Hemodynamic Response to Carvedilol is Maintained for Long Periods and Leads to Better Clinical Outcome in Cirrhosis: A Prospective Study

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• 作者：Vijendra Kirnake ; Anil Arora ; ^{dranilarora50@hotmail.com" class="auth_mail" title="E-mail the corresponding author} ; Varun Gupta ; Praveen Sharma ; Vikas Singla ; Naresh Bansal ; Mohan Goyal ; Romesh Chawlani ; Ashish Kumar
• 关键词：CTP ; Child-Turcotte-Pugh ; EVL ; endoscopic variceal ligation ; FHVP ; free hepatic venous pressure ; HVPG ; hepatic venous pressure gradient ; MELD ; model for end-stage liver disease ; NSBB ; non-selective beta-blocker ; VBL ; variceal band ligation ; WHVP ; wedged hepatic venous pressure
• 刊名：Journal of Clinical and Experimental Hepatology
• 出版年：2016
• 出版时间：September 2016
• 年：2016
• 卷：6
• 期：3
• 页码：175-185
• 全文大小：495 K

文摘

Non-selective beta-blockers (NSBBs), e.g. propranolol, are recommended for prophylaxis of variceal bleeding in cirrhosis. Carvedilol, a newer NSBB with additional anti-α1-adrenergic activity, is superior to propranolol in reducing portal pressure. Repeated HVPG measurements are required to identify responders to NSBB. We aimed to determine whether a single-time HVPG measurement, using acute-hemodynamic-response-testing, is sufficient to predict long-term response to carvedilol, and whether these responders have better clinical outcome.

Methods

Consecutive patients with cirrhosis, aged 18–70 years, in whom NSBB was indicated for primary/secondary prophylaxis of variceal bleeding, and who underwent HVPG were included. Acute-hemodynamic-response was defined as a decrease in HVPG ≥10% from baseline or absolute HVPG value declining to <12 mm Hg, 1 h after 25 mg oral carvedilol. The aims of the study were to determine: the proportion of patients who achieved acute-hemodynamic-response to carvedilol; whether HVPG-response is maintained for 6 months; and clinical outcome of acute-responders to carvedilol therapy for 6 months.

Results

The study included 69 patients (median age 51, males 93%). Alcohol was the most common etiology; 59% patients belonged to Child-Pugh class B. NSBB was indicated for primary prophylaxis in 36% and secondary prophylaxis in 64% patients. According to the response criteria, 67% patients were found to be acute-hemodynamic-responders. At 6 months, 92% patients were found to be still maintaining their hemodynamic response to carvedilol. Using intention-to-treat analysis, 76% patients maintained their response. These acute responders, on chronic treatment with carvedilol during the 6-month period, had lesser episodes of variceal bleeding, better ascites control, and improved MELD and CTP scores, than non-carvedilol treated non-responders. However, survival remained similar in both the groups.

Conclusions

A single-time HVPG measurement with acute-hemodynamic-response-testing is simple and reliable method for identifying patients who are more likely to respond to carvedilol therapy. The HVPG-response is maintained over a long period in majority of these patients and carvedilol therapy leads to better clinical outcome in these patients.