Acute haemodynamic response to intravenous propranolol predicts decompensation and mortality in patients with cirrhosis

Background & Aims Non-selective beta-blockers (NSBBs) are indicated for the prophylaxis of variceal bleeding. The acute haemodynamic response to intravenous propranolol (ivPROP-R; ≥10 % decrease of hepatic venous pressure gradient (HVPG)) is associated with a reduced risk of variceal bleeding. We explored the prognostic value of ivPROP-R in patients with compensated (cACLD) and decompensated (dACLD) advanced chronic liver disease.

Methods We analyzed prospectively recruited ACLD patients (Vienna Cirrhosis Study, NCT03267615) undergoing HVPG measurements with an intraprocedural assessment of ivPROP-R at baseline.

Results 98 ACLD patients (mean age: 56.4±11.5 years; 69.4 % male; 88.8 % varices; 72.4 % decompensated) with a mean HVPG of 19.9±4.4 mmHg were included. Overall, ivPROP-R was achieved in 57 patients (58.2 %). Carvedilol or propranolol were subsequently prescribed in 63 % and 37 % of patients with ivPROP-R, respectively, but also in 61 % and 39 % of acute non-responders. After a median period of 9.4 (IQR: 5.0-18.1) weeks, the chronic haemodynamic response to oral NSBB treatment was assessed in 54 patients (55.1 %). Sixty-five percent of acute responders also showed a chronic response. Importantly, 50 % of acute non-responders still achieved a chronic HVPG response with oral carvedilol. During a median follow-up of 9.6 (IQR: 6.5-18.2) months, achieving ivPROP-R predicted a lower risk of variceal bleeding (at 12 months: 3.6 % vs. 15 %; log-rank p = 0.038) and was associated with a lower risk of hepatic decompensation (at 12 months: 23 % vs. 33 %; log-rank p = 0.096). ivPROP-R was independently linked to a reduced risk of first/further decompensation in a multivariate analysis (adjusted HR: 0.31; 95 %CI: 0.13-0.70; p = 0.005). Importantly, transplant-free survival tended to be longer in patients with ivPROP-R (34.2, 95 %CI: 29.2-39.2 months vs. 25.2, 95 %CI: 19.8-30.6; log-rank p = 0.191).

Conclusion A single assessment of ivPROP-R is a valuable prognostic marker in patients with ACLD, since achieving ivPROP-R predicted a lower risk of variceal bleeding, hepatic decompensation and death.

Publication History

Article published online:
01 September 2021