Development of hyperdynamic circulation and response to -blockers in compensated cirrhosis with portal hypertension

Nonselective beta- blockers are useful to prevent bleeding in patients with cirrhosis and large varices but not to prevent the development of varices in those with compensated cirrhosis and portal hypertension ( PHT). This suggests that the evolutionary stage of PHTmay influence the response to b- blockers. To characterize the hemodynamic profile of each stage of PHT in compensated cirrhosis and the response to b- blockers according to stage, we performed a prospective, multicenter ( tertiary care setting), cross- sectional study. Hepatic venous pressure gradient ( HVPG) and systemic hemodynamic were measured in 273 patients with compensated cirrhosis before and after intravenous propranolol ( 0.15 mg/ kg): 194 patients had an HVPG >= 10 mm Hg ( clinically significant PHT [ CSPH]), with either no varices ( n 5 80) or small varices ( n= 114), and 79 had an HVPG > 5 and < 10 mm Hg ( subclinical PHT). Patients with CSPH had higher liver stiffness ( P < 0.001), worse Model for End- Stage Liver Disease score ( P < 0.001), more portosystemic collaterals ( P 5 0.01) and splenomegaly ( P 5 0.01) on ultrasound, and lower platelet count ( P < 0.001) than those with subclinical PHT. Patients with CSPH had lower systemic vascular resistance ( 1336 6 423 versus 1469 6 335 dyne center dot s center dot cm - 5, P < 0.05) and higher cardiac index ( 3.3 +/- 0.9 versus 2.8 +/- 0.4 L/ min/m(2), P < 0.01). After propranolol, the HVPG decreased significantly in both groups, although the reduction was greater in those with CSPH (- 16 +/- 12% versus - 8 +/- 9%, P < 0.01). The HVPG decreased >= 10% from baseline in 69% of patients with CSPH versus 35% with subclinical PHT ( P < 0.001) and decreased >= 20% in 40% versus 13%, respectively ( P 5 0.001). Conclusion: Patients with subclinical PHT have less hyperdynamic circulation and significantly lower portal pressure reduction after acute b- blockade than those with CSPH, suggesting that b- blockers are more suitable to prevent decompensation of cirrhosis in patients with CSPH than in earlier stages. ( HEPATOLOGY 2016; 63: 197- 206)