Atif Zaman, MD, MPH reviewing Villanueva C et al. Lancet 2019 Mar 22
In patients with compensated cirrhosis and portal hypertension, beta-blocker use reduced decompensation risk but not mortality.
Clinically significant portal hypertension (CSPH; portal pressure ≥10 mmHg) is a key driver of hepatic decompensation (development of ascites, encephalopathy, or variceal hemorrhage) in patients with compensated cirrhosis. To determine whether reducing portal pressure in this high-risk group using beta-blocker therapy lowers decompensation and death rates, investigators in Spain conducted a randomized, controlled trial in 201 patients with compensated cirrhosis and CSPH.
Participants were divided into a beta-blocker–responsive group (135 patients; defined as those who had a ≥10% drop in hepatic venous pressure gradient from baseline when given a propranolol infusion challenge) and a beta-blocker–nonresponsive group (66 patients). The responsive group was randomized to receive either propranolol or placebo and the nonresponsive group to either carvedilol or placebo. The primary endpoint was incidence of decompensation or death.
During a median follow-up of 37 months, among the 100 patients who received beta-blockers, the rate of decompensation or death was significantly lower compared with the 101 patients who received placebo (16% vs. 27%; hazard ratio 0.51). This difference was attributable to a significantly lower incidence of ascites; rates of encephalopathy, hemorrhage, and mortality were similar between groups.
Comment
This study suggests a role for beta-blockers beyond variceal management. In the early phases of cirrhosis, it might reduce rates of hepatic decompensation, mainly via reduction of ascites. However, beta-blocker use did not confer a survival benefit over a median follow-up of 2.5 years, and therapy compliance may be difficult to maintain in clinical practice. Additional studies of longer duration are needed and should target potential high-risk populations to determine which subset of patients would most benefit from beta-blocker therapy.
Editor Disclosures at Time of Publication
Disclosures for Atif Zaman, MD, MPH at time of publication
Grant/Research Support
Merck
Citation(s):
Villanueva C et al. β blockers to prevent decompensation of cirrhosis in patients with clinically significant portal hypertension (PREDESCI): A randomised, double-blind, placebo-controlled, multicentre trial. Lancet 2019 Mar 22; [e-pub]. (https://doi.org/10.1016/S0140-6736(18)31875-0)