Prognostic value of acute hemodynamic response to i.v. propranolol in patients with cirrhosis and portal hypertension

BNBackground/Aims: Cirrhotic patients chronically treated with beta-blockers who achieve a decrease of hepatic venous pressure gradient (HVPG) >= 20% from baseline or to <= 12 mmHg have a marked reduction of first bleeding or re-bleeding. However, two HVPG measurements are needed to evaluate response. This study was aimed at investigating the predictive role of acute HVPG response to i.v. propranolol for bleeding and survival. Methods: We retrospectively studied 166 cirrhotic patients with varices with HVPG response to i.v. propranolol (0.15 mg/kg). All patients subsequently received non-selective beta-blockers to prevent first bleeding (n = 78) or re-bleeding (n = 88). Results:Thirty-seven patients developed a portal hypertension-related bleeding over 2 years of follow-up. Decrease (12%) in HVPG was the best cut-off for bleeding risk discrimination. This parameter was used to classify patients in responders (it = 95) and non-responders (it = 71). In primary prophylaxis (54 responders vs. 24 non-responders) the actuarial probability of bleeding was half in responders than in non-responders (12% vs. 23% at 2 years; ns). In secondary prophylaxis (41 responders vs. 47 non-responders) a good hemodynamic response was also significantly and independently associated with a 50%, decrease in the probability of re-bleeding (23%, at 2 years vs. 46% in non-responders; p = 0.032.) and a better survival (95% vs. 65%; p = 0.003). Conclusion: The evaluation of acute HVPG response to i.v. propranolol before initiating secondary prophylaxis for variceal bleeding is a useful tool in predicting the efficacy of non-selective beta-blockers. If adequately validated, this might be a more cost-effective strategy than the chronic evaluation of HVPG response and might be useful to guide therapeutic decisions in these patients. (C) 2009 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.