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La dysfonction diastolique du ventricule gauche

Dans le document en fr (Page 49-54)

CARDIAQUE A FRACTION D'EJECTION PRESERVEE

C. La dysfonction diastolique du ventricule gauche

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1- Approche de lÕAmerican Heart Association

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Figure 11. PrŽvalence de lÕinsuffisance cardiaque en fonction de lÕorigine gŽographique. Les parties noires des

histogrammes indiquent la prŽvalence de lÕinsuffisance cardiaque, les parties blanches indiquent la proportion de cas avec une fraction dÕŽjection conservŽe. (dÕapr•s Hogg, 2004)

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B. Impact de lÕ‰ge

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