Capacitate ¦Gradul I    ¦
 ¦             ¦CMD cu insuficienta cardiaca¦        ¦de munca si¦            ¦
 ¦             ¦grava, ireversibila sau cu  ¦        ¦autoservire¦            ¦
 ¦             ¦sechele grave dupa accidente¦        ¦pierduta in¦            ¦
 ¦             ¦embolice care impiedica     ¦        ¦totalitate ¦            ¦
 ¦             ¦autoservirea                ¦        ¦           ¦            ¦
 ¦             ¦Disfunctie sistolica VS     ¦        ¦           ¦            ¦
 ¦             ¦grava (FE <30%)             ¦        ¦           ¦            ¦
 +-------------+----------------------------+--------+-----------+------------¦
 ¦Cardiomiopa- ¦Evaluarea se va face in     ¦        ¦           ¦            ¦
 ¦tia          ¦raport cu: dispnee, semne de¦        ¦           ¦            ¦
 ¦restrictiva  ¦staza periferica, cresterea ¦        ¦           ¦            ¦
 ¦             ¦mare a presiunii venoase la ¦        ¦           ¦            ¦
 ¦             ¦fel ca in pericardita       ¦        ¦           ¦            ¦
 ¦             ¦cronica                     ¦        ¦           ¦            ¦
 +-------------+----------------------------+--------+-----------+------------¦
 ¦Pericardita  ¦Constituirea unei           ¦        ¦           ¦            ¦
 ¦cronica      ¦pericardite cronice         ¦        ¦           ¦            ¦
 ¦             ¦constrictive este adesea    ¦        ¦           ¦            ¦
 ¦             ¦indelungata, putand sa apara¦        ¦           ¦            ¦
 ¦             ¦la un timp variabil de la   ¦        ¦           ¦            ¦
 ¦             ¦pericardita acuta (luni pana¦        ¦           ¦            ¦
 ¦             ¦la ani). Dupa aparitia      ¦        ¦           ¦            ¦
 ¦             ¦manifestarilor majore,      ¦        ¦           ¦            ¦
 ¦             ¦evolutia bolii este rapida  ¦        ¦           ¦            ¦
 ¦             +----------------------------+--------+-----------+------------¦
 ¦             ¦Deficienta functionala medie¦ 50-69% ¦Pierduta   ¦Gradul III  ¦
 ¦             ¦Starea dupa pericardita     ¦        ¦cel putin  ¦            ¦
 ¦             ¦acuta, ca si pericardita    ¦        ¦jumatate   ¦            ¦
 ¦             ¦cronica constrictiva cu     ¦        ¦           ¦            ¦
 ¦             ¦tulburari functionale       ¦        ¦           ¦            ¦
 ¦             ¦(dispnee) la eforturi mari  ¦        ¦           ¦            ¦
 ¦             ¦si medii, cu semne de       ¦        ¦           ¦            ¦
 ¦             ¦insuficienta cardiaca       ¦        ¦           ¦            ¦
 ¦             ¦NYHA II                     ¦        ¦           ¦            ¦
 ¦             +----------------------------+--------+-----------+------------¦
 ¦             ¦Pericardita cronica         ¦ 70-89% ¦Capacitate ¦Gradul II   ¦
 ¦             ¦constrictiva cu semne de    ¦        ¦de munca si¦            ¦
 ¦             ¦insuficienta cardiaca       ¦        ¦autoservire¦            ¦
 ¦             ¦NYHA III sau IV cu tulburari¦        ¦pierduta in¦            ¦
 ¦             ¦de ritm sau conducere, cu   ¦        ¦totalitate ¦            ¦
 ¦             ¦dispnee de repaus sau la    ¦        ¦           ¦            ¦
 ¦             ¦efort mic; determina        ¦        ¦           ¦            ¦
 ¦             ¦deficienta accentuata       ¦        ¦           ¦            ¦
 ¦             +----------------------------+--------+-----------+------------¦
 ¦             ¦Deficienta functionala grava¦ 90-100%¦Capacitate ¦Gradul I    ¦
 ¦             ¦Pericardita cronica         ¦        ¦de munca si¦            ¦
 ¦             ¦constrictiva cu insuficienta¦        ¦autoservire¦            ¦
 ¦             ¦cardiaca grava, ireversibila¦        ¦pierduta in¦            ¦
 ¦             ¦                            ¦        ¦totalitate ¦            ¦
 +-------------+----------------------------+--------+-----------+------------¦
 ¦Cordul       ¦Deficienta functionala se va¦        ¦           ¦            ¦
 ¦pulmonar     ¦aprecia prin coroborarea    ¦        ¦           ¦            ¦
 ¦cronic (CPC) ¦datelor clinice (ale        ¦        ¦           ¦            ¦
 ¦             ¦afectiunii respiratorii sau ¦        ¦           ¦            ¦
 ¦             ¦vasculare, care a generat   ¦        ¦           ¦            ¦
 ¦             ¦CPC) cu rezultatele testelor¦        ¦           ¦            ¦
 ¦             ¦functionale respiratorii si ¦        ¦           ¦            ¦
 ¦             ¦datele obiective care releva¦        ¦           ¦            ¦
 ¦             ¦HTP si suprasolicitarea VD  ¦        ¦           ¦            ¦
 ¦             ¦(HVD, cu sau fara dilatatie)¦        ¦           ¦            ¦
 ¦             ¦oferite de EKG, ecografie   ¦        ¦           ¦            ¦
 ¦             ¦cardiaca.                   ¦        ¦           ¦            ¦
 ¦             +----------------------------+--------+-----------+------------¦
 ¦             ¦Deficienta functionala      ¦ 20-49% ¦Pastrata   ¦Nu se       ¦
 ¦             ¦usoara                      ¦        ¦           ¦incadreaza  ¦
 ¦             ¦Bolnavii cu dispnee la      ¦        ¦           ¦            ¦
 ¦             ¦eforturi mari, HPT usoara,  ¦        ¦           ¦            ¦
 ¦             ¦HVD incipienta              ¦        ¦           ¦            ¦
 ¦             +----------------------------+--------+-----------+------------¦
 ¦             ¦Deficienta functionala medie¦ 50-69% ¦Pierduta   ¦Gradul III  ¦
 ¦             ¦Bolnavii cu dispnee la      ¦        ¦cel putin  ¦            ¦
 ¦             ¦eforturi mari si medii, HTP ¦        ¦jumatate   ¦            ¦
 ¦             ¦moderata, HVD moderata      ¦        ¦           ¦            ¦
 ¦             ¦(evaluata ecografic)        ¦        ¦           ¦            ¦
 ¦             +----------------------------+--------+-----------+------------¦
 ¦             ¦Deficienta functionala      ¦ 70-89% ¦Pierduta in¦Gradul II   ¦
 ¦             ¦accentuata                  ¦        ¦totalitate ¦            ¦
 ¦             ¦Bolnavi cu dispnee la       ¦        ¦           ¦            ¦
 ¦             ¦eforturi mici, HTP grava,   ¦        ¦           ¦            ¦
 ¦             ¦HVD, semne de insuficienta  ¦        ¦           ¦            ¦
 ¦             ¦cardiaca dreapta            ¦        ¦           ¦            ¦
 ¦             +----------------------------+--------+-----------+------------¦
 ¦             ¦Deficienta functionala grava¦ 90-100%¦Capacitate ¦Gradul I    ¦
 ¦             ¦Bolnavii cu dispnee la      ¦        ¦de munca si¦            ¦
 ¦             ¦eforturi minime sau cu orto-¦        ¦autoservire¦            ¦
 ¦             ¦pnee, cu semne de           ¦        ¦pierduta in¦            ¦
 ¦             ¦insuficienta cardiaca       ¦        ¦totalitate ¦            ¦
 ¦             ¦dreapta decompensata,       ¦        ¦           ¦            ¦
 ¦             ¦ireversibila, care conduc la¦        ¦           ¦            ¦
 ¦             ¦pierderea capacitatii de    ¦        ¦           ¦            ¦
 ¦             ¦autoservire                 ¦        ¦           ¦            ¦
 +----------------------------------------------------------------------------+
*ST*

    Severitatea hipertensiunii pulmonare (HTP): date ecocardiografice
    HTP usoara: PAP sistolica = 30-44 mmHg
    HTP moderata: PAP sistolica = 45-70 mmHg;
    HTP grava: PAP sistolica > 70 mmHg

    TRANSPLANTUL CARDIAC

    Transplantul cardiac se defineste ca terapie de electie in cazuri selectionate de boli cardio-vasculare ireversibile, care ameninta viata pacientului. Indicatia de transplant cardiac este limitata la un numar relativ restrans de pacienti, la care se estimeaza un beneficiu real in privinta cresterii duratei de supravietuire si a calitatii vietii.
    Sunt evaluati, de regula, in vederea transplantului cardiac pacienti cu insuficienta cardiaca congestiva clasele III, IV NYHA. Pacientii cu simptome clasificate in clasa II NYHA pot fi evaluati in vederea transplantului cardiac in cazul asocierii unor conditii severe care intuneca prognosticul bolii. Pot fi indicatii de transplant cardiac:
   - boala cardiaca ischemica refractara la terapia medicamentoasa;
   - tahicardia ventriculara sustinuta, refractara la toate metodele terapeutice, inclusiv implantarea de defibrilatoare;
   - cardiomiopatia dilatativa;
   - cardiomiopatia restrictiva;
   - cardiomiopatia dilatativa;
   - boli cardio-vasculare congenitale, in situatiile in care riscul chirurgical este foarte mare.

    Diagnostic functional
    In aprecierea deficientei functionale, a incapacitatii adaptative, respectiv a gradului de invaliditate, se va tine seama de:
   - gradul afectarii functiei cardio-vasculare, evaluata prin parametrii hemodinamici specifici;
   - evolutia post-transplant;
   - existenta complicatiilor cauzate de boala de fond, de interventia operatorie sau de tratamentul imunosupresor cronic.
    Pacientii cu evolutie post-operatorie favorabila, cu functie hemodinamica adecvata post-transplant prezinta deficienta functionala accentuata, incapacitate adaptativa 70-89%, capacitate de munca pierduta in totalitate.
    Evolutia nefavorabila cu restabilire inadecvata a parametrilor hemodinamici si/sau prezenta complicatiior determina deficienta functionala grava cu incapacitate adaptativa de 90-100%, capacitate de munca si autoservire pierdute in totalitate.
    Complicatiile care duc la includerea bolnavului in categoria invaliditatii totale cu insotitor sunt:
   - respingerea allogrefei;
   - disfunctia allogrefei (din cauza efectelor farmacologice sau vasculare - vasculopatia allogrefei);
   - boala coronariana ischemica;
   - complicatii cauzate de imunosupresia cronica (insuficienta renala - nefrotoxicitatea ciclosporinei, infectii severe, neoplazii);
   - tulburari psihice - depresie reactiva.
    Reluarea activitatii este posibila numai intr-un numar foarte restrans de cazuri. Daca pacientul doreste sa isi reia activitatea profesionala, se vor avea in vedere:
   - aspectele legate de locul de munca (solicitari energetice si neuro-psihice, conditii de microclimat, securitatea muncii);
   - nivelul de inteligenta, profilul psihologic, nivelul pregatirii profesionale, situatia familiala si sociala.

    BOLILE ARTERELOR PERIFERICE (BAP)

    Evaluarea functionala si aprecierea capacitatii de munca in arteriopatiile periferice

*T*
 +----------------------------------------------------------------------------+
 ¦Afectiunea   ¦         Deficienta         ¦Incapa- ¦Capacitatea¦Gradul de   ¦
 ¦             ¦         functionala        ¦citatea ¦de munca   ¦invaliditate¦
 ¦             ¦                            ¦adapta- ¦           ¦            ¦
 ¦             ¦                            ¦tiva    ¦           ¦            ¦
 +-------------+----------------------------+--------+-----------+------------¦
 ¦Arteriopa-   ¦Fara deficienta functionala ¦  0-19% ¦Pastrata   ¦Nu se       ¦
 ¦tiile        ¦- arteriopatii de st. I:    ¦        ¦           ¦incadreaza  ¦
 ¦periferice   ¦asimptomatic, absenta       ¦        ¦           ¦            ¦
 ¦             ¦pulsului arterial, raport   ¦        ¦           ¦            ¦
 ¦             ¦glezna/brat 0.9-0,8; indice ¦        ¦           ¦            ¦
 ¦             ¦oscilometric 0,5            ¦        ¦           ¦            ¦
 ¦             +----------------------------+--------+-----------+------------¦
 ¦             ¦Deficienta functionala      ¦ 20-49% ¦Pastrata.  ¦Nu se       ¦
 ¦             ¦usoara                      ¦        ¦Necesita   ¦incadreaza  ¦
 ¦             ¦- arteriopatii st. II A:    ¦        ¦schimbarea ¦            ¦
 ¦             ¦claudicatie intermitenta la ¦        ¦locului de ¦            ¦
 ¦             ¦> 200 m mers si terminarea  ¦        ¦munca (daca¦            ¦
 ¦             ¦testului de efort           ¦        ¦este cazul)¦            ¦
 ¦             ¦standardizat la covor       ¦        ¦si         ¦            ¦
 ¦             ¦rulant*, indicele           ¦        ¦urmarirea  ¦            ¦
 ¦             ¦glezna/brat intre 0,7-0,8;  ¦        ¦continua a ¦            ¦
 ¦             ¦indice oscilometric 0,5     ¦        ¦evolutiei  ¦            ¦
 ¦             ¦                            ¦        ¦bolii      ¦            ¦
 ¦             +----------------------------+--------+-----------+------------¦
 ¦             ¦Deficienta functionala medie¦ 50-69% ¦Pierduta   ¦Gradul III  ¦
 ¦             ¦- arteriopatii st. II B:    ¦        ¦cel putin  ¦            ¦
 ¦             ¦claudicatie intermitenta la ¦        ¦jumatate.  ¦            ¦
 ¦             ¦putin de 200 m de mers,     ¦        ¦Monitori-  ¦            ¦
 ¦             ¦incapacitatea de a termina  ¦        ¦zare       ¦            ¦
 ¦             ¦testul la covor rulant*,    ¦        ¦continua;  ¦            ¦
 ¦             ¦indicele glezna/brat        ¦        ¦in functie ¦            ¦
 ¦             ¦0,7-0,6; indice oscilometric¦        ¦de locul de¦            ¦
 ¦             ¦o, asociate si cu alte      ¦        ¦munca,     ¦            ¦
 ¦             ¦localizari atero-sclerotice ¦        ¦poate lucra¦            ¦
 ¦             ¦                            ¦        ¦si cu norma¦            ¦
 ¦             ¦                            ¦        ¦intreaga   ¦            ¦
 ¦             +----------------------------+--------+-----------+------------¦
 ¦             ¦Deficienta functionala      ¦ 70-89% ¦Pierduta in¦Gradul II   ¦
 ¦             ¦accentuata                  ¦        ¦totalitate ¦            ¦
 ¦             ¦- arteriopatii st. III:     ¦        ¦           ¦            ¦
 ¦             ¦durere ischemica de repaus; ¦        ¦           ¦            ¦
 ¦             ¦- arteriopatii st. IV: apar ¦        ¦           ¦            ¦
 ¦             ¦tulburari trofice;          ¦        ¦           ¦            ¦
 ¦             ¦- indice glezna /brat < 0,6;¦        ¦           ¦            ¦
 ¦             ¦indice oscilometric 0;      ¦        ¦           ¦            ¦
 ¦             ¦- amputatie pana la nivelul ¦        ¦           ¦            ¦
 ¦             ¦gambei unilateral + BAP st. ¦        ¦           ¦            ¦
 ¦             ¦II/III membru controlateral;¦        ¦           ¦            ¦
 ¦             ¦- *amputatie gambe bilateral¦        ¦           ¦            ¦
 ¦             ¦- *amputatie gamba          ¦        ¦           ¦            ¦
 ¦             ¦unilateral + anchiloza      ¦        ¦           ¦            ¦
 ¦             ¦genunchi, sold controlateral¦        ¦           ¦            ¦
 +-------------+----------------------------+--------+-----------+------------¦
 ¦             ¦Deficienta functionala grava¦ 90-100%¦Capacitate ¦Gradul I    ¦
 ¦             ¦- arteriopatii cu amputatii ¦        ¦de munca si¦            ¦
 ¦             ¦ce duc la tulburari         ¦        ¦autoservire¦            ¦
 ¦             ¦functionale grave si        ¦        ¦pierduta in¦            ¦
 ¦             ¦necesita ingrijire          ¦        ¦totalitate ¦            ¦
 ¦             ¦permanenta;                 ¦        ¦           ¦            ¦
 ¦             ¦- amputatie unilaterala     ¦        ¦           ¦            ¦
 ¦             ¦coapsa + BAP st. III-IV     ¦        ¦           ¦            ¦
 ¦             ¦membru controlateral;       ¦        ¦           ¦            ¦
 ¦             ¦- amputatia ambelor coapse; ¦        ¦           ¦            ¦
 ¦             ¦- amputatie coapsa          ¦        ¦           ¦            ¦
 ¦             ¦unilateral + anchiloza sold ¦        ¦           ¦            ¦
 ¦             ¦controlateral               ¦        ¦           ¦            ¦
 ¦             ¦BAP = boala arteriala       ¦        ¦           ¦            ¦
 ¦             ¦periferica                  ¦        ¦           ¦            ¦
 +----------------------------------------------------------------------------+
*ST*
-----
    * In aceste situatii, deficienta functionala poate fi accentuata sau grava, in functie de posibilitatile de protezare si de eventualele asocieri cu alte localizari ale aterosclerozei (coronariene, cerebrale etc.), precum si in functie de extensia si severitatea acesteia.

    Arteriopatii obliterante operate
    Evaluarea insuficientei arteriale postoperatorii implica determinarea semnelor si a simptomelor ce rezulta din diminuarea circulatiei arteriale tisulare locale.
    Aprecierea tulburarilor functionale se va face in raport cu evolutia simptomelor subiective (durere de repaus, claudicatie), existenta semnelor fizice revelatoare de insuficienta circulatorie arteriala, datele obiective oferite de investigatiile paraclinice specifice (oscilometrie, indice presional (IP), Doppler vascular, angiografie). Bolnavul va fi inclus intr-un stadiu evolutiv al clasificarii Leriche-Fontaine, dupa care se va stabili deficienta functionala si, implicit, capacitatea de munca. Se va tine cont de toleranta la tratamentul anticoagulant cronic, acolo unde este cazul.
-----
    * Testul de efort standardizat la covor rulant pentru aprecierea clinica a ischemiei cronice consta in 5 minute de mers cu o viteza de 3,2 km/h si o inclinare a pantei de 10°.
    Terminarea testului plaseaza bolnavul in st. IIA Fontaine, iar incapacitatea de a termina testul din cauza claudicatiei este echivalentul st. IIB Fontaine.

    INSUFICIENTA VENOASA CRONICA
    Evaluarea functionala si aprecierea capacitatii de munca in insuficienta venoasa cronica
*T*
 +----------------------------------------------------------------------------+
 ¦Afectiunea   ¦         Deficienta         ¦Incapa- ¦Capacitatea¦Gradul de   ¦
 ¦             ¦         functionala        ¦citatea ¦de munca   ¦invaliditate¦
 ¦             ¦                            ¦adapta- ¦           ¦            ¦
 ¦             ¦                            ¦tiva    ¦           ¦            ¦
 +-------------+----------------------------+--------+-----------+------------¦
 ¦CEAP- C0-C2  ¦Fara deficienta functionala ¦ 0-19%  ¦Pastrata.  ¦Nu se       ¦
 ¦             ¦- varice simple             ¦        ¦Schimbarea ¦incadreaza  ¦
 ¦             ¦- pachete varicoase         ¦        ¦locului de ¦            ¦
 ¦             ¦                            ¦        ¦munca      ¦            ¦
 ¦             ¦                            ¦        ¦nefavorabil¦            ¦
 ¦             ¦                            ¦        ¦prin       ¦            ¦
 ¦             ¦                            ¦        ¦temperaturi¦            ¦
 ¦             ¦                            ¦        ¦ridicate si¦            ¦
 ¦             ¦                            ¦        ¦ortostatism¦            ¦
 +-------------+----------------------------+--------+-----------+------------¦
 ¦Insuficienta ¦Deficienta functionala      ¦ 20-49% ¦Pastrata.  ¦Nu se       ¦
 ¦venoasa      ¦usoara                      ¦        ¦Schimbarea ¦incadreaza  ¦
 ¦cronica      ¦- dilatatii arciforme cu    ¦        ¦locului de ¦            ¦
 ¦gradul 1     ¦hipertensiune venoasa       ¦        ¦munca      ¦            ¦
 ¦CEAP- C3     ¦ortostatica                 ¦        ¦           ¦            ¦
 ¦             ¦- edem moderat              ¦        ¦           ¦            ¦
 +-------------+----------------------------+--------+-----------+------------¦
 ¦Insuficienta ¦Deficienta functionala medie¦ 50-69% ¦Pierduta   ¦Gradul III  ¦
 ¦venoasa      ¦- dilatatii varicoase       ¦        ¦cel putin  ¦            ¦
 ¦cronica      ¦extinse                     ¦        ¦jumatate   ¦            ¦
 ¦gradul 2     ¦- edem moderat/sever        ¦        ¦           ¦            ¦
 ¦CEAP- C4-C5  ¦- senzatie de greutate in   ¦        ¦           ¦            ¦
 ¦             ¦gamba marcata               ¦        ¦           ¦            ¦
 ¦             ¦- modificari pigmentare,    ¦        ¦           ¦            ¦
 ¦             ¦eczema, lipodermatoscleroza ¦        ¦           ¦            ¦
 ¦             ¦- ulcer venos de gamba      ¦        ¦           ¦            ¦
 ¦             ¦vindecat                    ¦        ¦           ¦            ¦
 +-------------+----------------------------+--------+-----------+------------¦
 ¦Insuficienta ¦Deficienta functionala      ¦ 70-89% ¦Pierduta in¦Gradul II   ¦
 ¦venoasa      ¦accentuata                  ¦        ¦totalitate ¦            ¦
 ¦cronica      ¦- edemul cuprinde intreaga  ¦        ¦           ¦            ¦
 ¦gradul 3     ¦gamba                       ¦        ¦           ¦            ¦
 ¦CEAP- C6     ¦- senzatie de greutate      ¦        ¦           ¦            ¦
 ¦             ¦imediat dupa adoptarea      ¦        ¦           ¦            ¦
 ¦             ¦ortostatismului             ¦        ¦           ¦            ¦
 ¦             ¦- ulcer venos de gamba activ¦        ¦           ¦            ¦
 +----------------------------------------------------------------------------+
*ST*

    Clasificarea CEAP - Stadializarea insuficientei venoase cronice pe baza criteriilor Clinice, Etiologice, Anatomice si Patofizologice

                           2. AFECTIUNI RESPIRATORII

    Pentru evaluarea capacitatii de munca in afectiunile respiratorii, sunt necesare:

    I. Evaluarea clinica:
    - Simptome (tuse, expectoratie, dispnee la efort, paroxistica sau permanenta);
    - Evolutie (forme stabile, exacerbari rare/frecvente);
    - Impactul asupra calitatii vietii;
    - Nivelul limitarii activitatii fizice;
    - Nivelul consumului de medicamente.

    II. Explorarile functionale pulmonare:
    - evaluarea ventilatiei pulmonare prin spirometrie;
    - evaluarea globala a schimburilor gazoase (gazanaliza sangelui arterial in repaus si efort);
    - evaluarea mecanismelor de adaptare la efort prin teste specifice;
    - efectuarea de teste suplimentare de explorare functionala pulmonara (determinarea VR si CRF, teste de mecanica pulmonara, teste de transfer gazos prin membrana alveolo-capilara, pletismografie cu determinarea rezistentei la flux in caile aerifere - Raw etc.).

    III. Examenul radiologic pulmonar:
    - este obligatoriu in toate afectiunile respiratorii;
    - este util pentru:
      - diagnosticul pozitiv si diferential;
      - urmarirea evolutiei bolii;
      - evidentierea complicatiilor.

    IV. Electrocardiograma, ecografia cardiaca in cazurile complicate cu cord pulmonar cronic sau insuficienta cardiaca dreapta.

    ASTMUL BRONSIC

    Criterii de diagnostic functional
    I. Simptome: diurne/nocturne, intermitente/permanente, controlate terapeutic sau nu, impactul asupra activitatii zilnice;
    II. Functia ventilatorie (VEMS, PEF variabilitate);
    III. Tratament (tratamentul cronic si tratamentul crizelor).

    Severitatea astmului bronsic
    In clinicile de pneumologie, acestea se clasifica pe baza elementelor clinice si functionale inainte de tratament.
    Daca pacientul se afla deja in tratament, severitatea bolii se apreciaza in functie de raspunsul la tratament (controlul clinic).

    Observatii:
    Tabelul 1 prezinta criteriile de evaluare a deficientei functionale, a incapacitatii adaptative si a capacitatii de munca stabilite pe baza clasificarii severitatii astmului bronsic conform caracteristicilor clinice si functionale (Global Initiative for Asthma-GINA 2006).
    Notiunea de control vizeaza componenta clinica si se refera la efectele tratamentului asupra manifestarilor bolii.
    Evaluarea functionala a severitatii prin spirometrie este obligatorie pentru stabilirea deficientei functionale.
    In cazurile corect tratate, se va tine seama in evaluarea cazurilor si de nivelul de control al astmului bronsic.

    Tabelul 1. Criterii de diagnostic clinic, diagnostic functional si al capacitatii de munca in astmul bronsic
*T*
 +----------------------------------------------------------------------------+
 ¦Afectiunea   ¦         Diagnosticul       ¦Incapa- ¦Capacitatea¦Gradul de   ¦
 ¦(forma clini-¦          functional        ¦citatea ¦de munca   ¦invaliditate¦
 ¦ca, stadiul) ¦                            ¦adapta- ¦           ¦            ¦
 ¦             ¦                            ¦tiva    ¦           ¦            ¦
 +-------------+----------------------------+--------+-----------+------------¦
 ¦Astm bronsic ¦Fara deficienta functionala ¦ 0-19%  ¦Pastrata   ¦Nu se       ¦
 ¦intermitent  ¦Simptome mai putin de o data¦        ¦           ¦incadreaza  ¦
 ¦             ¦pe saptamana; simptome      ¦        ¦           ¦in grad de  ¦
 ¦             ¦nocturne mai putin de doua  ¦        ¦           ¦invaliditate¦
 ¦             ¦ori pe luna; exacerbari rare¦        ¦           ¦            ¦
 ¦             ¦de scurta durata;           ¦        ¦           ¦            ¦
 ¦             ¦asimptomatic in afara       ¦        ¦           ¦            ¦
 ¦             ¦crizelor, nu afecteaza      ¦        ¦           ¦            ¦
 ¦             ¦activitatea zilnica         ¦        ¦           ¦            ¦
 ¦             ¦- VEMS, PEF = 80% din prezis¦        ¦           ¦            ¦
 ¦             ¦- Variabilitate PEF sau     ¦        ¦           ¦            ¦
 ¦             ¦VEMS = 20%                  ¦        ¦           ¦            ¦
 +-------------+----------------------------+--------+-----------+------------¦
 ¦Astm bronsic ¦Deficienta functionala      ¦ 20-49% ¦Pastrata   ¦Nu se       ¦
 ¦persistent   ¦usoara                      ¦        ¦           ¦incadreaza  ¦
 ¦usor         ¦Simptome mai mult de o data ¦        ¦           ¦in grad de  ¦
 ¦             ¦pe saptamana, dar mai putin ¦        ¦           ¦invaliditate¦
 ¦             ¦de o data pe zi; simptome   ¦        ¦           ¦            ¦
 ¦             ¦nocturne mai mult de doua   ¦        ¦           ¦            ¦
 ¦             ¦ori pe luna; exacerbari     ¦        ¦           ¦            ¦
 ¦             ¦frecvente, care pot afecta  ¦        ¦           ¦            ¦
 ¦             ¦activitatea zilnica si      ¦        ¦           ¦            ¦
 ¦             ¦somnul;                     ¦        ¦           ¦            ¦
 ¦             ¦- VEMS, PEF pana la 65% din ¦        ¦           ¦            ¦
 ¦             ¦prezis                      ¦        ¦           ¦            ¦
 ¦             ¦- Variabilitate PEF sau VEMS¦        ¦           ¦            ¦
 ¦             ¦20-30%                      ¦        ¦           ¦            ¦
 +-------------+----------------------------+--------+-----------+------------¦
 ¦Astm bronsic ¦Deficienta functionala medie¦ 50-69% ¦Pierduta   ¦III         ¦
 ¦persistent   ¦Simptome zilnice; simptome  ¦        ¦cel putin  ¦            ¦
 ¦moderat      ¦nocturne mai mult de o data ¦        ¦jumatate   ¦            ¦
 ¦             ¦pe saptamana; exacerbari    ¦        ¦           ¦            ¦
 ¦             ¦frecvente care pot afecta   ¦        ¦           ¦            ¦
 ¦             ¦activitatea zilnica si      ¦        ¦           ¦            ¦
 ¦             ¦somnul, insotite de         ¦        ¦           ¦            ¦
 ¦             ¦alterarea functiei          ¦        ¦           ¦            ¦
 ¦             ¦ventilatorii (VEMS, PEF     ¦        ¦           ¦            ¦
 ¦             ¦60-50% prezis, variabilitate¦        ¦           ¦            ¦
 ¦             ¦PEF sau VEMS > 30%)         ¦        ¦           ¦            ¦
 +-------------+----------------------------+--------+-----------+------------¦
 ¦Astm bronsic ¦Deficienta functionala      ¦ 70-89% ¦Pierduta in¦II          ¦
 ¦persistent   ¦accentuata                  ¦        ¦totalitate ¦            ¦
 ¦sever        ¦Simptome zilnice; exacerbari¦        ¦           ¦            ¦
 ¦             ¦frecvente, severe; simptome ¦        ¦           ¦            ¦
 ¦             ¦nocturne frecvente;         ¦        ¦           ¦            ¦
 ¦             ¦limitarea importanta a      ¦        ¦           ¦            ¦
 ¦             ¦activitatii zilnice,        ¦        ¦           ¦            ¦
 ¦             ¦insotita de alterarea       ¦        ¦           ¦            ¦
 ¦             ¦functiei ventilatorii (VEMS,¦        ¦           ¦            ¦
 ¦             ¦PEF = 50% prezis,           ¦        ¦           ¦            ¦
 ¦             ¦Variabilitate PEF sau       ¦        ¦           ¦            ¦
 ¦             ¦VEMS > 30%)                 ¦        ¦           ¦            ¦
 +-------------+----------------------------+--------+-----------+------------¦
 ¦Complicatii  ¦Deficienta functionala grava¦ 90-100%¦Capacitate ¦I           ¦
 ¦(insuficienta¦VEMS, PEF < 30% prezis,     ¦        ¦de         ¦            ¦
 ¦respiratorie ¦hipoxemie severa de repaus ±¦        ¦autoservire¦            ¦
 ¦cronica, CPC,¦hipercapnie (pa O(2) < 60   ¦        ¦pierduta   ¦            ¦
 ¦ICD)         ¦mmhg, pa C0(2) > 50 mmhg) + ¦        ¦           ¦            ¦
 ¦             ¦Semne de cord pulmonar      ¦        ¦           ¦            ¦
 ¦             ¦cronic, insuficienta        ¦        ¦           ¦            ¦
 ¦             ¦cardiaca ireductibila       ¦        ¦           ¦            ¦
 +----------------------------------------------------------------------------+
*ST*

    Tabelul 2. Stadializarea astmului bronsic in functie de nivelul de control terapeutic
*T*
 +-----------------------------------------------------------------------------+
 ¦  Caracteristici   ¦       Controlat     ¦Partial controlat¦   Necontrolat   ¦
 +-------------------+---------------------+-----------------+-----------------¦
 ¦Simptome pe        ¦Fara sau mai putin de¦Mai mult de doua ¦Cel putin trei   ¦
 ¦parcursul zilei    ¦doua ori/saptamana   ¦ori pe saptamana ¦dintre elementele¦
 ¦                   ¦                     ¦                 ¦precizate la     ¦
 ¦                   ¦                     ¦                 ¦astmul bronsic   ¦
 ¦                   ¦                     ¦                 ¦partial controlat¦
 ¦                   ¦                     ¦                 ¦in fiecare       ¦
 ¦                   ¦                     ¦                 ¦saptamana        ¦
 +-------------------+---------------------+-----------------+-----------------¦
 ¦Limitarea          ¦Fara                 ¦Prezenta         ¦                 ¦
 ¦activitatii        ¦                     ¦                 ¦                 ¦
 +-------------------+---------------------+-----------------+-----------------¦
 ¦Simptome nocturne  ¦Fara                 ¦Prezente         ¦                 ¦
 ¦(trezesc pacientul)¦                     ¦                 ¦                 ¦
 +-------------------+---------------------+-----------------+-----------------¦
 ¦Tratament de       ¦Nu este necesar sau  ¦Necesar de mai   ¦                 ¦
 ¦urgenta            ¦poate fi necesar de  ¦mult de doua ori ¦                 ¦
 ¦                   ¦mai putin de doua ori¦pe saptamana     ¦                 ¦
 ¦                   ¦pe saptamana         ¦                 ¦                 ¦
 +-------------------+---------------------+-----------------+-----------------¦
 ¦Functia pulmonara  ¦Normala              ¦< 80% din prezis ¦                 ¦
 ¦(VEMS sau PEF)     ¦                     ¦sau din cea mai  ¦                 ¦
 ¦                   ¦                     ¦buna valoare     ¦                 ¦
 ¦                   ¦                     ¦personala (daca  ¦                 ¦
 ¦                   ¦                     ¦este cunoscuta)  ¦                 ¦
 +-------------------+---------------------+-----------------+-----------------¦
 ¦Exacerbari         ¦Niciuna              ¦Cel putin una pe ¦Una pe saptamana ¦
 ¦                   ¦                     ¦an               ¦                 ¦
 +-----------------------------------------------------------------------------+
*ST*

    BOALA PULMONARA OBSTRUCTIVA CRONICA (BPOC)*
-----
    * Conform recomandarilor ghidurilor GOLD (Global Initiative for Chronic Obstructive Lung Disease, Initiativa Globala privind Diagnosticul, Monitorizarea si Prevenirea BPOC)

    Criterii de diagnostic functional
    I. Simptome: tuse, expectoratie, dispnee progresiva accentuata la efort;
    II. Functia ventilatorie: obstructie la flux partial reversibila, cu sau fara simptome prezente, evaluata prin spirometrie (VEMS, VEMS/ CVF).
    III. Determinari gazanalitice sanguine.

    Severitatea BPOC
    Se clasifica pe baza parametrilor ventilatori determinati prin spirometrie, corelati cu frecventa, durata si intensitatea exacerbarilor, eventual cu prezenta complicatiilor (insuficienta respiratorie cronica, CPC, ICD).

    Severitatea alterarilor spirografice definita prin valorile procentuale ale VEMS
*T*
 +-------------------------------------------+
 ¦  Gradul de severitate   ¦  VEMS % prezis  ¦
 +-------------------------+-----------------¦
 ¦         usor            ¦      80-65      ¦
 +-------------------------+-----------------¦
 ¦       moderat           ¦      64-50      ¦
 +-------------------------+-----------------¦
 ¦        sever            ¦      50-35      ¦
 +-------------------------+-----------------¦
 ¦     foarte sever        ¦      < 35       ¦
 +-------------------------------------------+
*ST*

    Criterii de diagnostic clinic, diagnostic functional si al capacitatii de munca in BPOC
*T*
 +----------------------------------------------------------------------------+
 ¦Afectiunea   ¦         Diagnosticul       ¦Incapa- ¦Capacitatea¦Gradul de   ¦
 ¦(forma       ¦         functional         ¦citatea ¦de munca   ¦invaliditate¦
 ¦clinica,     ¦                            ¦adapta- ¦           ¦            ¦
 ¦stadiul)     ¦                            ¦tiva    ¦           ¦            ¦
 +-------------+----------------------------+--------+-----------+------------¦
 ¦Stadiul I    ¦Deficienta functionala      ¦ 1-29%  ¦Pastrata   ¦Nu se       ¦
 ¦BPOC forma   ¦usoara                      ¦        ¦           ¦incadreaza  ¦
 ¦usoara       ¦- VEMS/CVF < 0,70           ¦        ¦           ¦in grad de  ¦
 ¦             ¦- VEMS, = 80% prezis        ¦        ¦           ¦invaliditate¦
 ¦             ¦Simptome prezente sau nu; nu¦        ¦           ¦            ¦
 ¦             ¦este afectata activitatea   ¦        ¦           ¦            ¦
 ¦             ¦zilnica                     ¦        ¦           ¦            ¦
 +-------------+----------------------------+--------+-----------+------------¦
 ¦Stadiul II   ¦Deficienta functionala      ¦ 30-49% ¦Pastrata   ¦Nu se       ¦
 ¦BPOC forma   ¦usoara                      ¦        ¦           ¦incadreaza  ¦
 ¦moderata     ¦- VEMS/CVF < 0,70           ¦        ¦           ¦in grad de  ¦
 ¦             ¦- VEMS 80-60% din prezis    ¦        ¦           ¦invaliditate¦
 ¦             ¦Dispnee la efort, exacerbari¦        ¦           ¦            ¦
 ¦             ¦care necesita tratament de  ¦        ¦           ¦            ¦
 ¦             ¦specialitate, nu este       ¦        ¦           ¦            ¦
 ¦             ¦afectata activitatea zilnica¦        ¦           ¦            ¦
 +-------------+----------------------------+--------+-----------+------------¦
 ¦Stadiul II   ¦Deficienta functionala medie¦ 50-69% ¦Pierduta   ¦III         ¦
 ¦BPOC forma   ¦- VEMS/CVF < 0,70%          ¦        ¦cel putin  ¦            ¦
 ¦moderata     ¦- VEMS 59-50% din prezis    ¦        ¦jumatate   ¦            ¦
 ¦             ¦Dispnee la efort, exacerbari¦        ¦           ¦            ¦
 ¦             ¦care necesita tratament de  ¦        ¦           ¦            ¦
 ¦             ¦specialitate; poate fi      ¦        ¦           ¦            ¦
 ¦             ¦afectata activitatea zilnica¦        ¦           ¦            ¦
 +-------------+----------------------------+--------+-----------+------------¦
 ¦Stadiul III  ¦Deficienta functionala      ¦ 70-89% ¦Pierduta in¦II          ¦
 ¦BPOC forma   ¦accentuata                  ¦        ¦totalitate ¦            ¦
 ¦grava        ¦- VEMS/CVF < 0,70           ¦        ¦           ¦            ¦
 ¦             ¦- VEMS 49-30% din prezis    ¦        ¦           ¦            ¦
 ¦             ¦Dispnee la eforturi         ¦        ¦           ¦            ¦
 ¦             ¦medii/mici, exacerbari      ¦        ¦           ¦            ¦
 ¦             ¦repetate, afectare          ¦        ¦           ¦            ¦
 ¦             ¦importanta a activitatii    ¦        ¦           ¦            ¦
 ¦             ¦zilnice                     ¦        ¦           ¦            ¦
 +-------------+----------------------------+--------+-----------+------------¦
 ¦Stadiul IV   ¦Deficienta functionala grava¦ 90-100%¦Capacitate ¦I           ¦
 ¦BPOC forma   ¦- VEMS/CVF < 70%            ¦        ¦de auto-   ¦            ¦
 ¦foarte grava ¦- VEMS < 30% din prezis sau ¦        ¦servire    ¦            ¦
 ¦             ¦VEMS 49-30% din prezis, dar ¦        ¦pierduta   ¦            ¦
 ¦             ¦cu complicatii              ¦        ¦           ¦            ¦
 ¦             ¦- Insuficienta respiratorie ¦        ¦           ¦            ¦
 ¦             ¦cronica (pa O(2) < 60 mmHg, ¦        ¦           ¦            ¦
 ¦             ¦pa CO(2) > 50 mmHg)         ¦        ¦           ¦            ¦
 ¦             ¦- CPC, ICD ireductibila     ¦        ¦           ¦            ¦
 ¦             ¦Afectare severa a           ¦        ¦           ¦            ¦
 ¦             ¦activitatii zilnice;        ¦        ¦           ¦            ¦
 ¦             ¦necesita OLD                ¦        ¦           ¦            ¦
 +----------------------------------------------------------------------------+
*ST*

    PNEUMOPATIILE INTERSTITIALE DIFUZE (PID)

    Pneumopatiile interstitiale difuze reprezinta un grup numeros si eterogen de afectiuni pulmonare care insotesc conditii clinice variate, congenitale sau dobandite, complicand tabloul clinic si evolutia acestora.
    Cauze mai frecvente de PID
    - Afectiuni pulmonare primitive: Fibroza interstitiala difuza idiopatica, sarcoidoza, histiocitoza X, brosiolita obliteranta, pneumonia limfocitara interstitiala;
    - Afectiuni reumatismale sistemice: artrita reumatoida, LES, sclerodermia, boala mixta de colagen, spondilita anchilozanta etc.
    - Iatrogene: antibiotice, antiinflamatoare, antihipertensive, citostatice etc;
    - Expunere profesionala: silicoza, azbestoza, berilioza, pulberi, gaze, vapori cu actiune fibrozanta etc.;
    - Vasculita pulmonara: granulomatoza Wegener;
    - Afectiuni congenitale: fibroza pulmonara idiopatica familiala, neurofibromatoza, scleroza tuberoasa, boala Gaucher etc.

    Observatie. In cazul in care conditia patologica primara este identificata, se vor aplica criteriile respective, considerand PID asociata ca un factor agravant.

    Tabelul 3. Criterii de diagnostic clinic, diagnostic functional si al capacitatii de munca in pneumopatiile interstitiale difuze (PID)
*T*
 +----------------------------------------------------------------------------+
 ¦  Stadiul  ¦     Diagnosticul clinic      ¦Incapa- ¦Capacitatea¦Gradul de   ¦
 ¦  clinic   ¦        si functional         ¦citatea ¦de munca   ¦invaliditate¦
 ¦           ¦                              ¦adapta- ¦           ¦            ¦
 ¦           ¦                              ¦tiva    ¦           ¦            ¦
 +-----------+------------------------------+--------+-----------+------------¦
 ¦Stadiul I  ¦Deficienta functionala usoara ¦ 20-49% ¦Pastrata   ¦Nu se       ¦
 ¦           ¦Dispnee la efort              ¦        ¦           ¦incadreaza  ¦
 ¦           ¦VEMS = 65% din prezis,        ¦        ¦           ¦in grad de  ¦
 ¦           ¦factorul de transfer gazos    ¦        ¦           ¦invaliditate¦
 ¦           ¦(TL,C0) normal sau usor scazut¦        ¦           ¦            ¦
 ¦           ¦(pana la 60% din prezis),     ¦        ¦           ¦            ¦
 ¦           ¦capacitate de efort normala   ¦        ¦           ¦            ¦
 ¦           ¦sau usor scazuta (5-7 MET),   ¦        ¦           ¦            ¦
 ¦           ¦eventual hipoxemie usoara la  ¦        ¦           ¦            ¦
 ¦           ¦efort (Sa0(2) = 95%)          ¦        ¦           ¦            ¦
 +-----------+------------------------------+--------+-----------+------------¦
 ¦Stadiul II ¦Deficienta functionala medie  ¦ 50-69% ¦Cel putin  ¦Gradul III  ¦
 ¦           ¦Dispnee la eforturi moderate  ¦        ¦jumatate   ¦            ¦
 ¦           ¦VEMS 64-50% din prezis, TL,C0 ¦        ¦pierduta   ¦            ¦
 ¦           ¦reducere moderata (60-40% din ¦        ¦           ¦            ¦
 ¦           ¦prezis), capacitatea de efort ¦        ¦           ¦            ¦
 ¦           ¦- reducere moderata (3-5MET), ¦        ¦           ¦            ¦
 ¦           ¦eventual hipoxemie usoara/    ¦        ¦           ¦            ¦
 ¦           ¦moderata la efort in repaus   ¦        ¦           ¦            ¦
 ¦           ¦sau efort (Sa0(2) 94 - 93%)   ¦        ¦           ¦            ¦
 +-----------+------------------------------+--------+-----------+------------¦
 ¦Stadiul III¦Deficienta functionala        ¦ 70-89% ¦Pierduta in¦Gradul II   ¦
 ¦           ¦accentuata. Dispnee in repaus.¦        ¦totalitate ¦            ¦
 ¦           ¦VEMS < 50% din prezis, Tl, C0 ¦        ¦           ¦            ¦
 ¦           ¦reducere severa (< 40% din    ¦        ¦           ¦            ¦
 ¦           ¦prezis), reducere accentuata a¦        ¦           ¦            ¦
 ¦           ¦capacitatii de efort (<3MET), ¦        ¦           ¦            ¦
 ¦           ¦hipoxemie moderata sau severa ¦        ¦           ¦            ¦
 ¦           ¦in repaus sau la efort        ¦        ¦           ¦            ¦
 ¦           ¦(Sa0(2) < 93%)                ¦        ¦           ¦            ¦
 +-----------+------------------------------+--------+-----------+------------¦
 ¦Stadiul IV ¦Deficienta functionala grava  ¦ 90-100%¦Capacitate ¦Gradul I    ¦
 ¦           ¦VEMS < 30% din prezis sau     ¦        ¦de         ¦            ¦
 ¦           ¦VEMS 49-30% din prezis, dar cu¦        ¦autoservire¦            ¦
 ¦           ¦complicatii                   ¦        ¦pierduta   ¦            ¦
 ¦           ¦Insuficienta respiratorie     ¦        ¦           ¦            ¦
 ¦           ¦conica (pa0(2) < 60 mmHg,     ¦        ¦           ¦            ¦
 ¦           ¦paC0(2) > 50 mmHg             ¦        ¦           ¦            ¦
 ¦           ¦CPC, ICD ireductibila         ¦        ¦           ¦            ¦
 ¦           ¦Afectare severa a activitatii ¦        ¦           ¦            ¦
 ¦           ¦zilnice; necesita 0LD         ¦        ¦           ¦            ¦
 +----------------------------------------------------------------------------+
*ST*

    SUPURATII BRONHOPULMONARE CRONICE

    Supuratiile bronhopulmonare constituie un grup eterogen de afectiuni, caracterizate prin infectie recurenta sau persistenta de tip supurativ, care se manifesta clinic prin:
    - bronhoree purulenta - recurenta si/sau persistenta, eventual fetida sau hemoptoica (in fazele acute depasind 50 ml/24 h);
    - dispnee de efort sau repaus;
    - semne generalizate de infectie.
    Se includ in acest grup:
    - supuratii bronsice - bronsite cronice purulente, bronsiectazii supurate;
    - supuratii pulmonare - abcese pulmonare, supuratii pulmonare, difuzepioscleroza pulmonara.

    Supuratii bronhopulmonare
    Criterii de diagnostic clinic, diagnostic functional si al capacitatii de munca in supuratiile bronhopulmonare cronice
*T*
 +----------------------------------------------------------------------------+
 ¦Clinic si functional¦ Exacerbari¦Controlul ¦Incapa- ¦Deficienta  ¦Gradul de ¦
 ¦                    ¦           ¦terapeutic¦citatea ¦functionala/¦invalidi- ¦
 ¦                    ¦           ¦          ¦adapta- ¦Capacitatea ¦tate      ¦
 ¦                    ¦           ¦          ¦tiva    ¦de munca    ¦          ¦
 +--------------------+-----------+----------+--------+------------+----------¦
 ¦- pusee supurative  ¦< 2 luni/an¦complet   ¦ 1-19%  ¦Fara        ¦Nu se     ¦
 ¦episodice           ¦           ¦reversibi-¦        ¦Pastrata    ¦incadreaza¦
 ¦- dispnee gr. I     ¦           ¦le        ¦        ¦            ¦          ¦
 ¦- fara disfunctie   ¦           ¦          ¦        ¦            ¦          ¦
 ¦ventilatorie        ¦           ¦          ¦        ¦            ¦          ¦
 +--------------------+-----------+----------+--------+------------+----------¦
 ¦- disfunctie        ¦< 2 luni/an¦complet   ¦ 20-49% ¦Usoara      ¦Nu se     ¦
 ¦ventilatorie usoara ¦           ¦reversibi-¦        ¦Pastrata    ¦incadreaza¦
 ¦VEMS > 65%          ¦           ¦le        ¦        ¦            ¦          ¦
 ¦- bronhoree         ¦           ¦          ¦        ¦            ¦          ¦
 ¦50-70 ml/24 h in    ¦           ¦          ¦        ¦            ¦          ¦
 ¦cursul puseelor     ¦           ¦          ¦        ¦            ¦          ¦
 ¦supurative          ¦           ¦          ¦        ¦            ¦          ¦
 +--------------------+-----------+----------+--------+------------+----------¦
 ¦- disfunctie        ¦           ¦reversibi-¦ 50-69% ¦Medie       ¦III       ¦
 ¦ventilatorie        ¦           ¦le prin   ¦        ¦Capacitatea ¦          ¦
 ¦moderata VEMS 50-65%¦           ¦tratament ¦        ¦de munca    ¦          ¦
 ¦din prezis          ¦           ¦          ¦        ¦pierduta cel¦          ¦
 ¦a) bronhoree >      ¦> 2 luni/an¦          ¦        ¦putin       ¦          ¦
 ¦70 ml/24 h in timpul¦           ¦          ¦        ¦jumatate    ¦          ¦
 ¦puseelor supurative ¦           ¦          ¦        ¦            ¦          ¦
 ¦- dispnee gr. I-II  ¦           ¦          ¦        ¦            ¦          ¦
 ¦b) bronhoree        ¦< 3 luni/an¦          ¦        ¦            ¦          ¦
 ¦70 ml/24 h in timpul¦           ¦          ¦        ¦            ¦          ¦
 ¦puseelor supurative.¦           ¦          ¦        ¦            ¦          ¦
 ¦- hipoxemie la efort¦           ¦          ¦        ¦            ¦          ¦
 ¦- reducere moderata ¦           ¦          ¦        ¦            ¦          ¦
 ¦a capacitatii de    ¦           ¦          ¦        ¦            ¦          ¦
 ¦efort               ¦           ¦          ¦        ¦            ¦          ¦
 +--------------------+-----------+----------+--------+------------+----------¦
 ¦- disfunctie        ¦> 3 luni/an¦Partial   ¦ 70-89% ¦Accentuata  ¦II        ¦
 ¦ventilatorie severa ¦           ¦sau       ¦        ¦Capacitatea ¦          ¦
 ¦VEMS 35-49% din     ¦           ¦temporar  ¦        ¦de munca    ¦          ¦
 ¦prezis              ¦           ¦reversibi-¦        ¦pierduta in ¦          ¦
 ¦- bronhoree >       ¦           ¦le        ¦        ¦totalitate  ¦          ¦
 ¦70 ml/24 h          ¦           ¦          ¦        ¦            ¦          ¦
 ¦- hipoxemie in      ¦           ¦          ¦        ¦            ¦          ¦
 ¦repaus sau la efort ¦           ¦          ¦        ¦            ¦          ¦
 ¦- semne prezente de ¦           ¦          ¦        ¦            ¦          ¦
 ¦CPC                 ¦           ¦          ¦        ¦            ¦          ¦
 +--------------------+-----------+----------+--------+------------+----------¦
 ¦- disfunctie        ¦persistent ¦ineficient¦ 90-100%¦Grava       ¦I         ¦
 ¦ventilatorie foarte ¦           ¦          ¦        ¦Capacitatea ¦          ¦
 ¦severa VEMS < 35%   ¦           ¦          ¦        ¦de          ¦          ¦
 ¦din prezis          ¦           ¦          ¦        ¦autoservire ¦          ¦
 ¦- bronhoree         ¦           ¦          ¦        ¦pierduta    ¦          ¦
 ¦purulenta permanenta¦           ¦          ¦        ¦            ¦          ¦
 ¦> 70 ml/24 h        ¦           ¦          ¦        ¦            ¦          ¦
 ¦- insuficienta      ¦           ¦          ¦        ¦            ¦          ¦
 ¦respiratorie cronica¦           ¦          ¦        ¦            ¦          ¦
 ¦manifesta           ¦           ¦          ¦        ¦            ¦          ¦
 ¦(pa0(2) = 60 mmHg in¦           ¦          ¦        ¦            ¦          ¦
 ¦repaus), CPC, ICD   ¦           ¦          ¦        ¦            ¦          ¦
 ¦ireductibila,       ¦           ¦          ¦        ¦            ¦          ¦
 ¦capacitate de       ¦           ¦          ¦        ¦            ¦          ¦
 ¦autoservire pierduta¦           ¦          ¦        ¦            ¦          ¦
 +----------------------------------------------------------------------------+
*ST*

    PLEUREZII PURULENTE
    (empiem pleural, piotorax, abces pulmonar)
    Sunt afectiuni determinate de acumularea de lichid purulent in cavitatea pleurala. Pun problema aprecierii incapacitatii si a deficientei functionale in urmatoarele situatii:
    a) determina sechele importante (pahipleurita, calcificari pleurale);
    b) au necesitat tratament chirurgical (decorticare, exereza pulmonara, toracoplastie).
    Aprecierea incapacitatii si a deficientei functionale se bazeaza pe:
    - evolutia clinica;
    - severitatea disfunctiei ventilatorii;
    - reducerea capacitatii de efort estimata prin teste specifice.

    TUBERCULOZA PULMONARA
    Conform Programului National de Control al Tuberculozei:
    1. cazul de tuberculoza este considerat:
    - pacientul cu simptome si semne sugestive de tuberculoza, confirmat bacteriologic si/sau histopatologic, la care este obligatorie instruirea tratamentului antituberculos;
    - pacientul care nu are confirmare bacteriologica si/sau histopatologica, dar are un context clinic si paraclinic compatibil cu tuberculoza, iar medicul specialist decide instituirea tratamentului antituberculos.
    2. pacientii cu diagnosticul de tuberculoza se clasifica in urmatoarele categorii:
    - caz nou: pacientul care nu a mai facut tratament cu medicamente antituberculoase in asociere pe o perioada mai mare de o luna;
    - recidiva: pacientul cu tuberculoza pulmonara care a primit o cura de tratament antituberculos in antecedente, a fost declarat vindecat si are un nou episod evolutiv confirmat bacteriologic;
    - esec: pacientul cu tuberculoza pulmonara care a ramas sau a devenit pozitiv (conform criteriilor de confirmare bacteriologica) la examenul bacteriologic al sputei pentru BK dupa 4 luni de tratament;
    - cronic: pacientul cu esec terapeutic la primul retratament.
    3. categoriile de evaluare a tratamentului pentru pacientii cu tuberculoza pulmonara confirmati bacteriologic initial:
    - vindecati: pacienti confirmati bacteriologic, cu tratament corect efectuat, care au cel putin doua controale de sputa negative, din care unul in ultima luna de tratament;
    - tratament incheiat: pacient cu tratament corect efectuat, neconfirmat initial bacteriologic sau confirmat bacteriologic, dar care nu are doua controale de sputa negative, pentru a fi etichetat vindecat;
    - esec terapeutic: pacientul care este pozitiv la orice examen bacteriologic al sputei efectuat dupa 4 luni de tratament.
    Bolnavii confirmati clinic si bacteriologic cu tuberculoza pulmonara beneficiaza de concedii medicale de 360 de zile, conform legii. Dupa aceasta perioada, deficienta functionala si incapacitatea adaptativa se apreciaza in functie de categoria clinica si terapeutica in care se afla bolnavul.
*T*
 +----------------------------------------------------------------------------+
 ¦  Categoria clinica si terapeutica   ¦Incapaci- ¦Deficienta    ¦Gradul de   ¦
 ¦                                     ¦tatea     ¦functionala/  ¦invaliditate¦
 ¦                                     ¦adaptativa¦Capacitatea de¦            ¦
 ¦                                     ¦          ¦munca         ¦            ¦
 +-------------------------------------+----------+--------------+------------¦
 ¦Vindecat (fara sechele)              ¦  20-49%  ¦Usoara        ¦Nu se       ¦
 ¦                                     ¦          ¦Pastrata      ¦incadreaza  ¦
 ¦                                     ¦          ¦              ¦in grad de  ¦
 ¦                                     ¦          ¦              ¦invaliditate¦
 +-------------------------------------+----------+--------------+------------¦
 ¦Tratament incheiat                   ¦  50-69%  ¦Medie         ¦III         ¦
 ¦                                     ¦          ¦Cel putin     ¦            ¦
 ¦                                     ¦          ¦jumatate      ¦            ¦
 ¦                                     ¦          ¦pierduta      ¦            ¦
 +-------------------------------------+----------+--------------+------------¦
 ¦- esec terapeutic                    ¦  70-89%  ¦Accentuata    ¦II          ¦
 ¦- cronic                             ¦          ¦In totalitate ¦            ¦
 ¦- recidiva (precoce - la mai putin de¦          ¦pierduta      ¦            ¦
 ¦un an de la vindecare)               ¦          ¦              ¦            ¦
 ¦- complicatii severe, cronice        ¦          ¦              ¦            ¦
 ¦(fistule bronho-pleuro-bronsice,     ¦          ¦              ¦            ¦
 ¦empieme tbc reziduale)               ¦          ¦              ¦            ¦
 +-------------------------------------+----------+--------------+------------¦
 ¦Forme cronice severe insotite de:    ¦  90-100% ¦Grava         ¦I           ¦
 ¦- casexie                            ¦          ¦Capacitatea de¦            ¦
 ¦- insuficienta respiratorie cronica  ¦          ¦autoservire   ¦            ¦
 ¦manifesta                            ¦          ¦pierduta      ¦            ¦
 ¦- ICD ireductibila                   ¦          ¦              ¦            ¦
 +----------------------------------------------------------------------------+
*ST*

    TUBERCULOZA PULMONARA OPERATA
    In stabilirea incapacitatii si a gradului de invaliditate la acesti bolnavi, se va tine seama de:
    - criteriile de activitate a tuberculozei;
    - consecintele morfofunctionale ale interventiei chirurgicale:
    1. Bolnavii cu interventie chirurgicala pe torace pentru tuberculoza pulmonara prezinta incapacitate de 70-89% (deficienta functionala accentuata - gradul II de invaliditate) timp de 1 an de la interventie;
    2. Bolnavii operati pentru tuberculoza pulmonara, care au evoluat favorabil, se considera ca prezinta incapacitate adaptativa de 50-69% (deficienta functionala medie - gradul III de invaliditate) pentru inca 6 luni in vederea readaptarii progresive la activitatea profesionala si a evitarii recaderilor (chiar daca nu prezinta afectarea functiei respiratorii);
    3. Dupa aceasta perioada, bolnavii vor fi reevaluati, iar incapacitatea adaptativa si deficienta functionala vor fi stabilite conform criteriilor din capitolul introductiv, in functie de:
    - prezenta sechelelor;
    - severitatea disfunctiei ventilatorii;
    - alte tulburari functionale;
    - capacitatea de efort.

    AFECTIUNI RESPIRATORII SECHELARE POSTTUBERCULOASE
    In acest grup sunt cuprinse formele de tuberculoza pulmonara vindecate cu sechele morfo-functionale importante.

    Caracteristici:
    - se manifesta dupa luni sau ani de la vindecarea procesului bacilar;
    - baciloscopie directa constant negativa timp de cel putin 18 luni (cel putin 3 culturi);
    - imagini radiologice nemodificate (controale repetate la cateva luni).
    Forme clinice mai frecvente:
    - bronsita cronica;
    - bronsiectazii;
    - insuficienta respiratorie cronica cu acutizari repetate;
    - fibrotorax;
    - pahipleurite calcare extinse;
    - emfizem cicatriceal.
    Stabilirea incapacitatii adaptative si incadrarea in grad de invaliditate se bazeaza pe:
    - severitatea afectarii ventilatiei pulmonare;
    - severitatea afectarii schimburilor gazoase la nivel pulmonar;
    - reducerea capacitatii la efort estimata prin teste specifice;
    - riscul de reactivare.

    SINDROMUL DE APNEE IN SOMN (SAS)

    Sindromul de apnee in somn, inainte de tratament si in absenta complicatiilor, poate beneficia de concediu medical conform legii, timp in care vor fi aplicate metodele terapeutice adecvate (tratament chirurgical, tratament specific CPAP/BIPAP).
    Postterapeutic, capacitatea de munca se evalueaza in functie de raspunsul la terapia specifica, severitatea fenomenelor reziduale, prezenta complicatiilor si a asocierilor morbide.
    Evaluarea complexa cuprinde:
    - examen pneumologic - severitatea fenomenelor reziduale: indicele apnee/hipopnee rezidual (IA/H), somnolenta diurna, complicatiile respiratorii;
    - test de efort - capacitatea de efort, raspunsul hemodinamic, prognostic;
    - examen psihologic - evidentierea tulburarilor cognitive, de atentie/concentrare;
    - examen psihiatric (eventual);
    - alte investigatii in functie de prezenta complicatiilor si/sau a afectiunilor asociate.
*T*
 +----------------------------------------------------------------------------+
 ¦      Aspecte clinice      ¦Deficienta ¦Incapaci- ¦Capacitatea¦Gradul de    ¦
 ¦                           ¦functionala¦tatea     ¦de munca   ¦ invaliditate¦
 ¦                           ¦           ¦adaptativa¦           ¦             ¦
 +---------------------------+-----------+----------+-----------+-------------¦
 ¦Raspuns terapeutic bun,    ¦Usoara     ¦  20-49%  ¦Pastrata   ¦Nu se        ¦
 ¦IA/H rezidual = 10, deficit¦           ¦          ¦           ¦incadreaza   ¦
 ¦minor de                   ¦           ¦          ¦           ¦(eventual,   ¦
 ¦atentie/concentrare, fara  ¦           ¦          ¦           ¦loc de munca ¦
 ¦somnolenta diurna, reducere¦           ¦          ¦           ¦in care sa   ¦
 ¦usoara a capacitatii de    ¦           ¦          ¦           ¦fie protejata¦
 ¦efort                      ¦           ¦          ¦           ¦siguranta    ¦
 ¦                           ¦           ¦          ¦           ¦proprie si a ¦
 ¦                           ¦           ¦          ¦           ¦celorlalti)  ¦
 +---------------------------+-----------+----------+-----------+-------------¦
 ¦Raspuns terapeutic         ¦Medie      ¦  50-69%  ¦Cel putin  ¦Gradul III   ¦
 ¦satisfacator, IA/H rezidual¦           ¦          ¦jumatate   ¦             ¦
 ¦11-20, deficit moderat de  ¦           ¦          ¦pierduta   ¦             ¦
 ¦atentie/concentrare,       ¦           ¦          ¦           ¦             ¦
 ¦somnolenta diurna, reducere¦           ¦          ¦           ¦             ¦
 ¦moderata a capacitatii de  ¦           ¦          ¦           ¦             ¦
 ¦efort, raspuns hemodinamic ¦           ¦          ¦           ¦             ¦
 ¦inadecvat la efort         ¦           ¦          ¦           ¦             ¦
 +---------------------------+-----------+----------+-----------+-------------¦
 ¦Raspuns terapeutic slab,   ¦Accentuata ¦  70-90%  ¦Pierduta in¦Gradul II    ¦
 ¦non-complianta la          ¦           ¦          ¦totalitate ¦             ¦
 ¦tratamentul specific, IA/H ¦           ¦          ¦           ¦             ¦
 ¦rezidual > 20, deficit     ¦           ¦          ¦           ¦             ¦
 ¦sever de                   ¦           ¦          ¦           ¦             ¦
 ¦atentie/concentrare,       ¦           ¦          ¦           ¦             ¦
 ¦somnolenta diurna, reducere¦           ¦          ¦           ¦             ¦
 ¦accentuata a capacitatii de¦           ¦          ¦           ¦             ¦
 ¦efort, raspuns hemodinamic ¦           ¦          ¦           ¦             ¦
 ¦inadecvat la efort         ¦           ¦          ¦           ¦             ¦
 ¦Asociere cu sindrom        ¦           ¦          ¦           ¦             ¦
 ¦obezitate/hipoventilatie   ¦           ¦          ¦           ¦             ¦
 ¦(IMC > 40 kg/m?,           ¦           ¦          ¦           ¦             ¦
 ¦hipercapnie si hipoxemie   ¦           ¦          ¦           ¦             ¦
 ¦diurna, fara alte cauze)   ¦           ¦          ¦           ¦             ¦
 +----------------------------------------------------------------------------+
*ST*

    In prezenta complicatiilor/afectiunilor asociate (HTA, infarct miocardic, AVC, diabet zaharat, BPOC, insuficienta respiratorie, tulburari psihice), cazul se evalueaza conform criteriilor pentru afectiunile respective, considerand SAS ca factor agravant.

                      3. AFECTIUNI ALE APARATULUI DIGESTIV

    Evaluarea deficientei functionale, a incapacitatii adaptative si a capacitatii de munca in afectiunile digestive se bazeaza pe:
    - prezenta si intensitatea simptomelor;
    - starea generala si de nutritie;
    - severitatea anemiei;
    - prognosticul bolii.
    Investigatiile aparatului digestiv necesare in expertiza medicala a capacitatii de munca sunt:
    - investigatii radio-imagistice, tranzit baritat esofagian, gastric, intestinal, ultrasonografie, ecoendoscopie, CT, RMN etc.;
    - investigatii endoscopice specifice segmentelor de tub digestiv afectate: endoscopie esogastrica, colonica, rectala sau ecoendoscopie;
    - investigatii specifice chirurgiei generale prin laparoscopie, injectare de substante de contrast etc;
    - examen histopatologic al diverselor fragmente de tesut prelevat fie prin abord chirurgical, fie endoscopic sau prin punctie de organ;
    - examene de laborator biochimice si hematologice de uz curent si/sau speciale;
    - teste imunologice;
    - markeri virali si oncologici.
    Pentru aprecierea starii de nutritie se va utiliza grila de stabilire a indicelui de masa corporala (IMC), in functie de parametrii antropomorfici.
    IMC - se masoara in numarul de kilograme pe metrul patrat de suprafata corporala.
    Astfel, se considera urmatoarele intervale:
    - normal - 20-24,9 kg/m²;
    - preobez - 25-29,9 kg/m²;
    - obezitate - > 30 kg/m²;
    - subponderal - 20-18,5 kg/m²;
    - deficit ponderal < 18,5 kg/m².
    Severitatea anemiei se apreciaza astfel:
    Anemie:
    - usoara Hb = 10-12 g%;
    - moderata Hb = 8-10 g%;
    - severa Hb < 8 g%.

    BOLILE ESOFAGULUI
    A. Afectiunile motorii si tulburarile functionale ale esofagului:
    - acalazia;
    - boala de reflux gastro-esofagian;
    - hernia gastrica transhiatala;
    - diverticulii esofagieni;
    - bolile neurologice;
    - boala Parkinson;
    - stenozele esofagiene post-caustice;
    - colagenozele etc.
    B. Tumorile esofagiene sunt:
    - benigne: leiomiom;
    - maligne:
            - carcinom scuamos;
            - adenocarcinom;
            - melanocarcinom;
            - carcinom cu celule mici;
            - sarcom;
            - carcinosarcom.

    Simptomatologie:
    - disfagie;
    - dureri presternale inferioare;
    - regurgitatii;
    - pirozis.
    Tratamentul tumorilor esofagiene este chirurgical, iar uneori se asociaza si tratamentul oncologic.
    Procedurile de reconstructie dupa esofagectomia terapeutica, care se aplica atat in cazul tumorilor, cat si al stenozelor esofagiene post-caustice, sunt:
*T*
 +-------------------------------------------------------------+
 ¦Esofagogastrostomie:   ¦- by-pass gastric substernal         ¦
 ¦                       ¦- by-pass gastric inversat           ¦
 ¦                       ¦- by-pass gastric intratoracic       ¦
 ¦                       ¦- tub gastric izoperistaltic         ¦
 +-----------------------+-------------------------------------¦
 ¦Interpozitie colonica: ¦- stanga (antiperistaltica)          ¦
 ¦                       ¦- dreapta (esoperistaltica)          ¦
 ¦                       ¦- transvers.                         ¦
 +-----------------------+-------------------------------------¦
 ¦Interpozitie jejunala. ¦                                     ¦
 +-------------------------------------------------------------+
*ST*

    Diagnosticul clinic se precizeaza prin: examen radiologic baritat, endoscopie, biopsie din mucoasa esofagiana.
    Diagnosticul functional se precizeaza in functie de intensitatea si de frecventa simptomatologiei, imaginea radiologica, diagnosticul endoscopic, deficitul ponderal, complicatii.
*T*
 +----------------------------------------------------------------------------+
 ¦Afectiunea. Forma clinica¦Deficienta ¦Incapacitatea¦Capacitatea¦Gradul de   ¦
 ¦                         ¦functionala¦adaptativa   ¦de munca   ¦invaliditate¦
 +-------------------------+-----------+-------------+-----------+------------¦
 ¦A. Afectiuni motorii si  ¦           ¦             ¦           ¦            ¦
 ¦   tulburari functionale ¦           ¦             ¦           ¦            ¦
 ¦   ale esofagului        ¦           ¦             ¦           ¦            ¦
 +-------------------------+-----------+-------------+-----------+------------¦
 ¦B. Tumori esofagiene     ¦           ¦             ¦           ¦            ¦
 ¦   benigne               ¦           ¦             ¦           ¦            ¦
 +-------------------------+-----------+-------------+-----------+------------¦
 ¦a) simptomatologie de    ¦Fara       ¦    0-19%    ¦Pastrata   ¦Nu se       ¦
 ¦intensitate mica         ¦deficienta ¦             ¦           ¦incadreaza  ¦
 ¦b) episoade rare         ¦functionala¦             ¦           ¦            ¦
 ¦c) fara deficit ponderal ¦           ¦             ¦           ¦            ¦
 +-------------------------+-----------+-------------+-----------+------------¦
 ¦a) simptomatologie de    ¦Deficienta ¦    20-49%   ¦Pastrata   ¦Nu se       ¦
 ¦intensitate mica         ¦functionala¦             ¦           ¦incadreaza  ¦
 ¦b) episoade frecvent     ¦usoara     ¦             ¦           ¦            ¦
 ¦c) deficit ponderal usor ¦           ¦             ¦           ¦            ¦
 +-------------------------+-----------+-------------+-----------+------------¦
 ¦a) simptomatologie de    ¦Deficienta ¦    50-69%   ¦Pierduta   ¦Gradul III  ¦
 ¦intensitate medie        ¦functionala¦             ¦cel putin  ¦            ¦
 ¦b) complicatii:          ¦medie      ¦             ¦jumatate   ¦            ¦
 ¦esofagita, hemoragii     ¦           ¦             ¦           ¦            ¦
 ¦medii, complicatii       ¦           ¦             ¦           ¦            ¦
 ¦bronhopulmonare          ¦           ¦             ¦           ¦            ¦
 ¦c) deficit ponderal mediu¦           ¦             ¦           ¦            ¦
 +-------------------------+-----------+-------------+-----------+------------¦
 ¦a) simptomatologie       ¦Deficienta ¦   70-89%    ¦Pierduta in¦Gradul II   ¦
 ¦permanenta               ¦functionala¦             ¦totalitate ¦            ¦
 ¦b) complicatii: ulcer    ¦accentuata ¦             ¦           ¦            ¦
 ¦esofagian, hemoragii     ¦           ¦             ¦           ¦            ¦
 ¦digestive importante,    ¦           ¦             ¦           ¦            ¦
 ¦stenoza peptica          ¦           ¦             ¦           ¦            ¦
 ¦c) denutritie accentuata,¦           ¦             ¦           ¦            ¦
 ¦anemie.                  ¦           ¦             ¦           ¦            ¦
 +----------------------------------------------------------------------------+
*ST*

    Tumorile maligne vorfi incadrate conform criteriilor de la capitolul Afectiuni neoplazice.

    BOLILE STOMACULUI SI ALE DUODENULUI

    A. Ulcerul gastric si duodenal
    Se caracterizeaza prin durere epigastrica cu ritmicitate si periodicitate caracteristice.
    Este diagnosticat radiologic si endoscopic. Prezenta infectiei cu Helicobacter Pylori P. poate fi depistata endoscopic sau prin teste biologice si beneficiaza de tratament specific.
    In perioadele dureroase, cand sunt necesare atat repausul fizic, cat si tratamentul medicamentos, pacientul beneficiaza de concediu medical conformi legii.
    Lipsa raspunsului terapeutic si aparitia complicatiilor (HDS, stenoza pilorica, denutritia) recomanda pacientul pentru interventiei chirurgicala.

    B. Tumorile gastrice
    Pot fi
    benigne: polipul, leiomiomul, leiomioblastul.
    Diagnosticate endoscopic, radiologic si prin biopsie, beneficiaza de cura chirurgicala.
    Capacitatea de munca se va aprecia in functie de rezultatele terapeutice, de starea de nutritie si de complicatii, conform criteriilor cuprinse in capitolul Suferintele stomacului operat.
    - sau maligne: adenocarcinomul, limfomul, carcinoidul.
    Diagnosticate prin endoscopie, examen radiologic si biopsie, pot beneficia de cura chirurgicala si de tratament oncologic. Capacitatea de munca se va aprecia conform criteriilor pentru afectiuni neoplazice.

    Stomacul operat
    Suferintele stomacului operat instalate precoce, pana in 4 saptamani post-operator (sindrom diareic, hemoragie, fistula, pancreatita, stenoza gurii de anastomoza) beneficiaza de tratament in serviciile de chirurgie in timpul concediului medical.
    Suferintele tardive, instalate dupa 6-8 saptamani de la interventia chirurgicala (ulcerul peptic post-operator, sindromuli postprandial precoce - dumping si sindromul post prandial tardiv) beneficiaza, de asemenea, de concediu medical conform legii.
    Diagnosticul clinic se precizeaza prin: examen radiologic baritat si endoscopie.
    Diagnosticul functional se precizeaza in functie de:
    - intensitatea si frecventa simptomatologiei;
    - date imagistice (radiologic, endoscopic);
    - deficitul ponderal;
    - severitatea anemiei.
*T*
 +----------------------------------------------------------------------------+
 ¦Afectiunea. Forma clinica¦Deficienta ¦Incapacitatea¦Capacitatea¦Gradul de   ¦
 ¦                         ¦functionala¦adaptativa   ¦de munca   ¦invaliditate¦
 +-------------------------+-----------+-------------+-----------+------------¦
 ¦Stomac operat (fara      ¦Fara       ¦    0-19%    ¦Pastrata   ¦Nu se       ¦
 ¦rezectie de organ)       ¦deficienta ¦             ¦           ¦incadreaza  ¦
 ¦a) fara simptomatologie  ¦functionala¦             ¦           ¦            ¦
 ¦postoperatorie           ¦           ¦             ¦           ¦            ¦
 ¦b)fara deficit ponderal  ¦           ¦             ¦           ¦            ¦
 ¦c) fara anemie           ¦           ¦             ¦           ¦            ¦
 +-------------------------+-----------+-------------+-----------+------------¦
 ¦Stomac operat (fara      ¦Deficienta ¦    20-49%   ¦Pastrata   ¦Nu se       ¦
 ¦rezectie de organ sau cu ¦functionala¦             ¦           ¦incadreaza  ¦
 ¦rezectie gastrica)       ¦usoara     ¦             ¦           ¦            ¦
 ¦a) cu simptomatologie    ¦           ¦             ¦           ¦            ¦
 ¦minima                   ¦           ¦             ¦           ¦            ¦
 ¦b) deficit ponderal usor ¦           ¦             ¦           ¦            ¦
 ¦c) anemie usoara         ¦           ¦             ¦           ¦            ¦
 +-------------------------+-----------+-------------+-----------+------------¦
 ¦a) deficit ponderal mediu¦Deficienta ¦   50-69%    ¦Cel putin  ¦Gradul III  ¦
 ¦b) anemie feripriva medie¦functionala¦             ¦jumatate   ¦            ¦
 ¦                         ¦medie      ¦             ¦pierduta   ¦            ¦
 +-------------------------+-----------+-------------+-----------+------------¦
 ¦Stomacul operat          ¦Deficienta ¦   70-89%    ¦Pierduta in¦Gradul II   ¦
 ¦a) rezectie gastrica:    ¦functionala¦             ¦totalitate ¦            ¦
 ¦- antrectomie            ¦accentuata ¦             ¦           ¦            ¦
 ¦- hemigastrectomie       ¦           ¦             ¦           ¦            ¦
 ¦- gastrectomie subtotala,¦           ¦             ¦           ¦            ¦
 ¦in functie de starea     ¦           ¦             ¦           ¦            ¦
 ¦generala, de starea de   ¦           ¦             ¦           ¦            ¦
 ¦nutritie si de prognostic¦           ¦             ¦           ¦            ¦
 ¦b) deficit ponderal      ¦           ¦             ¦           ¦            ¦
 ¦accentuat                ¦           ¦             ¦           ¦            ¦
 ¦c) anemie feripriva      ¦           ¦             ¦           ¦            ¦
 ¦severa                   ¦           ¦             ¦           ¦            ¦
 +----------------------------------------------------------------------------+
*ST*

    HEPATITA CRONICA SI CIROZA HEPATICA
    Hepatita cronica (HC) este un sindrom clinico-histo-patologic cu etiologii diferite, caracterizat de inflamatie cronica, necroza hepato-celulara si adesea fibroza, care evolueaza fara ameliorare cel putin 6 luni.
    Diagnosticul de HC este clinic, biologic si histologic.
    In evaluarea capacitatii de munca a unui pacient cu HC se vor avea in vedere:
    - Examenul obiectiv;
    - Testele biochimice (TFH - teste functionale hepatice), care includ:
      - dozarile de aminotransferaze (AT);
      - fosfataza alcalina (FA);
      - gama-glutamil transpeptidaza (GGT);
      - bilirubinemia totala si fractiuni;
      - serinemia;
      - gama-globulinemia.
    - Bilantul hematologic:
      - include o hemograma completa si evaluarea hemostazei, fiind un indicator fidel al functiei hepatice (TP = timpul de protrombina).
    - Teste speciale pentru diagnosticul etiologic:
      - teste screening pentru markerii de infectie cu virusurile B, C etc., completate in caz de pozitivitate cu teste pentru stadiul de evolutie a infectiei;
      - teste pentru diagnosticul etiopatogeniei autoimune (ANA, ASMA, anti-LKM1) sau speciale (ASGPR, pANCA);
      - dozari de ceruloplasmina, cupremie, cuprurie (b. Wilson);
      - dozari de feritina in hemocromatoza;
      - dozari de alfa-antitripsina in deficitul de alfa-antitripsina.
    - Diagnosticul histologic:
      - teste invazive - punctia biopsie hepatica (PBH);
      - teste non-invazive (alternative) - testul FibroMax.
    - Alte examene:
      - ecografia abdominala;
      - ecoendoscopie;
      - TC etc.
*T*
 +----------------------------------------------------------------------------+
 ¦Afectiunea. Forma clinica¦Deficienta ¦Incapacitatea¦Capacitatea¦Gradul de   ¦
 ¦                         ¦functionala¦adaptativa   ¦de munca   ¦invaliditate¦
 +-------------------------+-----------+-------------+-----------+------------¦
 ¦- Purtatorii cronici     ¦Fara       ¦    0-19%    ¦Pastrata   ¦Nu se       ¦
 ¦inactivi de virus B, C.  ¦deficienta ¦             ¦           ¦incadreaza  ¦
 ¦- HC stabilizate         ¦functionala¦             ¦           ¦            ¦
 ¦Fara semne               ¦           ¦             ¦           ¦            ¦
 ¦clinico-biologice de     ¦           ¦             ¦           ¦            ¦
 ¦activitate la cel putin  ¦           ¦             ¦           ¦            ¦
 ¦doua examinari pe an     ¦           ¦             ¦           ¦            ¦
 +-------------------------+-----------+-------------+-----------+------------¦
 ¦- HC                     ¦Deficienta ¦   20-49%    ¦Pastrata   ¦Nu se       ¦
 ¦Cu semne minime de       ¦functionala¦             ¦           ¦incadreaza  ¦
 ¦activitate               ¦usoara     ¦             ¦           ¦Pot         ¦
 ¦clinico-biologice ±      ¦           ¦             ¦           ¦beneficia de¦
 ¦tratament antiviral      ¦           ¦             ¦           ¦concediu    ¦
 ¦- ± PBH care confirma    ¦           ¦             ¦           ¦medical     ¦
 ¦diagnosticul             ¦           ¦             ¦           ¦conform     ¦
 ¦- alternativ - test      ¦           ¦             ¦           ¦legii ±     ¦
 ¦FibroMax                 ¦           ¦             ¦           ¦schimbarea  ¦
 ¦                         ¦           ¦             ¦           ¦locului de  ¦
 ¦                         ¦           ¦             ¦           ¦munca       ¦
 +-------------------------+-----------+-------------+-----------+------------¦
 ¦- HC                     ¦Deficienta ¦   50-69%    ¦Cel putin  ¦Gradul III  ¦
 ¦Cu semne moderate de     ¦functionala¦             ¦jumatate   ¦            ¦
 ¦activitate               ¦medie      ¦             ¦pierduta   ¦            ¦
 ¦clinico-biologice, cu    ¦           ¦             ¦           ¦            ¦
 ¦perturbarea testelor de  ¦           ¦             ¦           ¦            ¦
 ¦citoliza, cifrele        ¦           ¦             ¦           ¦            ¦
 ¦nedepasind de 5 ori      ¦           ¦             ¦           ¦            ¦
 ¦valoarea normala ±       ¦           ¦             ¦           ¦            ¦
 ¦eventual confirmate de   ¦           ¦             ¦           ¦            ¦
 ¦PBH                      ¦           ¦             ¦           ¦            ¦
 ¦- alternativ - test      ¦           ¦             ¦           ¦            ¦
 ¦FibroMax                 ¦           ¦             ¦           ¦            ¦
 +-------------------------+-----------+-------------+-----------+------------¦
 ¦- HC                     ¦Deficienta ¦   70-89%    ¦Pierduta in¦Gradul II   ¦
 ¦Cu evolutie severa, cu   ¦functionala¦             ¦totalitate ¦            ¦
 ¦teste de citoliza        ¦accentuata ¦             ¦           ¦            ¦
 ¦depasind de 5 ori        ¦           ¦             ¦           ¦            ¦
 ¦valorile normale         ¦           ¦             ¦           ¦            ¦
 ¦± gamaglobuline serice ce¦           ¦             ¦           ¦            ¦
 ¦depasesc 20 g/l sau > 30%¦           ¦             ¦           ¦            ¦
 ¦± hiposerinemie          ¦           ¦             ¦           ¦            ¦
 ¦± cresteri stabile ale   ¦           ¦             ¦           ¦            ¦
 ¦bilirubinemiei > 2 mg/dl ¦           ¦             ¦           ¦            ¦
 ¦± alungirea timpului de  ¦           ¦             ¦           ¦            ¦
 ¦protrombina confirmata de¦           ¦             ¦           ¦            ¦
 ¦PBH                      ¦           ¦             ¦           ¦            ¦
 +----------------------------------------------------------------------------+
*ST*

    De retinut:
    - Purtator cronic inactiv - notiune folosita cand AgHBs este prezent la pacientul asimptomatic, cu functie hepatica normala si absenta markerilor de replicare virala (AND, VHB, anti-HBC, IgM).
    - Factori de prognostic nefavorabil in HC: hiposerinemia, alungirea timpului de protrombina, cresterea bilirubinemiei.
    - Leziunile histologice hepatice (evaluate prin PBH sau testul FibroMax).

    Ciroza hepatica (CH) este o boala hepatica difuza, caracterizata de asocierea fibrozei, nodulilor de regenerare si a necrozei hepatocitare, cu alterarea arhitecturii hepatice.
    Evaluarea gradului de activitate a CH se realizeaza prin examen clinic, biologic si eventual morfopatologic. In general, punctia biopsie hepatica este rar indicata, din cauza rezultatelor fals negative sau a contraindicatiilor (ascita, tulburari de coagulare, trombocitopenie marcata).
    CH inactiva (stationara) - transaminaze normale. Biologic, fara semne de insuficienta hepatica (albuminemie si coagulare normale).
    CH activa - transaminazele crescute, iar in cele de etiologie autoimuna, semne inflamatorii evidente: VSH crescut, gamaglobulinemie crescuta. Atunci cand exista, punctia hepatica arata infiltrat inflamator important.
    Din punct de vedere evolutiv, cirozele hepatice pot fi compensate sau decompensate.
    In CH compensate, pacientii sunt asimptomatici, iar biologic exista modificari minime ale transaminazelor serice.
    In CH decompensate, apar icterul, ascita, hemoragiile digestive, encefalopatia. Cel mai sensibil si cel mai frecvent element de diferentiere intre cirozele compensate si cele decompensate este ascita.
    Pentru evaluarea evolutiva este utila clasificarea Child-Pugh.
*T*
                 Clasificarea Child-Pugh a cirozelor hepatice
 +--------------------------------------------------------------------+
 ¦      Parametri        ¦                   Punctaj                  ¦
 ¦                       +--------------------------------------------¦
 ¦                       ¦      1       ¦       2      ¦      3       ¦
 +-----------------------+--------------+--------------+--------------¦
 ¦Ascita                 ¦absenta       ¦moderata      ¦sub tensiune  ¦
 +-----------------------+--------------+--------------+--------------¦
 ¦Encefalopatia portala  ¦absenta       ¦gradul I-II   ¦gradul III-IV ¦
 +-----------------------+--------------+--------------+--------------¦
 ¦Albumina serica (g%)   ¦> 3,5         ¦2,8-3,5       ¦< 2,8         ¦
 +-----------------------+--------------+--------------+--------------¦
 ¦Bilirubina serica (mg%)¦< 2           ¦2-3           ¦> 3           ¦
 +-----------------------+--------------+--------------+--------------¦
 ¦Timp de protrombina    ¦< 4           ¦4-6           ¦> 6           ¦
 ¦(secunde peste normal) ¦              ¦              ¦              ¦
 +--------------------------------------------------------------------+
*ST*
    Clasele A = 5-6 puncte, B = 7-9 puncte, C = 10-15 puncte
*T*
 +----------------------------------------------------------------------------+
 ¦Afectiunea. Forma clinica¦Deficienta ¦Incapacitatea¦Capacitatea¦Gradul de   ¦
 ¦                         ¦functionala¦adaptativa   ¦de munca   ¦invaliditate¦
 +-------------------------+-----------+-------------+-----------+------------¦
 ¦CH compensata            ¦Deficienta ¦   20-49%    ¦Pastrata   ¦Nu se       ¦
 ¦asimptomatica sau cu     ¦functionala¦             ¦           ¦incadreaza  ¦
 ¦semne minime             ¦usoara     ¦             ¦           ¦            ¦
 ¦clinico-biologice. Clasa ¦           ¦             ¦           ¦            ¦
 ¦Child A (fara ascita)    ¦           ¦             ¦           ¦            ¦
 +-------------------------+-----------+-------------+-----------+------------¦
 ¦CH decompensata vascular ¦Deficienta ¦   50-69%    ¦Cel putin  ¦Gradul III  ¦
 ¦si/sau parenchimatos     ¦functionala¦             ¦jumatate   ¦            ¦
 ¦Cu ascita usor           ¦medie      ¦             ¦pierduta   ¦            ¦
 ¦reductibila in cantitate ¦           ¦             ¦           ¦            ¦
 ¦mica, eventual icter, dar¦           ¦             ¦           ¦            ¦
 ¦fara hemoragii digestive,¦           ¦             ¦           ¦            ¦
 ¦fara encefalopatie       ¦           ¦             ¦           ¦            ¦
 ¦hepatica. Clasa Child B. ¦           ¦             ¦           ¦            ¦
 +-------------------------+-----------+-------------+-----------+------------¦
 ¦CH decompensata, cu      ¦Deficienta ¦    70-89%   ¦Pierduta in¦Gradul II   ¦
 ¦ascita controlabila,     ¦functionala¦             ¦totalitate ¦            ¦
 ¦eventual peritonita      ¦accentuata ¦             ¦           ¦            ¦
 ¦bacteriana spontana, fara¦           ¦             ¦           ¦            ¦
 ¦sangerari variceale.     ¦           ¦             ¦           ¦            ¦
 ¦Clasa Child C.           ¦           ¦             ¦           ¦            ¦
 ¦Encefalopatia hepatica   ¦           ¦             ¦           ¦            ¦
 ¦gradul I-II, episodica,  ¦           ¦             ¦           ¦            ¦
 ¦indusa de factori        ¦           ¦             ¦           ¦            ¦
 ¦predispozanti            ¦           ¦             ¦           ¦            ¦
 ¦identificabili.          ¦           ¦             ¦           ¦            ¦
 ¦± hiposerinemia 3-3,5 g/L¦           ¦             ¦           ¦            ¦
 ¦± bilirubinemia 2-3 mg/dl¦           ¦             ¦           ¦            ¦
 ¦± indice de protrombina  ¦           ¦             ¦           ¦            ¦
 ¦40-50%                   ¦           ¦             ¦           ¦            ¦
 ¦± semne minime de        ¦           ¦             ¦           ¦            ¦
 ¦encefalopatie            ¦           ¦             ¦           ¦            ¦
 ¦± semne de citoliza      ¦           ¦             ¦           ¦            ¦
 ¦± gamaglobuline = 30%    ¦           ¦             ¦           ¦            ¦
 +-------------------------+-----------+-------------+-----------+------------¦
 ¦- CH decompensata - grava¦Deficienta ¦   90-100%   ¦Capacitate ¦Gradul I    ¦
 ¦ - cu hemoragii prin     ¦functionala¦             ¦de munca si¦            ¦
 ¦ruptura de varice        ¦grava      ¦             ¦autoservire¦            ¦
 ¦esofagiene               ¦           ¦             ¦pierduta in¦            ¦
 ¦± ascite greu de         ¦           ¦             ¦totalitate ¦            ¦
 ¦controlat                ¦           ¦             ¦           ¦            ¦
 ¦± semne de encefalopatie ¦           ¦             ¦           ¦            ¦
 ¦hepatica -> coma         ¦           ¦             ¦           ¦            ¦
 ¦± hiposerinemie < 3 g/l  ¦           ¦             ¦           ¦            ¦
 ¦± bilirubinemie > 3 mg/dl¦           ¦             ¦           ¦            ¦
 ¦± indice de protrombina  ¦           ¦             ¦           ¦            ¦
 ¦< 40%                    ¦           ¦             ¦           ¦            ¦
 +-------------------------+-----------+-------------+-----------+------------¦
 ¦- CH complicata cu       ¦Deficienta ¦   90-100%   ¦Capacitate ¦Gradul I    ¦
 ¦adenocarcinom            ¦functionala¦             ¦de munca si¦            ¦
 ¦                         ¦grava      ¦             ¦autoservire¦            ¦
 ¦                         ¦           ¦             ¦pierduta in¦            ¦
 ¦                         ¦           ¦             ¦totalitate ¦            ¦
 +----------------------------------------------------------------------------+
*ST*

    N.B. Factori de prognostic nefavorabil in CH:
    - ficatul mic;
    - varsta inaintata;
    - icterul;
    - hipotensiunea arteriala persistenta (valori sub 100 mmHg pentru sistolica);
    - hemoragia;
    - albuminemia sub 2,5 g/l;
    - echimoze spontane;
    - timp de protrombina prelungit;
    - ascita greu/deloc controlabila terapeutic;
    - encefalopatie cu evolutie spre coma.
    CH complicata cu hepatocarcinom (prezenta in ser de markeri specifici cu nivel semnificativ: a fetoproteina > 500 nanograme/ml ± anomalii ecografice demonstrative ± argumente histologice decisive).

    Transplantul de ficat
    Transplantul de ficat, cu sau fara indepartarea ficatului lezat al primitorului, apare ca ultima resursa terapeutica in bolile hepatice terminale.
    Transplantul auxiliar (heterotopic) conserva ficatul receptorului si grefeaza un nou ficat, de regula in regiunea paravertebrala dreapta.
    In transplantul ortotopic ficatul bolnav este extirpat, transplantul efectuandu-se in locul acestuia.

    Alternative ale transplantului ortotopic de ficat:
    - transplantul de hepatocite izolate de la donor cadavru;
    - folosirea de surse alternative pentru transplantul de hepatocite adulte primare: celule stem hepatice, maduva osoasa, celule din cordonul ombilical si hepatocite imortalizate, hepatoblasti fetali, embrioni.
    In aprecierea capacitatii de munca la pacientii cu transplant hepatic, se vor lua in considerare urmatoarele:
    1. media supravietuirii la 5 ani este de aproximativ 60%;
    2. complicatiile postoperatorii;
    3. rejetul cronic;
    4. reactiile adverse ale medicatiei imunosupresoare (hepatotoxicitate);
    5. recurenta bolii primare (hepatite cronice active autoimune, colangite sclerozante primare, colangiocarcinom, carcinom hepatocelular care recidiveaza dupa un an);
    6. reinfectia grefei VHB si necesitatea retransplantului;
    7. aparitia hepatitei colestatice fibrozante (cresterea marcata a bilirubinei si scaderea protrombinei in discordanta cu hipertransaminazemia mica, pe fondul unei insuficiente hepatice rapid progresive);
    8. dezvoltarea unor hepatite cronice active sau fulminante;
    9. stari septicemice si pancreatite (mai ales in hepatitele cu virus B);
    10. recurenta infectiei cu virus C.
    In primul an de interventie, precum si in cazul prezentei uneia dintre complicatiile de mai sus, pacientul cu transplant hepatic are capacitatea de autoservire pierduta, deficienta functionala grava, I.A. = 90-100%.
    Daca evolutia este favorabila dupa un an de la transplant, dar si in functie de starea clinico-biologica, pacientul cu transplant hepatic poate avea:
    - deficienta functionala accentuata I.A. = 70-89%;
    - capacitatea de munca pierduta in totalitate sau deficienta functionala medie, I.A. = 50-69%;
    - capacitatea de munca cel putin jumatate pierduta, in raport de pregatirea profesionala si solicitarile de la locul de munca.

    BOLILE PANCREASULUI
    Intra in discutie pancreatitele cronice severe, cancerul pancreatic, precum si rezectiile pancreatico-duodenale (pentru neoplazii sau alte cauze) cu insuficienta pancreatica grava.
    Diagnosticul pozitiv al insuficientei pancreatice cronice exocrine
    Clinic: diaree, steatoree, scadere ponderala, disconfort abdominal, dureri abdominale de intensitate variabila;
    - semne clinice ale malabsorbtiei de vitamine liposolubile A, D, E, K.
    Biologic: testul cu secretina - CCK (dificil, invaziv, accesibilitate limitata)
    - elastaza I fecala:
    i. < 100 mcg/g -> insuficienta severa;
    ii. > 200 mcg/g -> normal;
    iii. 100-200 mcg/g -> sugestiv pentru insufucienta pancreatica, daca exista si alte criterii;
    - stimulare secretina la MRCP - pentru forme de PC usoara.
    Diagnosticul pozitiv al insuficientei pancreatice endocrine
    Biologic: TTGO, glicemie
    Teste speciale:
    - Imagistic - ultrasonografie, CT, RMN, ERCP, ecoendoscopie (EUS);
      - anomalii ductale - calcificari, dilatatii, stenoze;
      - anomalii parenchim - calcificari, pseudochisturi;
      - complicatii - stenoze duoden, stenoze CBP, pseudoanevrisme, tromboze;
      - utile in suspiciunea de neoplazie - inclusiv punctia cu ac fin FNB;
      - tumori.
    - Histologic - din biopsii EUS sau chirurgicale: distructia acinilor, dilatarea ductelor, fibroza, infiltrate inflamatorii.
*T*
 +----------------------------------------------------------------------------+
 ¦Afectiunea. Forma clinica¦Deficienta ¦Incapacitatea¦Capacitatea¦Gradul de   ¦
 ¦                         ¦functionala¦adaptativa   ¦de munca   ¦invaliditate¦
 +-------------------------+-----------+-------------+-----------+------------¦
 ¦Pancreatita cronica      ¦Deficienta ¦    20-49%   ¦Pastrata   ¦Nu se       ¦
 ¦usoara si moderata, fara ¦functionala¦             ¦           ¦incadreaza  ¦
 ¦diaree, fara diabet,     ¦usoara     ¦             ¦           ¦            ¦
 ¦durere controlabila      ¦           ¦             ¦           ¦            ¦
 +-------------------------+-----------+-------------+-----------+------------¦
 ¦Pancreatita cronica      ¦Deficienta ¦    50-69%   ¦Cel putin  ¦Gradul III  ¦
 ¦moderat-severa cu sindrom¦functionala¦             ¦jumatate   ¦            ¦
 ¦diareic moderat, fara    ¦medie      ¦             ¦pierduta   ¦            ¦
 ¦scadere ponderala        ¦           ¦             ¦           ¦            ¦
 ¦semnificativa, cu durere ¦           ¦             ¦           ¦            ¦
 ¦controlabila             ¦           ¦             ¦           ¦            ¦
 +-------------------------+-----------+-------------+-----------+------------¦
 ¦Pancreatita cronica      ¦Deficienta ¦    70-89%   ¦Pierduta   ¦Gradul II   ¦
 ¦severa cu diaree grava si¦functionala¦             ¦           ¦            ¦
 ¦denutritie severa, dureri¦accentuata ¦             ¦           ¦            ¦
 ¦persistente rezistente la¦           ¦             ¦           ¦            ¦
 ¦tratamentul medicamentos.¦           ¦             ¦           ¦            ¦
 ¦Pacienti cu              ¦           ¦             ¦           ¦            ¦
 ¦duodeno-pancreatectomie, ¦           ¦             ¦           ¦            ¦
 ¦cu diaree controlabila   ¦           ¦             ¦           ¦            ¦
 +----------------------------------------------------------------------------+
*ST*

    BOLILE INTESTINULUI
    a) Boala celiaca a adultului (enteropatia glutemica)
    Criterii de diagnostic (clinice si paraclinice):
    - diaree cronica cu steatoree macroscopica;
    - raspuns favorabil la regimul fara gluten;
    - semne de malabsorbtie globala (pierdere ponderala, hipocalcemie, hiposideremie, hipopotasemie);
    - biopsie jejunala caracteristica (atrofie jejunala).
    Pentru diagnostic este necesara evidentierea raspunsului favorabil la regimul fara gluten si un semn clinic.
*T*
 +----------------------------------------------------------------------------+
 ¦Afectiunea. Forma clinica¦Deficienta ¦Incapacitatea¦Capacitatea¦Gradul de   ¦
 ¦                         ¦functionala¦adaptativa   ¦de munca   ¦invaliditate¦
 +-------------------------+-----------+-------------+-----------+------------¦
 ¦Boala celiaca a          ¦Fara       ¦    0-19%    ¦Pastrata   ¦Nu se       ¦
 ¦adultului-forma usoara   ¦deficienta ¦             ¦           ¦incadreaza  ¦
 ¦Bolnavii care prezinta   ¦functionala¦             ¦           ¦            ¦
 ¦diaree intermitenta cu   ¦           ¦             ¦           ¦            ¦
 ¦steatoree macroscopica,  ¦           ¦             ¦           ¦            ¦
 ¦cu raspuns favorabil la  ¦           ¦             ¦           ¦            ¦
 ¦regimul de gluten, fara  ¦           ¦             ¦           ¦            ¦
 ¦tulburari de nutritie sau¦           ¦             ¦           ¦            ¦
 ¦cu un deficit ponderal   ¦           ¦             ¦           ¦            ¦
 ¦usor                     ¦           ¦             ¦           ¦            ¦
 +-------------------------+-----------+-------------+-----------+------------¦
 ¦Idem sub aspectul        ¦Deficienta ¦    20-49%   ¦Pastrata   ¦Nu se       ¦
 ¦manifestarilor           ¦functionala¦             ¦           ¦incadreaza  ¦
 ¦(diagnostic pus pe baza  ¦usoara     ¦             ¦           ¦            ¦
 ¦biopsiei jejunale        ¦           ¦             ¦           ¦            ¦
 ¦caracteristice: atrofie  ¦           ¦             ¦           ¦            ¦
 ¦jejunala cu semne de     ¦           ¦             ¦           ¦            ¦
 ¦malabsorbtie,            ¦           ¦             ¦           ¦            ¦
 ¦mal-asimilatie (pierdere ¦           ¦             ¦           ¦            ¦
 ¦ponderala intre 15-20%   ¦           ¦             ¦           ¦            ¦
 ¦din greutate),           ¦           ¦             ¦           ¦            ¦
 ¦hipocalcemie,            ¦           ¦             ¦           ¦            ¦
 ¦hiposideremie,           ¦           ¦             ¦           ¦            ¦
 ¦hipopotasemie - usoare,  ¦           ¦             ¦           ¦            ¦
 ¦precum si bolnavii cu    ¦           ¦             ¦           ¦            ¦
 ¦pusee diareice frecvente ¦           ¦             ¦           ¦            ¦
 ¦(1-2 ori/ luna) cu semne ¦           ¦             ¦           ¦            ¦
 ¦de malasimilatie         ¦           ¦             ¦           ¦            ¦
 ¦(hipopotasemie,          ¦           ¦             ¦           ¦            ¦
 ¦hiposideremie,           ¦           ¦             ¦           ¦            ¦
 ¦hipocalcemie - medii),   ¦           ¦             ¦           ¦            ¦
 ¦reversibile la tratament ¦           ¦             ¦           ¦            ¦
 ¦si malasorbtie (deficit  ¦           ¦             ¦           ¦            ¦
 ¦ponderal usor)           ¦           ¦             ¦           ¦            ¦
 +-------------------------+-----------+-------------+-----------+------------¦
 ¦Boala celiaca a adultului¦Deficienta ¦    50-69%   ¦Pierduta   ¦Gradul III  ¦
 ¦- forma medie            ¦functionala¦             ¦cel putin  ¦            ¦
 ¦Bolnavii care prezinta:  ¦medie      ¦             ¦jumatate   ¦            ¦
 ¦- diaree cronica cu      ¦           ¦             ¦           ¦            ¦
 ¦steatoree macroscopica;  ¦           ¦             ¦           ¦            ¦
 ¦- raspuns favorabil la   ¦           ¦             ¦           ¦            ¦
 ¦tratament si regim fara  ¦           ¦             ¦           ¦            ¦
 ¦gluten;                  ¦           ¦             ¦           ¦            ¦
 ¦- sindrom de malabsorbtie¦           ¦             ¦           ¦            ¦
 ¦globala cu pierdere      ¦           ¦             ¦           ¦            ¦
 ¦ponderala medie;         ¦           ¦             ¦           ¦            ¦
 ¦- sindrom de             ¦           ¦             ¦           ¦            ¦
 ¦malasimilatie selectiva  ¦           ¦             ¦           ¦            ¦
 ¦(hipopotasemie,          ¦           ¦             ¦           ¦            ¦
 ¦hiposideremie,           ¦           ¦             ¦           ¦            ¦
 ¦hipocalcemie - medii).   ¦           ¦             ¦           ¦            ¦
 +-------------------------+-----------+-------------+-----------+------------¦
 ¦Boala celiaca a adultului¦Deficienta ¦    70-89%   ¦Pierduta in¦Gradul II   ¦
 ¦- forma accentuata       ¦functionala¦             ¦totalitate ¦            ¦
 ¦Pacientii care prezinta  ¦accentuata ¦             ¦           ¦            ¦
 ¦manifestarile de mai sus,¦           ¦             ¦           ¦            ¦
 ¦dar de intensitate mai   ¦           ¦             ¦           ¦            ¦
 ¦mare si cu rasunet       ¦           ¦             ¦           ¦            ¦
 ¦evident nutritiv (deficit¦           ¦             ¦           ¦            ¦
 ¦ponderal), hipocalcemie, ¦           ¦             ¦           ¦            ¦
 ¦hiposideremie,           ¦           ¦             ¦           ¦            ¦
 ¦hipopotasemie, evidente  ¦           ¦             ¦           ¦            ¦
 ¦si persistente la        ¦           ¦             ¦           ¦            ¦
 ¦masurile de recuperare.  ¦           ¦             ¦           ¦            ¦
 +----------------------------------------------------------------------------+
*ST*

    b) Enterita regionala (boala Crohn - BC)
    Boala Crohn (BC) reprezinta o afectiune cronica cu etiologie necunoscuta si patogeneza incomplet elucidata, in care procesul inflamator intereseaza transmural oricare segment al tubului digestiv, in asociere cu variate complicatii intestinale si manifestari extraintestinale.
    Cele doua metode majore de diagnostic sunt:
    1. examenul radiologic cu substanta de contrast;
    2. endoscopia digestiva.
    Diagnosticul pozitiv: diagnosticul complet al BC trebuie sa cuprinda: localizarea, severitatea puseului inflamator, forma clinico-evolutiva, tipul de complicatie.
    Pentru aprecierea severitatii inflamatiei intestinale se utilizeaza, de regula, scoruri semicantitative, cel mai cunoscut fiind Crohn's Disease Activity Index (CDAI), ce cuantifica 8 variabile: numarul de scaune lichidiene sau moi, durerea abdominala, starea generala, numarul complicatiilor (artrite, uveite, eritem nodos sau stomatita aftoasa, fisuri sau abcese anale, fistule, febra), utilizarea opiaceelor antidiareice, prezenta maselor abdominale, hematocritul si procentul deviatiei greutatii corporale fata de standard.
    - CDAI sub 150 -> remisiunea bolii;
    - CDAI intre 200-450 -> activare moderata a bolii;
    - CDAI peste 450 -> boala cu activare severa.
    In practica, se utilizeaza o incadrare simplificata a bolii in raport cu severitatea, in 3 forme:
    1) Formele usoare (blande-moderate): cel mult 4 scaune/zi, durere abdominala minima sau absenta, fara mase abdominale palpabile, fara semne de iritatie peritoneala sau obstructie intestinala, fara febra, fara semne de deshidratare si toxicitate sistemica, fara complicatii, fara anemie, greutate normala, pacienti cu toleranta orala conservata, care pot fi tratati cu succes in regim ambulatoriu.
    2) Formele moderate: 4-6 scaune/zi, dureri abdominale de intensitate moderata, greata, varsaturi, febra, complicatii, scadere ponderala, anemie sau pacienti cu forme blande, care nu au raspuns la terapia corespunzatoare.
    3) Formele severe: peste 6 scaune/zi, dureri abdominale severe, mase abdominale palpabile, anemie, scadere ponderala, pacienti cu manifestari persistente, in pofida tratamentului cu corticosteroizi, sau cu simptome severe ca: deshidratare, febra, frisoane, tahicardie, semne de iritatie peritoneala sau obstructie intestinala, casexie, sepsis.
    4) Remisiunea: pacientii asimptomatici sau fara sechele inflamatorii in urma interventiilor medicamentoase sau a rezectiilor chirurgicale.
    Diagnosticul clinic se precizeaza prin examen clinic, radiologic cu substanta de control si endoscopie digestiva.
    Diagnosticul functional se stabileste in functie de intensitatea simptomatologiei, a anemiei si in functie de deficitul ponderal.
*T*
 +----------------------------------------------------------------------------+
 ¦Afectiunea. Forma clinica¦Deficienta ¦Incapacitatea¦Capacitatea¦Gradul de   ¦
 ¦                         ¦functionala¦adaptativa   ¦de munca   ¦invaliditate¦
 +-------------------------+-----------+-------------+-----------+------------¦
 ¦Boala Crohn usoara       ¦Deficienta ¦    20-49%   ¦Pastrata   ¦Nu se       ¦
 ¦1) BC in remisiune       ¦functionala¦             ¦           ¦incadreaza  ¦
 ¦2) BC forma usoara       ¦usoara     ¦             ¦           ¦            ¦
 +-------------------------+-----------+-------------+-----------+------------¦
 ¦Boala Crohn moderata     ¦Deficienta ¦    50-69%   ¦Pierduta   ¦Gradul III  ¦
 ¦1) BC forma moderata cu  ¦functionala¦             ¦cel putin  ¦            ¦
 ¦deficit ponderal mediu   ¦medie      ¦             ¦jumatate   ¦            ¦
 +-------------------------¦           ¦             ¦           ¦            ¦
 ¦2) BC forma moderata, cu ¦           ¦             ¦           ¦            ¦
 ¦deficit ponderal mediu,  ¦           ¦             ¦           ¦            ¦
 ¦anemie (Hb 8-10 g/dl), cu¦           ¦             ¦           ¦            ¦
 ¦raspuns partial la       ¦           ¦             ¦           ¦            ¦
 ¦tratament                ¦           ¦             ¦           ¦            ¦
 +-------------------------+-----------+-------------+-----------+------------¦
 ¦Boala Crohn severa       ¦Deficienta ¦    70-89%   ¦Pierduta in¦Gradul II   ¦
 ¦1) BC forma severa, cu   ¦functionala¦             ¦totalitate ¦            ¦
 ¦sindrom de malabsorbtie, ¦accentuata ¦             ¦           ¦            ¦
 ¦anemie (Hb < 8 g/dl),    ¦           ¦             ¦           ¦            ¦
 ¦deficit ponderal         ¦           ¦             ¦           ¦            ¦
 ¦< 16 kg/m?.              ¦           ¦             ¦           ¦            ¦
 +-------------------------¦           ¦             ¦           ¦            ¦
 ¦2) BC cu complicatii:    ¦           ¦             ¦           ¦            ¦
 ¦- enterale (fistule,     ¦           ¦             ¦           ¦            ¦
 ¦stenoze)                 ¦           ¦             ¦           ¦            ¦
 ¦- sistemice (oculare,    ¦           ¦             ¦           ¦            ¦
 ¦articulare, hepatice)    ¦           ¦             ¦           ¦            ¦
 +-------------------------+-----------+-------------+-----------+------------¦
 ¦3) BC cu rezectii        ¦           ¦             ¦           ¦            ¦
 ¦intestinale si ileostomie¦           ¦             ¦           ¦            ¦
 +----------------------------------------------------------------------------+
*ST*

    c) Rectocolita ulcero-hemoragica (RCUH)
    Cele doua metode majore de diagnostic sunt examenul radiologic cu substanta de contrast si endoscopia digestiva.
    Diagnosticul pozitiv: diagnosticul clinic complet trebuie sa cuprinda - forma clinica evolutiva, severitatea puseului de activitate, extensia bolii, complicatiile sistemice (cand exista).

    Clasificarea puseelor de activitate clinica (dupa Truelove si Witts)
    1) Forma clinica usoara (minima)
    - paucisimptomatica: diaree blanda (< 4 scaune/zi, in cantitate mica, cu cateva glere si sange inconstant), fara febra, tahicardie, stare generala buna;
    - tuseul rectal nesemnificativ;
    - fara sau cu usoara anemie (Hb > 9 g/dl - VSH < 30 ml/1h).
    - imagine radiologica necaracteristica.
    Endoscopia indica modificari minime, localizate la o portiune a rectului sau a sigmoidului terminal: mucoasa congestionata, stralucitoare, usor edematiata, fragila, usor sangeranda.
    2) Forma moderata (medie, mijlocie)
    - diaree (4-6 scaune/zi, pastoase, glero-sanguinolente, uneori emisiuni afecale si tenesme rectale), subfebrilitate, inapetenta, greturi, dureri abdominale si rectale, astenie discreta, stare generala buna (alteori manifestari generale mai severe: febra mare, stare toxica, anemie intensa);
    - tuseul rectal indica o crestere a tonusului sfincterului anal, iar pe varful degetului se recolteaza sange, mucus si eventual puroi, anemie (Hb - 7,5-9 g/dl);
    - radiologic: tablou complet de RCUH forma ulcero-proliferativa;
    - endoscopia: congestia mucoasei, edem accentuat si ulceratii acoperite de membrane pultacee si polipi inflamatorii, secretii muco-sanguino-purulente. Se pot ivi si complicatii.
    3) Forma severa (grava)
    - diaree severa (> 6 scaune/zi cu sange in amestec), pana la diaree profuza (30-40 scaune/zi, diaree afecala alcatuita din glere, puroi si sange cu importanta deperditie hidroelectrolitica si proteica consecutiva);
    - febra > 37,5°, minimum 2 din 4 zile; tahicardie sinusala > 90 b./min., abdomen meteorizat, sensibil, sindrom toxiinfectios (stare generala profund alterata, stare de prostatie, astenie, febra mare, tahicardie, edeme declive), anemie severa (Hb < 7,5 g/dl) si hiperleucocitoza cu neutrofilie si deviere la stanga a firului, VSH > 30 mm/h;
    - radiologic - distensia colonului (irigografia este periculoasa din cauza fragilitatii peretelui intestinal).
    Diagnosticul clinic se precizeaza prin examen clinic, radiologic cu substante de contrast si cu endoscopie digestiva.
    Diagnosticul functional se stabileste in functie de intensitatea simptomatologiei, de anemie si de deficitul ponderal.
*T*
 +----------------------------------------------------------------------------+
 ¦Afectiunea. Forma clinica¦Deficienta ¦Incapacitatea¦Capacitatea¦Gradul de   ¦
 ¦                         ¦functionala¦adaptativa   ¦de munca   ¦invaliditate¦
 +-------------------------+-----------+-------------+-----------+------------¦
 ¦Rectocolita              ¦Fara       ¦    0 - 19%  ¦Pastrata   ¦Nu se       ¦
 ¦ulcero-hemoragica        ¦deficienta ¦             ¦           ¦incadreaza  ¦
 ¦- RCUH forma regresiva,  ¦functionala¦             ¦           ¦            ¦
 ¦bolnavi cu un singur     ¦           ¦             ¦           ¦            ¦
 ¦puseu de activitate in   ¦           ¦             ¦           ¦            ¦
 ¦antecedente, de          ¦           ¦             ¦           ¦            ¦
 ¦intensitate usoara sau   ¦           ¦             ¦           ¦            ¦
 ¦medie, cu raspuns prompt ¦           ¦             ¦           ¦            ¦
 ¦la tratamentul aplicat,  ¦           ¦             ¦           ¦            ¦
 ¦urmat de o perioada de   ¦           ¦             ¦           ¦            ¦
 ¦remisi-une completa si   ¦           ¦             ¦           ¦            ¦
 ¦durabila de cel putin    ¦           ¦             ¦           ¦            ¦
 ¦1 an                     ¦           ¦             ¦           ¦            ¦
 +-------------------------+-----------+-------------+-----------+------------¦
 ¦Rectocolita              ¦Deficienta ¦    20-49%   ¦Pastrata   ¦Nu se       ¦
 ¦ulcero-hemoragica - forma¦functionala¦             ¦           ¦incadreaza  ¦
 ¦clinica usoara           ¦usoara     ¦             ¦           ¦            ¦
 ¦- RCUH forma recurenta,  ¦           ¦             ¦           ¦            ¦
 ¦cu pusee rare (1-2/an),de¦           ¦             ¦           ¦            ¦
 ¦intensitate usoara sau   ¦           ¦             ¦           ¦            ¦
 ¦medie, cu remisiune      ¦           ¦             ¦           ¦            ¦
 ¦completa                 ¦           ¦             ¦           ¦            ¦
 +-------------------------+-----------+-------------+-----------+------------¦
 ¦Rectocolita              ¦Deficienta ¦    50-69%   ¦Pierduta   ¦Gradul III  ¦
 ¦ulcero-hemoragica - forma¦functionala¦             ¦cel putin  ¦            ¦
 ¦medie, mijlocie)         ¦medie      ¦             ¦jumatate   ¦            ¦
 ¦1) RCUH forma recurenta, ¦           ¦             ¦           ¦            ¦
 ¦cu pusee rare (1-2/an),  ¦           ¦             ¦           ¦            ¦
 ¦de intensitate medie sau ¦           ¦             ¦           ¦            ¦
 ¦grava (atestate prin     ¦           ¦             ¦           ¦            ¦
 ¦documente medicale),     ¦           ¦             ¦           ¦            ¦
 ¦tratata cu salazopirina  ¦           ¦             ¦           ¦            ¦
 ¦si eventual prednison in ¦           ¦             ¦           ¦            ¦
 ¦doze mici, cu deficit    ¦           ¦             ¦           ¦            ¦
 ¦ponderal mediu si anemie ¦           ¦             ¦           ¦            ¦
 ¦(Hb = 8-10g/dl)          ¦           ¦             ¦           ¦            ¦
 ¦2) RCUH forma cronica cu ¦           ¦             ¦           ¦            ¦
 ¦evolutie continua sub    ¦           ¦             ¦           ¦            ¦
 ¦tratament cu salazopirina¦           ¦             ¦           ¦            ¦
 ¦si eventual prednison in ¦           ¦             ¦           ¦            ¦
 ¦doze mici, cu sindrom    ¦           ¦             ¦           ¦            ¦
 ¦diareic si dureros       ¦           ¦             ¦           ¦            ¦
 ¦moderat, deficit ponderal¦           ¦             ¦           ¦            ¦
 ¦mediu si anemie          ¦           ¦             ¦           ¦            ¦
 ¦(Hb = 8-10 g/dl)         ¦           ¦             ¦           ¦            ¦
 +-------------------------+-----------+-------------+-----------+------------¦
 ¦Rectocolita              ¦Deficienta ¦    70-89%   ¦Pierduta in¦Gradul II   ¦
 ¦ulcero-hemoragica - forma¦functionala¦             ¦totalitate ¦            ¦
 ¦severa (grava)           ¦accentuata ¦             ¦           ¦            ¦
 ¦1) RCUH forma recurenta  ¦           ¦             ¦           ¦            ¦
 ¦cu episoade acute        ¦           ¦             ¦           ¦            ¦
 ¦frecvente (peste 27/an), ¦           ¦             ¦           ¦            ¦
 ¦de intensitate severa,   ¦           ¦             ¦           ¦            ¦
 ¦care au necesitat        ¦           ¦             ¦           ¦            ¦
 ¦internare intr-o sectie  ¦           ¦             ¦           ¦            ¦
 ¦de reanimare, cu perioada¦           ¦             ¦           ¦            ¦
 ¦de remisiune cu durata   ¦           ¦             ¦           ¦            ¦
 ¦mai mica de 6 luni,      ¦           ¦             ¦           ¦            ¦
 ¦incompleta, care necesita¦           ¦             ¦           ¦            ¦
 ¦corti-coterapie continua ¦           ¦             ¦           ¦            ¦
 ¦2) RCUH cu complicatii   ¦           ¦             ¦           ¦            ¦
 ¦sistemice                ¦           ¦             ¦           ¦            ¦
 ¦3) RCUH in primele 6-12  ¦           ¦             ¦           ¦            ¦
 ¦luni dupa o interventie  ¦           ¦             ¦           ¦            ¦
 ¦chirurgicala de amploare ¦           ¦             ¦           ¦            ¦
 ¦(colectomie totala cu    ¦           ¦             ¦           ¦            ¦
 ¦anastomoza ileocecala sau¦           ¦             ¦           ¦            ¦
 ¦ileoanala)               ¦           ¦             ¦           ¦            ¦
 ¦4) RCUH cronica cu       ¦           ¦             ¦           ¦            ¦
 ¦agravare progresiva, fara¦           ¦             ¦           ¦            ¦
 ¦remisiuni                ¦           ¦             ¦           ¦            ¦
 ¦5) RCUH cu ileostomie sau¦           ¦             ¦           ¦            ¦
 ¦sigmoidostomie definitiva¦           ¦             ¦           ¦            ¦
 +----------------------------------------------------------------------------+
*ST*

    d) Rezectii intestinale posttraumatisme abdominale, pentru tumori benigne, maligne si alte cauze
*T*
 +----------------------------------------------------------------------------+
 ¦Afectiunea. Forma clinica¦Deficienta ¦Incapacitatea¦Capacitatea¦Gradul de   ¦
 ¦                         ¦functionala¦adaptativa   ¦de munca   ¦invaliditate¦
 +-------------------------+-----------+-------------+-----------+------------¦
 ¦Rezectie de intestin     ¦Fara       ¦    20-49%   ¦Pastrata   ¦Nu se       ¦
 ¦subtire cu               ¦deficienta ¦             ¦           ¦incadreaza  ¦
 ¦simptomatologie usoara,  ¦functionala¦             ¦           ¦            ¦
 ¦anemie usoara, deficit   ¦           ¦             ¦           ¦            ¦
 ¦ponderal                 ¦           ¦             ¦           ¦            ¦
 +-------------------------+-----------+-------------+-----------+------------¦
 ¦Rezectii de intestin     ¦Deficienta ¦    50-60%   ¦Pierduta   ¦Gradul III  ¦
 ¦subtire - sindrom        ¦functionala¦             ¦cel putin  ¦            ¦
 ¦intestin scurt, cu dureri¦medie      ¦             ¦jumatate   ¦            ¦
 ¦abdominale, diaree sau/si¦           ¦             ¦           ¦            ¦
 ¦fenomene subocluzive din ¦           ¦             ¦           ¦            ¦
 ¦cauza perivisceritei,    ¦           ¦             ¦           ¦            ¦
 ¦malasimilatie cu         ¦           ¦             ¦           ¦            ¦
 ¦denutritie medie (deficit¦           ¦             ¦           ¦            ¦
 ¦ponderal mediu)          ¦           ¦             ¦           ¦            ¦
 +-------------------------+-----------+-------------+-----------+------------¦
 ¦Rezectie de intestin     ¦Deficienta ¦    70-89%   ¦Pierduta in¦Gradul II   ¦
 ¦subtire cu dereglari     ¦functionala¦             ¦totalitate ¦Contraindi- ¦
 ¦severe: malabsorbtie,    ¦accentuata ¦             ¦           ¦catie pentru¦
 ¦malasimilatie, cu deficit¦           ¦             ¦           ¦orice       ¦
 ¦ponderal sever; anemie   ¦           ¦             ¦           ¦activitate  ¦
 ¦severa (< 8g/dl),        ¦           ¦             ¦           ¦profesionala¦
 ¦manifestari ameliorate   ¦           ¦             ¦           ¦            ¦
 ¦partial la tratament.    ¦           ¦             ¦           ¦            ¦
 ¦Bolnavii cu fistule      ¦           ¦             ¦           ¦            ¦
 ¦pararectale, fistule     ¦           ¦             ¦           ¦            ¦
 ¦anorectale, cu           ¦           ¦             ¦           ¦            ¦
 ¦incontinenta de materii  ¦           ¦             ¦           ¦            ¦
 ¦fecale, stare septica,   ¦           ¦             ¦           ¦            ¦
 ¦denutritie progresiva,   ¦           ¦             ¦           ¦            ¦
 ¦amendate sau ameliorate  ¦           ¦             ¦           ¦            ¦
 ¦dupa tratamentul         ¦           ¦             ¦           ¦            ¦
 ¦chirurgical              ¦           ¦             ¦           ¦            ¦
 +-------------------------+-----------+-------------+-----------+------------¦
 ¦Pacientii cu rezectii de ¦Deficienta ¦   90-100%   ¦Capacitatea¦Gradul I    ¦
 ¦colon pentru tumori      ¦functionala¦             ¦de munca si¦            ¦
 ¦maligne, cu anus iliac,  ¦grava      ¦             ¦autoservire¦            ¦
 ¦sigma anus sau anus      ¦           ¦             ¦pierduta in¦            ¦
 ¦contra lateralis si cei  ¦           ¦             ¦totalitate ¦            ¦
 ¦cu agravare progresiva,  ¦           ¦             ¦           ¦            ¦
 ¦anemie severa, stare de  ¦           ¦             ¦           ¦            ¦
 ¦casexie                  ¦           ¦             ¦           ¦            ¦
 +----------------------------------------------------------------------------+
*ST*

    EVENTRATIILE
    Eventratia reprezinta hernierea unei parti a continutului abdominal printr-un orificiu, care se creeaza intr-o zona slaba a unei cicatrici postoperatorii sau posttraumatice.
*T*
 +----------------------------------------------------------------------------+
 ¦Afectiunea. Forma clinica¦Deficienta ¦Incapacitatea¦Capacitatea¦Gradul de   ¦
 ¦                         ¦functionala¦adaptativa   ¦de munca   ¦invaliditate¦
 +-------------------------+-----------+-------------+-----------+------------¦
 ¦Eventratii               ¦Deficienta ¦   20-49%    ¦Pastrata   ¦Nu se       ¦
 ¦- neoperate sau operate  ¦functionala¦             ¦           ¦incadreaza  ¦
 ¦si recidivate, cu        ¦usoara     ¦             ¦           ¦Pot         ¦
 ¦posibilitati de          ¦           ¦             ¦           ¦beneficia de¦
 ¦reinterventie            ¦           ¦             ¦           ¦concediu    ¦
 ¦                         ¦           ¦             ¦           ¦medical     ¦
 ¦                         ¦           ¦             ¦           ¦conform     ¦
 ¦                         ¦           ¦             ¦           ¦legii       ¦
 ¦                         ¦           ¦             ¦           ¦± schimbarea¦
 ¦                         ¦           ¦             ¦           ¦locului de  ¦
 ¦                         ¦           ¦             ¦           ¦munca       ¦
 ¦                         ¦           ¦             ¦           ¦± program   ¦
 ¦                         ¦           ¦             ¦           ¦redus       ¦
 +-------------------------+-----------+-------------+-----------+------------¦
 ¦- operate multiplu,      ¦Deficienta ¦    50-69%   ¦Cel putin  ¦Gradul III  ¦
 ¦recidivate, fara         ¦functionala¦             ¦jumatate   ¦            ¦
 ¦posibilitate de a se     ¦medie      ¦             ¦pierduta   ¦            ¦
 ¦interveni chirurgical in ¦           ¦             ¦           ¦            ¦
 ¦prezent;                 ¦           ¦             ¦           ¦            ¦
 ¦- ± tulburari de tranzit ¦           ¦             ¦           ¦            ¦
 +----------------------------------------------------------------------------+
*ST*

                              4. AFECTIUNI RENALE

    BOLILE GLOMERULARE (Glomerulonefritele)

    Glomerulonefrite acute
    Glomerulonefritele acute evolueaza cel mai frecvent spre vindecare (uneori pana la 2-3 ani). Vindecarea nu poate fi afirmata decat dupa 1-2 ani (uneori pana la 2-3 ani). Exista forme clinice recidivante, cu tendinta la cronicizare.
    Evaluarea periodica, respectiv revizuirea la termen a bolnavilor cu glomerulonefrita acuta, cuprinde:
    1. examenul clinic: edeme, curba ponderala, presiunea arteriala, diureza;
    2. explorarea functionala a rinichiului:
    - examen sumar de urina;
    - sediment urinar cantitativ (Stansfeld-Webb, Addis-Hamburger);
    - examen de urina din 24 de ore (densitate si osmolaritate, proteinurie, albuminurie, uree, creatinina, sodiu, potasiu);
    - clearance-ul creatininei si al ureei endogene;
    - creatinina si uree serica;
    3. explorarea imagistica renala (ecografie);
    4. explorarea imunologica:
    - complement seric (total, C3);
    - crioglobulinemie;
    - titru ASLO;
    - probe de inflamatie (VSH, fibrinemie).

    Diagnostic functional
    Aprecierea deficientei functionale si a incapacitatii adaptative trebuie realizata dupa expirarea perioadei legale de concediu medical, conform tabelului I.

    Tabelul I. Criteriile de apreciere a gradului de invaliditate in glomerulonefritele acute
*T*
 +----------------------------------------------------------------------------+
 ¦Forma clinica de         ¦Deficienta ¦Incapacitatea¦Capacitatea¦Gradul de   ¦
 ¦glomerulonefrita acuta   ¦functionala¦adaptativa   ¦de munca   ¦invaliditate¦
 +-------------------------+-----------+-------------+-----------+------------¦
 ¦Usoara                   ¦   Usoara  ¦   20-49%    ¦Pastrata   ¦Nu se       ¦
 ¦- simptomatologie stearsa¦           ¦             ¦           ¦incadreaza  ¦
 ¦- evolutie peste 3 luni  ¦           ¦             ¦           ¦in grad de  ¦
 ¦- tendinta la cronicizare¦           ¦             ¦           ¦invaliditate¦
 ¦(uneori)                 ¦           ¦             ¦           ¦(eventual   ¦
 ¦                         ¦           ¦             ¦           ¦schimbarea  ¦
 ¦                         ¦           ¦             ¦           ¦locului de  ¦
 ¦                         ¦           ¦             ¦           ¦munca)      ¦
 +-------------------------+-----------+-------------+-----------+------------¦
 ¦Medie                    ¦   Medie   ¦   50-69%    ¦Pierduta   ¦III         ¦
 ¦- tablou clinic moderat  ¦           ¦             ¦cel putin  ¦            ¦
 ¦- proteinurie si         ¦           ¦             ¦jumatate   ¦            ¦
 ¦hematurie persistente    ¦           ¦             ¦           ¦            ¦
 ¦- hipertensiune arteriala¦           ¦             ¦           ¦            ¦
 +-------------------------+-----------+-------------+-----------+------------¦
 ¦Grava                    ¦Accentuata ¦    70-89%   ¦Pierduta in¦II          ¦
 ¦- tablou clinic complet  ¦           ¦             ¦totalitate ¦            ¦
 ¦- simptomatologie intensa¦           ¦             ¦           ¦            ¦
 ¦Evolutie spre IRC:       ¦           ¦             ¦           ¦            ¦
 ¦- lenta cu perioade de   ¦           ¦             ¦           ¦            ¦
 ¦remisiune                ¦           ¦             ¦           ¦            ¦
 ¦- accelerata             ¦           ¦             ¦           ¦            ¦
 +-------------------------+-----------+-------------+-----------+------------¦
 ¦In formele care au       ¦Variabil in¦Variabil in  ¦Variabil in¦Variabil in ¦
 ¦evoluat spre IRC,        ¦functie de ¦functie de   ¦functie de ¦functie de  ¦
 ¦deficienta functionala,  ¦stadiul IRC¦stadiul IRC  ¦stadiul IRC¦stadiul IRC ¦
 ¦incapacitatea adaptativa ¦           ¦             ¦           ¦            ¦
 ¦si capacitatea de munca  ¦           ¦             ¦           ¦            ¦
 ¦sunt stabilite conform   ¦           ¦             ¦           ¦            ¦
 ¦criteriilor pentru IRC.  ¦           ¦             ¦           ¦            ¦
 +----------------------------------------------------------------------------+
*ST*

    Glomerulonefrite subacute (rapid progresive)
    Sunt afectiuni severe care, in absenta tratamentului, evolueaza invariabil catre insuficienta renala terminala si deces in 6-24 de luni.
    Din cauza tratamentului imunosupresor agresiv, asociat cu plasmafereza si metode de substitutie a functiilor renale, sunt posibile remisiuni de durata. Alteori, supravietuirea este posibila cu ajutorul mijloacelor de substitutie a functiilor renale.
    Evaluarea periodica a bolnavilor este asemanatoare celei prezentate pentru glomerulonefritele acute, cu particularizarea probelor imunologice in functie de contextul etiologic. In plus, sunt indicate investigatii biologice pentru urmarirea toxicitatii potentiale a medicatiei imunosupresoare (hemograma, transaminaze serice) si analizele periodice adecvate gradului insuficientei renale.

    Diagnostic functional
    Bolnavii cu glomerulonefrita subacuta au deficienta functionala accentuata, cu incapacitate adaptativa de 70-89%, capacitate de munca pierduta in totalitate si gradul II de invaliditate. In functie de raspunsul la tratament, aprecierea ulterioara a deficientei functionale depinde de tendinta evolutiva a bolii:
   - pentru formele cu evolutie spre insuficienta renala cronica persistenta, vor fi aplicate criteriile stabilite pentru aceasta afectiune;
   - pentru formele cu evolutie favorabila spre remisiune, vor fi aplicate criteriile mentionate la glomerulonefritele acute, tinandu-se cont si de solicitarile locului de munca.

    Glomerulonefrite cronice
    Manifestarile clinice sunt variabile si constau in: sindrom nefritic cronic, sindrom nefrotic, HTA renoparenchimatoasa, insuficienta renala cronica si anomalii urinare asimptomatice.
    Evaluarea periodica trebuie sa cuprinda:
    - examen sumar de urina;
    - sediment urinar cantitativ;
    - examenul urinei din 24 de ore (proteinurie, albuminurie, uree, creatinina);
    - uree si creatinina serica;
    - estimarea filtrarii glomerulare (clearance-ul creatininei si al ureei endogene, formula Cokcroft-Gault sau ecuatia MDRD);
    - bilant hidroelectrolitic si acidobazic (sodiu, potasiu, bicarbonat in ser);
    - explorare imagistica renala (ecografie).

    Diagnostic functional
    Aprecierea deficientei functionale si a incapacitatii adaptative la bolnavii cu glomerulonefrite cronice depinde, in primul rand, de asocierea insuficientei renale cronice. In cazul prezentei acesteia, vor fi aplicate criteriile stabilite pentru IRC.
    Pentru cazurile care prezinta sindrom nefrotic, vor fi aplicate criteriile adecvate acestuia.
    Diagnosticul functional depinde, de asemenea, de:
    - etiologie (in formele secundare);
    - comorbiditati (hipertensiune arteriala, boli cardiovasculare, hiperparatiroidism secundar).
    Glomerulonefrite cronice fara declinul functiei renale (rata de filtrare glomerulara peste 60 mL/min/1,73 m²), cu proteinurie subnefrotica si fara hipertensiune arteriala, nu determina invaliditate. In functie de solicitarile specifice locului de munca, poate fi indicata schimbarea acestuia.

    Sindrom nefrotic
    Evaluarea functionala a pacientului cu sindrom nefrotic trebuie sa tina seama de contextul clinic in care acesta a aparut, de potentialul evolutiv spre insuficienta renala cronica, de severitatea tabloului clinico-biologic si de asocierea complicatiilor (altele decat IRC):
    - complicatii cardiovasculare (hipertensiune arteriala, insuficienta cardiaca prin hipervolemie);
    - tromboze venoase si arteriale;
    - complicatii infectioase;
    - complicatii metabolice;
    - complicatii ale terapiei (corticoizi, imunosupresoare).

    Elementele de apreciere a evolutiei sunt:
    1. Examenul clinic: curba ponderala, sindromul edematos, presiunea arteriala, manifestarile cardiovasculare (dispnee, raluri de staza pulmonara), manifestarile insuficientei renale;
    2. Explorari de laborator:
    - examenul sumar de urina;
    - sediment urinar cantitativ (Stansfeld-Webb, Addis-Hamburger);
    - proteinuria/24 de ore;
    - proteinemie, albuminemie si electroforeza proteinelor serice;
    - colesterolemia si trigliceridemia;
    - sindromul biologic inflamator (VSH, fibrinogen);
    - ureea si creatinina serica;
    - estimarea filtrarii glomerulare (clearance-ul creatininei si al ureei endogene, formule de calcul: Cockroft-Gault sau MDRD);
    - explorari adecvate diferitelor complicatii asociate.

    Diagnostic functional
    La bolnavii cu proteinurie nefrotica si/sau complicatii ale sindromului nefrotic, deficienta functionala este accentuata, incapacitatea adaptativa este de 70-89%, capacitatea de munca este in totalitate pierduta - gradul II de invaliditate.
    Dupa instalarea insuficientei renale cronice, deficienta functionala, incapacitatea si invaliditatea sunt apreciate conform criteriilor stabilite pentru aceasta.
    In perioadele de remisiune persistenta a sindromului nefrotic (proteinurie sub 1g/zi de cel putin 6 luni) si in absenta complicatiilor, deficienta functionala este medie, incapacitatea adaptativa este de 50-69%, capacitatea de munca este pierduta cel putin jumatate - gradul III. Poate fi prestata o activitate profesionala cu program redus, dar trebuie evitat efortul fizic mare, turele prelungite si de noapte, cat si expunerea la conditii de mediu extreme.

    NEFROPATII TUBULOINTERSTITIALE CRONICE

    Diagnostic functional
    Bolnavii cu nefropatii tubulointerstitiale obstructive sau de cauza medicala beneficiaza de concediu medical conform legii. Dupa expirarea acestei perioade, bolnavii pot prezenta invaliditate numai daca exista afectarea functiei renale sau co-morbiditati. In acest caz, deficienta functionala si incapacitatea adaptativa sunt apreciate conform criteriilor stabilite pentru insuficienta renala cronica, respectiv pentru patologia asociata.

    TUBERCULOZA RENO-URINARA
    Tuberculoza urinara este intotdeauna secundara unui focar de primoinfectie cel mai adesea pulmonar, mai rar osos, pleural sau ganglionar. Intre manifestarile clinice ale focarului primar si cele ale localizarii secundare renale, exista o perioada de latenta variabila intre o luna si 30 de ani.

    Diagnostic functional
    1. Cazurile confirmate de tuberculoza renourinara beneficiaza de concediu medical conform legii.
    2. Dupa expirarea perioadei de concediu medical:
    - daca evolutia este nefavorabila si criteriile de vindecare partial indeplinite, se considera deficienta functionala accentuata, cu incapacitate adaptativa 70-89%, capacitate de munca pierduta in totalitate - gradul II de invaliditate;
    - daca evolutia este favorabila si sunt indeplinite criteriile de vindecare, se considera deficienta functionala medie, cu incapacitate 50-69%, capacitate de munca cel putin jumatate pierduta - gradul II de invaliditate. In functie de solicitarile energetice si de conditiile ambientale ale locului de munca, bolnavul poate lucra cu program redus, fie pe locul de munca anterior, fie pe un alt loc de munca (cu indicatie pentru afectiunile renale).
    3. In cazul reluarii activitatii cu program redus, bolnavul este urmarit o perioada de 6-12 luni. Daca in aceasta perioada boala este stabilizata si nu sunt semne de afectare a functiei renale, nu exista reactivari si adaptarea la locul de munca este corespunzatoare, se poate trece la programul normal de activitate (deficienta usoara cu incapacitate adaptativa de 20-49%, capacitate de munca pastrata).

    RINICHIUL UNIC CHIRURGICAL/ FUNCTIONAL
    In aprecierea incapacitatii adaptative (a deficientei functionale - gradului de invaliditate) a pacientilor cu rinichi unic chirurgical, se va tine seama de urmatoarele:
    - un singur rinichi este capabil sa asigure toate functiile secretorii, homeostatice si endocrine ale unui adult activ in conditii normale;
    - adaptarea compensatorie renala in urma nefrectomiei unilaterale este rapida: 80% in primele 15 zile, 90% in primele 3 luni si 94% in primul an; ramane un deficit functional permanent de aproximativ 6%.
    In cazul in care nu sunt deja pensionari de invaliditate, pacientii nefrectomizati beneficiaza de concediu medical conform legii. Incapacitatea adaptativa (deficienta functionala) se apreciaza in functie de situatia rinichiului restant (tabelul II). Dupa instalarea insuficientei renale cronice, incapacitatea se stabileste conform criteriilor de la capitolul respectiv.

    Tabelul II. Criterii de apreciere a gradului de invaliditate la bolnavii cu rinichi unic chirurgical
*T*
 +----------------------------------------------------------------------------+
 ¦Patologia rinichiului    ¦Deficienta ¦Incapacitatea¦Capacitatea¦Gradul de   ¦
 ¦restant/asociata         ¦functionala¦adaptativa   ¦de munca   ¦invaliditate¦
 +-------------------------+-----------+-------------+-----------+------------¦
 ¦Absenta, functie normala ¦Usoara     ¦   20-49%    ¦Pastrata   ¦Nu se       ¦
 ¦                         ¦           ¦             ¦           ¦incadreaza  ¦
 ¦                         ¦           ¦             ¦           ¦in grad de  ¦
 ¦                         ¦           ¦             ¦           ¦invaliditate¦
 +-------------------------+-----------+-------------+-----------+------------¦
 ¦- litiaza asimptomatica  ¦Medie      ¦   50-69%    ¦Pierduta   ¦III         ¦
 ¦sau cu simptomatologie   ¦           ¦             ¦cel putin  ¦            ¦
 ¦minora                   ¦           ¦             ¦jumatate   ¦            ¦
 ¦- comorbiditati:         ¦           ¦             ¦           ¦            ¦
 ¦obezitate, HTA           ¦           ¦             ¦           ¦            ¦
 ¦- IRC compensata         ¦           ¦             ¦           ¦            ¦
 +-------------------------+-----------+-------------+-----------+------------¦
 ¦- pielonefrita cronica   ¦Accentuata ¦   70-89%    ¦Pierduta in¦II          ¦
 ¦- litiaza cu colici      ¦           ¦             ¦totalitate ¦            ¦
 ¦frecvente                ¦           ¦             ¦           ¦            ¦
 ¦- tuberculoza rinichiului¦           ¦             ¦           ¦            ¦
 ¦restant                  ¦           ¦             ¦           ¦            ¦
 ¦- stenoze ale cailor     ¦           ¦             ¦           ¦            ¦
 ¦urinare inferioare       ¦           ¦             ¦           ¦            ¦
 ¦- IRC decompensata       ¦           ¦             ¦           ¦            ¦
 +----------------------------------------------------------------------------+
*ST*

    MALFORMATIILE RENALE
    Malformatiile aparatului renourinar sunt alterari ale formei, pozitiei si structurii parenchimului renal si/sau ale cailor urinare, produse in timpul vietii intrauterine de factori variati (genetici, toxici, infectiosi sau factori de mediu). Acestea pot deveni manifeste in functie de severitatea alterarilor structurale si functionale si de complicatiile care le insotesc.
    Stabilirea incapacitatii (deficientei functionale) se face dupa criteriile mentionate pentru:
    - insuficienta renala cronica;
    - hipertensiunea arteriala.

    INSUFICIENTA RENALA CRONICA
    Insuficienta renala cronica (IRC) este un sindrom cronic progresiv, avand o evolutie stadiala progresiva catre exitus, in ani de zile. IRC reprezinta expresia functionala a diferitelor tipuri de boli cronice ale rinichiului. IRC presupune existenta de leziuni in ambii rinichi sau intr-un singur rinichi, cand acesta este unic. Prezenta de leziuni intr-un singur rinichi, celalalt fiind sanatos, exclude aparitia IRC, rinichiul sanatos compensand functiile pierdute ale rinichiului lezat.
    Boala cronica de rinichi (BCR) este un concept clinico-epidemiologic care permite clasificarea stadiala a nivelului de afectare globala a functiei renale, evaluata prin rata de filtrare glomerulara estimata prin masurarea clearence-ului creatininei endogene sau, indirect, prin ecuatii de predictie (Cockroft-Gault, MDRD), fara a inlocui diagnosticul entitatii anatomo-clinice de afectiune renala. Boala cronica de rinichi poate fi afirmata daca:
    1. rata de filtrare glomerulara este sub 60 mL/min/1,73 m² persistent peste 3 luni;
    2. exista indicatori de afectare a rinichiului persistenti peste 3 luni, cu filtrare glomerulara peste 60 mL/min/1,73 m².
    Indicatorii de afectare a rinichiului sunt unul sau mai multi dintre urmatorii:
    - anomalii ale examenelor de urina: proteinurie, albuminurie, hematurie, leucociturie, cilindrurie;
    - anomalii ale probelor sanguine: dezechilibru hidroelectrolitic, acidobazic;
    - anomalii imagistice ale rinichilor;
    - anomalii ale aspectului histologic renal (la biopsia renala).
    Diagnostic functional
    Deficienta functionala si incadrarea in grade de invaliditate a bolnavilor cu boala cronica de rinichi depinde de stadiul evolutiv al acesteia (tabelul III).
*T*
        Tabelul III. Invaliditatea determinata de boala cronica de rinichi
 +----------------------------------------------------------------------------+
 ¦Stadiul ¦Caracteristici ¦Deficienta ¦Incapaci- ¦Capacitatea¦Gradul de       ¦
 ¦BCR     ¦               ¦functionala¦tatea     ¦de munca   ¦invaliditate    ¦
 ¦        ¦               ¦           ¦adaptativa¦           ¦                ¦
 +--------+---------------+-----------+----------+-----------+----------------¦
 ¦Stadiile¦Afectarea      ¦Absenta*   ¦  1-19%*  ¦Pastrata   ¦Nu se incadreaza¦
 ¦1 si 2  ¦rinichiului cu ¦           ¦          ¦           ¦in grad de      ¦
 ¦        ¦RFG > 60 mL/min¦           ¦          ¦           ¦invaliditate    ¦
 ¦        ¦               +-----------+----------+-----------+----------------¦
 ¦        ¦               ¦Usoara*    ¦  20-49%* ¦Pastrata   ¦Nu se incadreaza¦
 ¦        ¦               ¦           ¦          ¦           ¦in grad de      ¦
 ¦        ¦               ¦           ¦          ¦           ¦invaliditate    ¦
 ¦        ¦               ¦           ¦          ¦           ¦(eventual,      ¦
 ¦        ¦               ¦           ¦          ¦           ¦schimbarea      ¦
 ¦        ¦               ¦           ¦          ¦           ¦locului de      ¦
 ¦        ¦               ¦           ¦          ¦           ¦munca)          ¦
 +--------+---------------+-----------+----------+-----------+----------------¦
 ¦Stadiul ¦RFG =          ¦Usoara*    ¦  20-49%* ¦Pastrata   ¦Nu se incadreaza¦
 ¦3       ¦30-59 mL/min   ¦           ¦          ¦           ¦in grad de      ¦
 ¦        ¦               ¦           ¦          ¦           ¦invaliditate    ¦
 ¦        ¦               ¦           ¦          ¦           ¦(eventual,      ¦
 ¦        ¦               ¦           ¦          ¦           ¦schimbarea      ¦
 ¦        ¦               ¦           ¦          ¦           ¦locului de      ¦
 ¦        ¦               ¦           ¦          ¦           ¦munca)          ¦
 ¦        ¦               +-----------+----------+-----------+----------------¦
 ¦        ¦               ¦Medie*     ¦  50-69%* ¦Pierduta   ¦III             ¦
 ¦        ¦               ¦           ¦          ¦cel putin  ¦                ¦
 ¦        ¦               ¦           ¦          ¦jumatate   ¦                ¦
 +--------+---------------+-----------+----------+-----------+----------------¦
 ¦Stadiul ¦RFG =          ¦Medie*     ¦  50-69%* ¦Pierduta   ¦III             ¦
 ¦4       ¦15-29 mL/min   ¦           ¦          ¦cel putin  ¦                ¦
 ¦        ¦               ¦           ¦          ¦jumatate   ¦                ¦
 ¦        ¦               +-----------+----------+-----------+----------------¦
 ¦        ¦               ¦Accentuata*¦  70-89%* ¦Pierduta in¦II              ¦
 ¦        ¦               ¦           ¦          ¦totalitate ¦                ¦
 +--------+---------------+-----------+----------+-----------+----------------¦
 ¦Stadiul ¦RFG <15 mL/min ¦Accentuata*¦  70-89%* ¦Pierduta in¦II              ¦
 ¦5       ¦sau dializa    ¦           ¦          ¦totalitate ¦                ¦
 ¦        ¦               +-----------+----------+-----------+----------------¦
 ¦        ¦               ¦Grava*     ¦ 90-100%* ¦Capacitatea¦I               ¦
 ¦        ¦               ¦           ¦          ¦de         ¦                ¦
 ¦        ¦               ¦           ¦          ¦autoservire¦                ¦
 ¦        ¦               ¦           ¦          ¦poate fi   ¦                ¦
 ¦        ¦               ¦           ¦          ¦pierduta in¦                ¦
 ¦        ¦               ¦           ¦          ¦totalitate*¦                ¦
 +----------------------------------------------------------------------------+
*ST*

    RFG - rata de filtrare glomerulara; * functie de simptomatologia clinica si de patologia asociata.
    Rata de filtrare glomerulara poate fi estimata prin formula Cockroft-Gault:
*T*
                 [140- varsta (ani)] x G (kg)
 CLcr(mL/ min) = ---------------------------- X 0,85 (daca subiectul este femeie)
                       72xScr(mg/dL)
*ST*

    IRC in stadiul de uremie depasita prin mijloace de epurare extrarenala (hemodializa, hemodiafiltrare, dializa peritoneala continua, ambulatorie sau automata)

    Diagnostic functional
    Evaluarea clinico-functionala a bolnavului cu insuficienta renala cronica tratata prin mijloace de epurare extrarenala va tine seama de urmatorii factori:
    - statusul functional renal;
    - stadiul evolutiv al bolii renale sau al bolii generale cu atingere renala care a dus la insuficienta renala cronica;
    - prezenta patologiei induse de hemodializa sau de dializa peritoneala;
    - profilul psihointelectual al pacientului;
    - nivelul responsabilitatilor sociale si familiale ale bolnavului;
    - motivatia pentru munca a deficientului si atitudinea familiei fata de caz;
    - resursele tehnice si financiare existente.
    Toti bolnavii cu IRC tratati prin metode de epurare extrarenala au functia renala grav afectata, cu o rata de filtrare a rinichilor nativi sub 5 mL/min. Exista o anemie renala severa (in absenta tratamentului concomitent cu eritropoietina umana), iar hiperparatiroidismul secundar se agraveaza progresiv. Exista elemente clinice si paraclinice ale comorbiditatilor. Principalele comorbiditati asociate insuficientei renale cronice in stadiul terminal (sub tratament prin epurare extrarenala) sunt enumerate in tabelul IV.

    Tabelul IV. Comorbiditati ale insuficientei renale cronice in stadiul terminal
*T*
 +----------------------------------------------------------------------------+
 ¦   I. Manifestari cardiovasculare    ¦ VI. Manifestari endocrino-metabolice ¦
 +-------------------------------------+--------------------------------------¦
 ¦- hipertensiune arteriala            ¦- hiperparatiroidism secundar         ¦
 +-------------------------------------+--------------------------------------¦
 ¦- hipotensiune arteriala             ¦- osteodistrofie renala               ¦
 +-------------------------------------+--------------------------------------¦
 ¦- pericarditauremica                 ¦- calcificari extraosoase             ¦
 +-------------------------------------+--------------------------------------¦
 ¦- cardiomiopatie uremica             ¦- malnutritie                         ¦
 +-------------------------------------+--------------------------------------¦
 ¦- aritmii                            ¦ VIII. Anomalii hidroelectrolitice si ¦
 ¦                                     ¦ acidobazice                          ¦
 +-------------------------------------+--------------------------------------¦
 ¦- arteroscleroza accelerata          ¦- hiperpotasemie (rar, hipopotasemie) ¦
 +-------------------------------------+--------------------------------------¦
 ¦- insuficienta cardiaca              ¦- hiponatremie/hipernatremie          ¦
 +-------------------------------------+--------------------------------------¦
 ¦II. Manifestari respiratorii         ¦- alterari ale izohidriei:            ¦
 +-------------------------------------+--------------------------------------¦
 ¦- plaman uremic                      ¦- mai frecvent, deshidratare          ¦
 ¦                                     ¦extracelulara                         ¦
 +-------------------------------------+--------------------------------------¦
 ¦III. Manifestari gastrointestinale   ¦- hiperhidratare                      ¦
 +-------------------------------------+--------------------------------------¦
 ¦- gastrita                           ¦- hipocalcemie (cu hipocalciurie)     ¦
 +-------------------------------------+--------------------------------------¦
 ¦- enterocolita                       ¦- hiperfosfatemie                     ¦
 +-------------------------------------+--------------------------------------¦
 ¦- sangerari digestive                ¦- acidoza metabolica                  ¦
 +-------------------------------------+--------------------------------------¦
 ¦IV. Manifestari hematologice         ¦VII. Patologie indusa de metodele de  ¦
 ¦                                     ¦epurare extrarenala                   ¦
 +-------------------------------------+--------------------------------------¦
 ¦- anemie                             ¦- sindrom de dezechilibru osmotic     ¦
 +-------------------------------------+--------------------------------------¦
 ¦- disfunctii leucocitare (disfunctie ¦- complicatii ale caii de abord       ¦
 ¦imunitara)                           ¦vascular (cateter/ fistula)           ¦
 +-------------------------------------+--------------------------------------¦
 ¦- diateze hemoragipare               ¦- complicatii infectioase/inflamatorii¦
 ¦                                     ¦ale dializei peritoneale (peritonita  ¦
 ¦                                     ¦acuta, peritonita sclerozanta)        ¦
 +-------------------------------------+--------------------------------------¦
 ¦V. Manifestari neurologice           ¦                                      ¦
 +-------------------------------------+--------------------------------------¦
 ¦- encefalopatie uremica              ¦- complicatii mecanice ale dializei   ¦
 ¦                                     ¦peritoneale (scurgeri de dializant,   ¦
 ¦                                     ¦hernii, ileus, hemoragii de perete    ¦
 ¦                                     ¦abdominal)                            ¦
 +-------------------------------------+--------------------------------------¦
 ¦- polineuropatie periferica          ¦- amiloidoza beta 2-microglobulinica  ¦
 ¦senzitivo-motorie                    ¦                                      ¦
 +----------------------------------------------------------------------------+
*ST*

    In functie de starea clinica generala a bolnavului si de asocierile comorbide, este propusa urmatoarea incadrare in grade de invaliditate (tabelul V).

    Tabelul V. Incadrarea in grade de invaliditate la bolnavii cu IRC tratati prin metode de epurare extrarenala
*T*
 +----------------------------------------------------------------------------+
 ¦Stadiul ¦Caracteristici ¦Deficienta ¦Incapaci- ¦Capacitatea¦Gradul de       ¦
 ¦BCR     ¦               ¦functionala¦tatea     ¦de munca   ¦invaliditate    ¦
 ¦        ¦               ¦           ¦adaptativa¦           ¦                ¦
 +--------+---------------+-----------+----------+-----------+----------------¦
 ¦Stabili-¦    Absenta    ¦ Usoara**  ¦ 20-49%** ¦Pastrata   ¦Nu se incadreaza¦
 ¦zata*   ¦               ¦           ¦          ¦           ¦in grad de      ¦
 ¦        ¦               ¦           ¦          ¦           ¦invaliditate    ¦
 ¦        ¦               ¦           ¦          ¦           ¦(schimbarea     ¦
 ¦        ¦               ¦           ¦          ¦           ¦locului de      ¦
 ¦        ¦               ¦           ¦          ¦           ¦munca) ***      ¦
 ¦        ¦               +-----------+----------+-----------+----------------¦
 ¦        ¦               ¦  Medie**  ¦ 50-69%** ¦Pierduta   ¦IIII***         ¦
 ¦        ¦               ¦           ¦          ¦cel putin  ¦                ¦
 ¦        ¦               ¦           ¦          ¦jumatate   ¦                ¦
 +--------+---------------+-----------+----------+-----------+----------------¦
 ¦Perioade¦    Eventual   ¦   Medie   ¦  50-69%  ¦Pierduta   ¦IIII***         ¦
 ¦de      ¦               ¦           ¦          ¦cel putin  ¦                ¦
 ¦alterare¦               ¦           ¦          ¦jumatate   ¦                ¦
 ¦eviden- ¦               ¦           ¦          ¦           ¦                ¦
 ¦tiate   ¦               ¦           ¦          ¦           ¦                ¦
 ¦clinic  ¦               ¦           ¦          ¦           ¦                ¦
 ¦si/sau  ¦               ¦           ¦          ¦           ¦                ¦
 ¦functio-¦               ¦           ¦          ¦           ¦                ¦
 ¦nal     ¦               ¦           ¦          ¦           ¦                ¦
 +--------+---------------+-----------+----------+-----------+----------------¦
 ¦Alterare¦    Prezenta   ¦Accentuata ¦  70-89%  ¦Pierduta in¦II              ¦
 ¦progre- ¦               ¦           ¦          ¦totalitate ¦                ¦
 ¦siva    ¦               ¦           ¦          ¦           ¦                ¦
 +--------+---------------+-----------+----------+-----------+----------------¦
 ¦Grav    ¦    Prezenta   ¦   Grava   ¦  90-100% ¦Pierduta in¦I               ¦
 ¦alterata¦               ¦           ¦          ¦totalitate ¦                ¦
 ¦        ¦               ¦           ¦          ¦cu I.A.P.  ¦                ¦
 +----------------------------------------------------------------------------+
*ST*
-----
    * Stare generala stabilizata:
    - criterii clinice:
      - apetit bun;
      - stare de nutritie buna;
      - tensiune arteriala normala (controlata terapeutic);
      - absenta comorbiditatilor manifeste clinic: polinevrita senzitivo-motorie, osteoartropatie renala, boala vasculara aterosclerotica (coronariana, cerebrala, vasculara), hipotensiune arteriala, malnutritie;
    - criterii paraclinice (functionale):
      - asigurarea unei echivalente de filtrare glomerulara de aproximativ 20 mL/min (calculata ca suma a functiei renale reziduale - clearance-ul renal echivalent al ureei si clearance-ul dialitic saptamanal al ureei - Kt/V);
      - uree sanguina < 150 mg/dL si creatininemie < 8mg/dL;
      - potasemie < 5 mEq/L;
      - bicarbonat seric > 20 mEq/L;
      - cresterea sau mentinerea constanta a hemoglobinei la valori > 10g/dL.
    ** In functie de toleranta clinica individuala. La evaluarea deficientei functionale vor fi luate in considerare si celelalte comorbiditati (de exemplu, insuficienta cardiaca, polinevrita, malnutritia).
    *** Activitate profesionala permisa:
      - solicitare energetica profesionala redusa;
      - pozitie sezanda;
      - conditii favorabile de microclimat (noxe, umiditate, curenti de aer, trepidatii etc.);
      - program de munca corespunzator (excluderea muncii in ture si a activitatilor secundare si ocazionale).
    Trebuie luate in considerare si elemente tehnice precum:
    - tipul dializei;
    - in cazul hemodializei: numar de sedinte/saptamana, durata sedintelor;
    - accesibilitatea centrului de dializa.

    IRC in stadiul de uremie depasita prin transplant renal

    Diagnostic functional
    Aprecierea deficientei functionale si a incapacitatii adaptative in vederea incadrarii in grade de invaliditate posttransplant renal va tine seama de:
    - gradul de restabilire a functiei renale;
    - evolutia postoperatorie;
    - existenta complicatiilor si a comorbiditatilor;
    - toxicitatea tratamentului imunosupresor.
    Bolnavii cu evolutie postoperatorie favorabila, in primele 6-12 luni dupa transplant, au deficienta functionala accentuata, cu incapacitate adaptativa de 70-89% si capacitate de munca pierduta in totalitate.
    Daca evolutia ulterioara este buna (grefa renala functionala care asigura mentinerea in limite normale a produsilor de retentie azotata in ser, absenta comorbiditatilor manifeste clinic, absenta complicatiilor terapiei imunosupresoare), bolnavul isi poate relua activitatea in conditii corespunzatoare de munca, cu program redus - deficienta functionala medie, incapacitate adaptativa 50-69%, capacitate de munca pejumatate pierduta.
    In cazul in care reluarea activitatii profesionale este posibila, se va tine seama de:
    - solicitarile specifice locului de munca;
    - profilul psihologic si situatia familiala a deficientului;
    - motivatia pentru munca a deficientului.
    Evolutia nefavorabila si prezenta complicatiilor post transplant renal pot duce la pierderea capacitatii de autoservire, cu deficiente functionale grave, incapacitate adaptiva 90-100%, cu incadrare in gradul I de invaliditate.
    Complicatiile posttransplant renal care conduc la invaliditate totala si la pierderea capacitatii de autoservire sunt:
    - disfunctia grefei renale;
    - rejetul cronic;
    - complicatii infectioase;
    - complicatii medicale ale bolii vasculare arterosclerotice: infarct miocardic, accidente cerebro-vasculare; HTA necontrolata;
    - diabet zaharat posttransplant;
    - insuficienta hepatica;
    - boli maligne.

                              5. BOLI DE NUTRITIE

                         CRITERII DE DIAGNOSTIC CLINIC,
                          DIAGNOSTIC FUNCTIONAL SI AL
                 CAPACITATII DE MUNCA IN DIABETUL ZAHARAT TIP 2

    Diabetul zaharat este o disfunctie metabolica cu etiologie multipla caracterizata de hiperglicemie cronica, cu modificarea metabolismului glucidic, lipidic si proteic care rezulta din defectele secretiei si/sau actiunii insulinei.
    Diabetul zaharat este asociat cu aparitia afectarii organice, cauzate de complicatiile cronice ale diabetului.
    Complicatiile cronice ale diabetului zaharat care determina deficienta functionala sunt:
    - nefropatia diabetica;
    - retinopatia diabetica;
    - polineuropatia diabetica;
    - leziunile trofice ale piciorului;
    - macroangiopatia, boala arteriala coronara, boala arteriala periferica, boala vasculara cerebrala;
    - osteoartropatia Charcot.
    Elementele de diagnostic functional sunt:
    - echilibrul metabolic;
    - prezenta (severitatea) complicatiilor.

    Criterii de diagnostic clinic, diagnostic functional si al capacitatii de munca in diabetul zaharat tip 2

*T*
 +----------------------------------------------------------------------------+
 ¦Afectiunea. Forma clinica¦Deficienta ¦Incapacitatea¦Capacitatea¦Gradul de   ¦
 ¦                         ¦functionala¦adaptativa   ¦de munca   ¦invaliditate¦
 +-------------------------+-----------+-------------+-----------+------------¦
 ¦Diabet zaharat tip 2,    ¦Fara       ¦    0-19%    ¦Pastrata   ¦Nu se       ¦
 ¦echilibrat, necomplicat  ¦deficienta ¦             ¦           ¦incadreaza  ¦
 ¦                         ¦functionala¦             ¦           ¦            ¦
 +-------------------------+-----------+-------------+-----------+------------¦
 ¦Diabet zaharat tip 2,    ¦Deficienta ¦    20-49%   ¦Pastrata   ¦Nu se       ¦
 ¦echilibrat, cu           ¦functionala¦             ¦           ¦incadreaza  ¦
 ¦complicatii cronice      ¦usoara     ¦             ¦           ¦            ¦
 ¦usoare:                  ¦(cand sunt ¦             ¦           ¦            ¦
 ¦- retinopatie de fond    ¦prezente   ¦             ¦           ¦            ¦
 ¦"background";            ¦cel mult   ¦             ¦           ¦            ¦
 ¦- neuropatie predominant ¦doua com-  ¦             ¦           ¦            ¦
 ¦senzitiva ± fruste       ¦plicatii)  ¦             ¦           ¦            ¦
 ¦deficite motorii;        +-----------+-------------+-----------+------------¦
 ¦- boala coronariana      ¦Deficienta ¦    50-69%   ¦Pierduta   ¦Gradul III  ¦
 ¦ischemica usoara (conform¦functionala¦             ¦cel putin  ¦            ¦
 ¦criteriilor);            ¦medie (cand¦             ¦jumatate   ¦            ¦
 ¦- boala arteriala        ¦sunt       ¦             ¦           ¦            ¦
 ¦aterosclerotica          ¦prezente   ¦             ¦           ¦            ¦
 ¦periferica stadiul I     ¦cel putin  ¦             ¦           ¦            ¦
 ¦Fontaine;                ¦trei       ¦             ¦           ¦            ¦
 ¦- sechele usoare ale     ¦complicatii¦             ¦           ¦            ¦
 ¦bolii vasculare cerebrale¦           ¦             ¦           ¦            ¦
 ¦(conform criteriilor)    ¦           ¦             ¦           ¦            ¦
 +-------------------------+-----------+-------------+-----------+------------¦
 ¦Diabet zaharat tip 2,    ¦Deficienta ¦    50-69%   ¦Pierduta   ¦Gradul III  ¦
 ¦echilibrat, asociat cu   ¦functionala¦             ¦cel putin  ¦            ¦
 ¦cel putin una dintre     ¦medie      ¦             ¦jumatate   ¦            ¦
 ¦complicatiile cronice de ¦           ¦             ¦           ¦            ¦
 ¦severitate moderata:     ¦           ¦             ¦           ¦            ¦
 ¦- retinopatie            ¦           ¦             ¦           ¦            ¦
 ¦preproliferativa;        ¦           ¦             ¦           ¦            ¦
 ¦- neuropatie motorie cu  ¦           ¦             ¦           ¦            ¦
 ¦deficit motor predominant¦           ¦             ¦           ¦            ¦
 ¦distal, cu tulburari de  ¦           ¦             ¦           ¦            ¦
 ¦sensibilitate;           ¦           ¦             ¦           ¦            ¦
 ¦- boala coronariana      ¦           ¦             ¦           ¦            ¦
 ¦aterosclerotica (care    ¦           ¦             ¦           ¦            ¦
 ¦determina deficienta     ¦           ¦             ¦           ¦            ¦
 ¦functionala medie,       ¦           ¦             ¦           ¦            ¦
 ¦conform criteriilor);    ¦           ¦             ¦           ¦            ¦
 ¦- cardiomiopatia         ¦           ¦             ¦           ¦            ¦
 ¦diabetica, diagnosticata ¦           ¦             ¦           ¦            ¦
 ¦ecografic, cu disfunctie ¦           ¦             ¦           ¦            ¦
 ¦sistolica moderata;      ¦           ¦             ¦           ¦            ¦
 ¦- boala arteriala        ¦           ¦             ¦           ¦            ¦
 ¦periferica               ¦           ¦             ¦           ¦            ¦
 ¦aterosclerotica stadiul  ¦           ¦             ¦           ¦            ¦
 ¦II Fontaine (conform     ¦           ¦             ¦           ¦            ¦
 ¦criteriilor);            ¦           ¦             ¦           ¦            ¦
 ¦- sechele ale bolii      ¦           ¦             ¦           ¦            ¦
 ¦vasculare cerebrale care ¦           ¦             ¦           ¦            ¦
 ¦determina deficienta     ¦           ¦             ¦           ¦            ¦
 ¦functionala medie,       ¦           ¦             ¦           ¦            ¦
 ¦conform criteriilor);    ¦           ¦             ¦           ¦            ¦
 ¦- nefropatie diabetica   ¦           ¦             ¦           ¦            ¦
 ¦incipienta, cu           ¦           ¦             ¦           ¦            ¦
 ¦microalbu-minurie        ¦           ¦             ¦           ¦            ¦
 ¦persistenta              ¦           ¦             ¦           ¦            ¦
 ¦(30-300 mg / 24 de ore); ¦           ¦             ¦           ¦            ¦
 ¦- piciorul diabetic, fara¦           ¦             ¦           ¦            ¦
 ¦prabusirea boltii        ¦           ¦             ¦           ¦            ¦
 ¦plantare, fara ulceratii;¦           ¦             ¦           ¦            ¦
 +-------------------------+-----------+-------------+-----------+------------¦
 ¦Diabet zaharat tip 2,    ¦Deficienta ¦    70-89%   ¦Pierduta in¦Gradul II   ¦
 ¦echilibrat, asociat cu   ¦functionala¦             ¦totalitate ¦            ¦
 ¦cel putin una dintre     ¦accentuata ¦             ¦           ¦            ¦
 ¦complicatiile cronice    ¦           ¦             ¦           ¦            ¦
 ¦severe:                  ¦           ¦             ¦           ¦            ¦
 ¦- retinopatie            ¦           ¦             ¦           ¦            ¦
 ¦proliferativa;           ¦           ¦             ¦           ¦            ¦
 ¦- neuropatie periferica  ¦           ¦             ¦           ¦            ¦
 ¦motorie (parapareza,     ¦           ¦             ¦           ¦            ¦
 ¦tetrapareza, cu tulburari¦           ¦             ¦           ¦            ¦
 ¦de sensibilitate);       ¦           ¦             ¦           ¦            ¦
 ¦- boala coronariana      ¦           ¦             ¦           ¦            ¦
 ¦aterosclerotica (care    ¦           ¦             ¦           ¦            ¦
 ¦determina deficienta     ¦           ¦             ¦           ¦            ¦
 ¦functionala accentuata,  ¦           ¦             ¦           ¦            ¦
 ¦conform criteriilor);    ¦           ¦             ¦           ¦            ¦
 ¦- cardiomiopatia         ¦           ¦             ¦           ¦            ¦
 ¦diabetica cu disfunctie  ¦           ¦             ¦           ¦            ¦
 ¦sistolica severa;        ¦           ¦             ¦           ¦            ¦
 ¦- disfunctie cardiaca    ¦           ¦             ¦           ¦            ¦
 ¦autonoma manifestata     ¦           ¦             ¦           ¦            ¦
 ¦prin: tahicardie fixa,   ¦           ¦             ¦           ¦            ¦
 ¦ischemie miocardica      ¦           ¦             ¦           ¦            ¦
 ¦silentioasa, tulburari de¦           ¦             ¦           ¦            ¦
 ¦ritm, hipotensiune       ¦           ¦             ¦           ¦            ¦
 ¦ortostatica;             ¦           ¦             ¦           ¦            ¦
 ¦- boala arteriala        ¦           ¦             ¦           ¦            ¦
 ¦periferica               ¦           ¦             ¦           ¦            ¦
 ¦aterosclerotica stadiul  ¦           ¦             ¦           ¦            ¦
 ¦III Fontaine (conform    ¦           ¦             ¦           ¦            ¦
 ¦criteriilor);            ¦           ¦             ¦           ¦            ¦
 ¦- nefropatia diabetica   ¦           ¦             ¦           ¦            ¦
 ¦clinic manifesta,        ¦           ¦             ¦           ¦            ¦
 ¦proteinurie clinica      ¦           ¦             ¦           ¦            ¦
 ¦(albuminurie peste       ¦           ¦             ¦           ¦            ¦
 ¦300 mg/24 ore), rata     ¦           ¦             ¦           ¦            ¦
 ¦filtrarii glomerulare    ¦           ¦             ¦           ¦            ¦
 ¦(RFG) < 30 ml/ minut;    ¦           ¦             ¦           ¦            ¦
 ¦- piciorul diabetic cu   ¦           ¦             ¦           ¦            ¦
 ¦ulcere trofice;          ¦           ¦             ¦           ¦            ¦
 ¦- sechele severe ale     ¦           ¦             ¦           ¦            ¦
 ¦bolii vasculare cerebrale¦           ¦             ¦           ¦            ¦
 ¦(conform criteriilor).   ¦           ¦             ¦           ¦            ¦
 +-------------------------+-----------+-------------+-----------+------------¦
 ¦Diabet zaharat tip 2,    ¦Deficienta ¦   90-100%   ¦Capacitate ¦Gradul I    ¦
 ¦asociat cu complicatii   ¦functionala¦             ¦de         ¦            ¦
 ¦cronice grave:           ¦grava      ¦             ¦autoservire¦            ¦
 ¦- boala coronariana      ¦           ¦             ¦pierduta   ¦            ¦
 ¦aterosclerotica,         ¦           ¦             ¦           ¦            ¦
 ¦cardiomiopatie diabetica ¦           ¦             ¦           ¦            ¦
 ¦cu insuficienta cardiaca,¦           ¦             ¦           ¦            ¦
 ¦disfunctie sistolica     ¦           ¦             ¦           ¦            ¦
 ¦severa (fractie de       ¦           ¦             ¦           ¦            ¦
 ¦ejectie FE < 30%);       ¦           ¦             ¦           ¦            ¦
 ¦- boala arteriala        ¦           ¦             ¦           ¦            ¦
 ¦periferica stadiul IV    ¦           ¦             ¦           ¦            ¦
 ¦Fontaine (conform        ¦           ¦             ¦           ¦            ¦
 ¦criteriilor);            ¦           ¦             ¦           ¦            ¦
 ¦- insuficienta renala    ¦           ¦             ¦           ¦            ¦
 ¦cronica terminala,       ¦           ¦             ¦           ¦            ¦
 ¦proteinurie variabila,   ¦           ¦             ¦           ¦            ¦
 ¦RFG <15 ml/ minut,       ¦           ¦             ¦           ¦            ¦
 ¦eventual dializa;        ¦           ¦             ¦           ¦            ¦
 ¦- sechele grave ale bolii¦           ¦             ¦           ¦            ¦
 ¦vasculare cerebrale      ¦           ¦             ¦           ¦            ¦
 ¦(conform criteriilor);   ¦           ¦             ¦           ¦            ¦
 ¦- dezlipire de retina cu ¦           ¦             ¦           ¦            ¦
 ¦pierderea completa si    ¦           ¦             ¦           ¦            ¦
 ¦definitiva a vederii.    ¦           ¦             ¦           ¦            ¦
 +----------------------------------------------------------------------------+
*ST*

    Criterii de diagnostic clinic, diagnostic functional si al capacitatii de munca in diabetul zaharat tip 1
*T*
 +----------------------------------------------------------------------------+
 ¦Afectiunea. Forma clinica¦Deficienta ¦Incapacitatea¦Capacitatea¦Gradul de   ¦
 ¦                         ¦functionala¦adaptativa   ¦de munca   ¦invaliditate¦
 +-------------------------+-----------+-------------+-----------+------------¦
 ¦Diabet zaharat tip 1,    ¦Deficienta ¦   20-49%    ¦Pastrata   ¦Nu se       ¦
 ¦echilibrat, necomplicat  ¦functionala¦             ¦           ¦incadreaza  ¦
 ¦si diabetul zaharat      ¦usoara     ¦             ¦           ¦Cu          ¦
 ¦tip 2, tratat cu insulina¦           ¦             ¦           ¦recomandarea¦
 ¦la care sunt necesare    ¦           ¦             ¦           ¦de schimbare¦
 ¦doua prize de insulina   ¦           ¦             ¦           ¦a locului de¦
 ¦                         ¦           ¦             ¦           ¦munca, in   ¦
 ¦                         ¦           ¦             ¦           ¦aceeasi     ¦
 ¦                         ¦           ¦             ¦           ¦profesie    ¦
 ¦                         ¦           ¦             ¦           ¦- fara ture,¦
 ¦                         ¦           ¦             ¦           ¦cu pauze de ¦
 ¦                         ¦           ¦             ¦           ¦masa; se    ¦
 ¦                         ¦           ¦             ¦           ¦contraindica¦
 ¦                         ¦           ¦             ¦           ¦munca la    ¦
 ¦                         ¦           ¦             ¦           ¦inaltime,   ¦
 ¦                         ¦           ¦             ¦           ¦langa foc,  ¦
 ¦                         ¦           ¦             ¦           ¦cu unelte in¦
 ¦                         ¦           ¦             ¦           ¦miscare si  ¦
 ¦                         ¦           ¦             ¦           ¦in alte     ¦
 ¦                         ¦           ¦             ¦           ¦locuri de   ¦
 ¦                         ¦           ¦             ¦           ¦munca in    ¦
 ¦                         ¦           ¦             ¦           ¦care poate  ¦
 ¦                         ¦           ¦             ¦           ¦fi          ¦
 ¦                         ¦           ¦             ¦           ¦periclitata ¦
 ¦                         ¦           ¦             ¦           ¦siguranta   ¦
 ¦                         ¦           ¦             ¦           ¦proprie si a¦
 ¦                         ¦           ¦             ¦           ¦celorlalti. ¦
 +-------------------------+-----------+-------------+-----------+------------¦
 ¦Diabet zaharat tip 1,    ¦Deficienta ¦    50-69%   ¦Pierduta   ¦Gradul III  ¦
 ¦echilibrat, tratat cu    ¦functionala¦             ¦cel putin  ¦            ¦
 ¦insulina, asociat cu     ¦medie (cand¦             ¦jumatate   ¦            ¦
 ¦complicatii cronice      ¦sunt       ¦             ¦           ¦            ¦
 ¦usoare:                  ¦prezente   ¦             ¦           ¦            ¦
 ¦- retinopatie de fond    ¦toate      ¦             ¦           ¦            ¦
 ¦"background";            ¦complica-  ¦             ¦           ¦            ¦
 ¦- neuropatie predominant ¦tiile)     ¦             ¦           ¦            ¦
 ¦senzitiva ± fruste       ¦           ¦             ¦           ¦            ¦
 ¦deficite motorii;        ¦           ¦             ¦           ¦            ¦
 ¦- boala coronariana      ¦           ¦             ¦           ¦            ¦
 ¦ischemica usoara (conform¦           ¦             ¦           ¦            ¦
 ¦criteriilor);            ¦           ¦             ¦           ¦            ¦
 ¦- boala arteriala        ¦           ¦             ¦           ¦            ¦
 ¦aterosclerotica          ¦           ¦             ¦           ¦            ¦
 ¦periferica stadiul I     ¦           ¦             ¦           ¦            ¦
 ¦Fontaine;                ¦           ¦             ¦           ¦            ¦
 ¦- sechele usoare ale     ¦           ¦             ¦           ¦            ¦
 ¦bolii vasculare cerebrale¦           ¦             ¦           ¦            ¦
 ¦(conform criteriilor).   ¦           ¦             ¦           ¦            ¦
 +-------------------------+-----------+-------------+-----------+------------¦
 ¦Diabet zaharat tip 1,    ¦Deficienta ¦    50-69%   ¦Pierduta   ¦Gradul III  ¦
 ¦tratat cu insulina,      ¦functionala¦             ¦cel putin  ¦            ¦
 ¦echilibrat, asociat cu   ¦medie      ¦             ¦jumatate   ¦            ¦
 ¦cel putin una dintre     ¦           ¦             ¦           ¦            ¦
 ¦complicatiile cronice de ¦           ¦             ¦           ¦            ¦
 ¦severitate moderata:     ¦           ¦             ¦           ¦            ¦
 ¦- retinopatie            ¦           ¦             ¦           ¦            ¦
 ¦preproliferativa;        ¦           ¦             ¦           ¦            ¦
 ¦- neuropatie motorie cu  ¦           ¦             ¦           ¦            ¦
 ¦deficit motor predominant¦           ¦             ¦           ¦            ¦
 ¦distal, cu tulburari de  ¦           ¦             ¦           ¦            ¦
 ¦sensibilitate;           ¦           ¦             ¦           ¦            ¦
 ¦- boala coronariana      ¦           ¦             ¦           ¦            ¦
 ¦aterosclerotica (care    ¦           ¦             ¦           ¦            ¦
 ¦determina deficienta     ¦           ¦             ¦           ¦            ¦
 ¦functionala medie conform¦           ¦             ¦           ¦            ¦
 ¦criteriilor);            ¦           ¦             ¦           ¦            ¦
 ¦- cardiomiopatia         ¦           ¦             ¦           ¦            ¦
 ¦diabetica, diagnosticata ¦           ¦             ¦           ¦            ¦
 ¦ecografic, cu disfunctie ¦           ¦             ¦           ¦            ¦
 ¦sistolica moderata;      ¦           ¦             ¦           ¦            ¦
 ¦- boala arteriala        ¦           ¦             ¦           ¦            ¦
 ¦periferica               ¦           ¦             ¦           ¦            ¦
 ¦aterosclerotica stadiul  ¦           ¦             ¦           ¦            ¦
 ¦II Fontaine (conform     ¦           ¦             ¦           ¦            ¦
 ¦criteriilor);            ¦           ¦             ¦           ¦            ¦
 ¦- sechele ale bolii      ¦           ¦             ¦           ¦            ¦
 ¦vasculare cerebrale care ¦           ¦             ¦           ¦            ¦
 ¦determina deficienta     ¦           ¦             ¦           ¦            ¦
 ¦functionala medie conform¦           ¦             ¦           ¦            ¦
 ¦criteriilor);            ¦           ¦             ¦           ¦            ¦
 ¦- nefropatie diabetica   ¦           ¦             ¦           ¦            ¦
 ¦incipienta, cu microalbu-¦           ¦             ¦           ¦            ¦
 ¦minurie persistenta      ¦           ¦             ¦           ¦            ¦
 ¦30-300 mg / 24 de ore);  ¦           ¦             ¦           ¦            ¦
 ¦- piciorul diabetic, fara¦           ¦             ¦           ¦            ¦
 ¦prabusirea boltii        ¦           ¦             ¦           ¦            ¦
 ¦plantare, fara ulceratii.¦           ¦             ¦           ¦            ¦
 +-------------------------+-----------+-------------+-----------+------------¦
 ¦Diabet zaharat tip 1,    ¦Deficienta ¦    70-89%   ¦Pierduta   ¦Gradul II   ¦
 ¦tratat cu insulina,      ¦functionala¦             ¦in         ¦            ¦
 ¦echilibrat, asociat cu   ¦accentuata ¦             ¦totalitate ¦            ¦
 ¦cel putin una dintre     ¦           ¦             ¦           ¦            ¦
 ¦complicatiile cronice    ¦           ¦             ¦           ¦            ¦
 ¦severe:                  ¦           ¦             ¦           ¦            ¦
 ¦- retinopatie            ¦           ¦             ¦           ¦            ¦
 ¦proliferativa;           ¦           ¦             ¦           ¦            ¦
 ¦- neuropatie periferica  ¦           ¦             ¦           ¦            ¦
 ¦motorie (parapareza,     ¦           ¦             ¦           ¦            ¦
 ¦tetrapareza, cu tulburari¦           ¦             ¦           ¦            ¦
 ¦de sensibilitate);       ¦           ¦             ¦           ¦            ¦
 ¦- boala coronariana      ¦           ¦             ¦           ¦            ¦
 ¦aterosclerotica (care    ¦           ¦             ¦           ¦            ¦
 ¦determina deficienta     ¦           ¦             ¦           ¦            ¦
 ¦functionala accentuata,  ¦           ¦             ¦           ¦            ¦
 ¦conform criteriilor);    ¦           ¦             ¦           ¦            ¦
 ¦- cardiomiopatia         ¦           ¦             ¦           ¦            ¦
 ¦diabetica cu disfunctie  ¦           ¦             ¦           ¦            ¦
 ¦sistolica severa;        ¦           ¦             ¦           ¦