Chronic decompensated

Both carvedilol and labetalol are contraindicated in patients with hypersensitivity to the drag, bronchial asthma, decompensated heart failure, and severe bradycardia The drugs are used cautiously in patients with drag-controlled congestive heart failure, chronic bronchitis, impaired hepatic or cardiac function, in those with diabetes, and during pregnancy (Category C) and lactation. 

The phrase acute heart failure (AHF) is used to signify either an acute decompensation of a patient with a history of chronic heart failure or to refer to a patient presenting with new-onset HF symptoms. Terms commonly associated with HF, such as cardiomyopathy and LV dysfunction, are not equivalent to HF but describe possible structural or functional reasons for the development of HF. 

The most serious side effects early in ACS are hypotension, bradycardia, and heart block. Initial acute administration of //-blockers is not appropriate for patients presenting with decompensated heart failure. However, therapy may be attempted in most patients before hospital discharge after treatment of acute heart failure. Diabetes mellitus is not a contraindication to //-blocker use. If possible intolerance to //-blockers is a concern (e.g., due to chronic obstructive pulmonary disease), a short-acting drug such as metoprolol or esmolol should be administered IV initially. 

Approximately 20% of patients with chronic HBV infection develop complications of decompensated cirrhosis, including hepatic insufficiency and portal hypertension. HBV is a risk factor for development of hepatocellular carcinoma. 

The most common symptom of chronic HCV infection is persistent fatigue. An estimated 20% of patients with chronic HCV infection will develop cirrhosis and half of those patients will progress to decompensated cirrhosis or hepatocellular carcinoma. 

Digoxin exhibits strong systolic action and slows heart rate. It is removed from the organism faster than digitoxin. It is used from chronic cardiac insufficiency in decompensated valvular disease of the heart, myocardium overload in arterial hypertension, tachycardia, ventricular fibrillation, and other analogous situations. Synonyms of this drug are cedoxin, lanacordin, lanoxin, and others. 

Strophanthin is used in severe cardiovascular insufficiency, in particular after myocardial infarction, for chronic cardiac insufficiency, cardiac decompensation, supraventricular tachycardia, and ventricular arrhythmia. Synonyms of this drug are combetin, strofopan, and others. 

Tipranavir coadministered with ritonavir 200 mg has been associated with reports of clinical hepatitis and hepatic decompensation including some fatalities. Extra vigilance is warranted in patients with chronic hepatitis B or hepatitis C coinfection because these patients have an increased risk of hepatotoxicity. 

Hepatic function impairment Patients with chronic hepatitis B or hepatitis C coinfection or elevations in transaminases are at an approximately 2.5-fold risk for developing further transaminase elevations or hepatic decompensation. Carcinogenesis Long-term animal carcinogenicity bioassays with tipranavir and tipranavir/ritonavir are currently in progress. 

Hepatic decompensation (Child-Pugh score greater than 6 class B and C) in cirrhotic chronic hepatitis C monoinfected patients before or during treatment, or... 

Hepatic function impairment Chronic hepatitis C patients with cirrhosis may be at risk of hepatic decompensation and death when treated with alfa interferons. 

Zanamivir is contraindicated in individuals with severe or decompensated chronic obstructive lung disease or asthma because it has not been shown to be effective in these individuals and can cause serious adverse pulmonary reactions. Individuals with mild to moderate asthma may have a decline in lung function when taking zanamivir. The safety and efficacy of this medication have not been determined in individuals with severe renal insufficiency. No clinically significant drug interactions have been reported. Zanamivir does not decrease the effectiveness of the influenza vaccine. 

About one-third of all adults suffer at some time in their lives from states of anxiety and tension that can considerably impair their quality of life (Lader, 1981). The majority of these individuals seek medical help sooner or later, about half of them within a year after the outbreak of the symptoms. Statistics from the UK show that some 10% of these patients are referred to a psychiatrist. Psychiatrists consequently only see a small proportion of patients suffering from states of anxiety, generally the rather severe, chronic, neurotic, perhaps socially decompensated cases. The remaining 90% of patients mostly turn to their general practitioner they are predominantly persons who react to burdensome circumstances with acute anxiety or stress symptoms. States of this nature are generally known to wane after some 6 weeks, although this remission can be facilitated by taking a tranquillizer. 

Perrillo, R., C. Tamburro, P. Regenstein, et al., Low-dose titratable interferon alfa in decompensated liver disease caused by chronic infection with hepatitis B virus. Gastroenterology, 1995.109 908-16. 

Carvedilol Competitively blocks receptors (see Chapter 10) Slows heart rate reduces blood pressure poorly understood effects reduces heart failure mortality Chronic heart failure To slow progression reduce mortality in moderate and severe heart failure many other indications in Chapter 10. Oral duration 10-12 h Toxicity Bronchospasm, bradycardia, atrioventricular block, acute cardiac decompensation t see Chapter 10 for other toxicities and interactions... 

Dobutamine Betai-selective agonist t increases cAMP synthesis Increases cardiac contractility, output Acute decompensated heart failure intermittent therapy in chronic failure reduces symptoms IV only duration a few minutes Toxicity Arrhythmias. Interactions Additive with other sympathomimetics... 

Mitral stenosis is seen typically as a consequence of chronic rheumatic fever. Isolated congenital mitral stenosis is very rare and not suitable for balloon valvuloplasty. Clinical symptoms depend on the degree of obstruction. Dyspnea, atrial fibrillation, embolic events, pulmonary edema, and right heart decompensation may occur and are all indications for treatment. Surgery and catheter intervention provide similar results. Balloon valvuloplasty produces best results in patients with little or no calcification of the mitral leaflets (20—23). 

VecchiM, FolliC, Donato MF, Formenti S, Arosio E, deFranchisR. High rate of positive anti-tissue transglutaminase antibodies in chronic liver disease. Role of liver decompensation and of the antigen source. Scand J Gastroenterol 2003 38 50-54. 

Some combination of two or more of the negative symptoms listed above have been present for the preceding 12 months and always were present during periods of clinical stability (including chronic psychotic states). These symptoms may or may not be detectable during transient episodes of acute psychotic disorganization or decompensation... 

Drugs with an acute positive inotropic action (e.g., catecholamines or phosphodiesterase inhibitors) may be of transient help in sudden decompensation but must not be given in chronic congestive failure. 

In chronic liver disease, PT may increase over a period of weeks or months to values up to about 30 seconds as the liver decompensates. In patients with acute liver failure the values may increase to over 100 seconds within a few hours. 

Table 4.3 summarises the potential extent of change in each individual LFT for an example patient with compensated chronic liver disease, decompensated chronic liver disease, hepatitis, hyperacute liver failure and cholestasis. This is a snapshot of the changes that may occur in these conditions however, if each patient s results were observed over time a range of results would be seen. 

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