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Hemodynamic response to beta-blockers and prediction of clinical efficacy in the primary prophylaxis of variceal bleeding in patients with cirrhosis

Hemodynamic response to beta-blockers and prediction of clinical efficacy in the primary prophylaxis of variceal bleeding in patients with cirrhosis

Hepatology 38(4 Suppl 1): 296A

Studies dealing with the prevention of rebleeding have shown that hemodynamic response to pharmacological treatment of portal hypertension is adequate when the hepatic venous pressure gradient (HVPG) decreases to ?12mmHg or by ?20% from baseline. With beta-blockers these targets are achieved in only around 30% of cases. However, even with such a high rate of poor hemodynamic response, variceal bleeding occurs in few patients when beta-blockers are used for primary prophylaxis (around 15%). The aim of this study was to assess whether the cut-off value to define response in primary prophylaxis may be defined more accurately and to investigate whether the acute response to beta-blockers may predict evolution (avoiding a second study). METHODS: A total of 101 cirrhotic patients with large varices and without previous bleeding were investigated. A baseline hemodynamic study was performed in all patients. After, initial measurements, propranolol was administered in 55 patients (0.15mg/kg i.v.) and measurements were repeated 20 minutes later. Subsequently, nadolol was chronically administered to prevent variceal bleeding. A second hemodynamic study was performed 1 to 3 months later in 72 patients. RESULTS: During a mean follow-up of 37 months, 17% of patients had a bleeding episode and 19% died. There was a significant correlation between acute and chronic hemodynamic response to beta-blockers (r=0.6, P=0.001). Using ROC curve a decrease of HVPG ?10% from baseline was the better cut-off point to predict bleeding, both for acute and chronic studies. Hemodynamic responders (defining response as a decrease of HVPG to ?12mmHg or ?10%), had a significantly lower probability of bleeding (P?0.01) and of requiring hospital admission because decompensations of cirrhosis, while survival probability was higher, both after acute and chronic beta-blocker administration. The HVPG decreased ?20% in 38% of cases and decreased ?10% in 74% (P?0.001) after acute beta-blocker. These figures were 31% vs 68% (P?0.001) after a chronic administration. CONCLUSIONS: Our results suggest that: 1) A decrease of HVPG ?10% from baseline may be the target to identify hemodynamic responders in primary prophylaxis of variceal bleeding; 2) Acute hemodynamic response to beta-blockers may provide an accurate prognostic information on long-term risk of variceal bleeding.

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Accession: 035023989

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DOI: 10.1016/s0270-9139(03)80334-8

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