Short-term hemodynamic effects of beta-blockers influence survival of patients with decompensated cirrhosis
Por:
Alvarado-Tapias, E, Ardevol, A, Garcia-Guix, M, Montanes, R, Pavel, O, Cuyas, B, Graupera, I, Brujats, A, Vilades, D, Colomo, A, Poca, M, Torras, X, Guarner, C, Concepcion, M, Aracil, C, Torres, F, Villanueva, C
Publicada:
1 ago 2020
Resumen:
Background & Aims: Whether the effect of beta-blockers on arterial pressure and/or cardiac function may offset the benefit of reducing portal pressure in advanced cirrhosis is controversial. Herein, we aimed to evaluate the systemic and splanchnic hemodynamic effects of beta-blockers in decompensated vs. compensated cirrhosis and to investigate the influence of systemic hemodynamic changes on survival times in decompensated cirrhosis.
Methods: Patients with cirrhosis and high-risk esophageal varices, without previous bleeding, were consecutively included and grouped according to the presence or absence of decompensation (ascites with or without overt encephalopathy). Systemic and hepatic hemodynamic measurements were performed before starting beta-blockers and again after 1 to 3 months of treatment (short-term).
Results: Four hundred and three patients were included (190 decompensated and 213 compensated). At baseline, decompensated patients had higher portal pressure than compensated patients and were more hyperdynamic, with higher cardiac output (CO) and lower arterial pressure. Under -blockers, decompensated patients had lower portal pressure decrease (10 +/- 18% vs. 15 +/- 12%; p <0.05) and had greater reductions in heart rate (p <0.001) and CO (17 +/- 15% vs. 10 +/- 21%; p <0.01). Among patients with decompensated cirrhosis, those who died had a greater decrease in CO with beta-blockers than survivors (21 +/- 14% vs. 15 +/- 16%; p <0.05) and CO under beta-blockers independently predicted death by competing-risk regression analysis, with good diagnostic accuracy (C-index 0.74; 95% CI 0.66-0.83). Death risk was higher in decompensated patients with CO <5 L/min vs. CO L/min (subdistribution hazard ratio 0.44; 95% CI 0.25-0.77; p = 0.004).
Conclusions: In patients with high-risk varices treated to prevent first bleeding, the systemic hemodynamic response to beta-blockers is greater and the portal pressure decrease is smaller in those with decompensated cirrhosis. The short-term effect of beta-blockers on CO might adversely influence survival in decompensated cirrhosis.
Lay summary: beta-blockers are often used to reduce the risk of variceal bleeding in patients with cirrhosis. However, it is not known whether the effect of beta-blockers on arterial pressure and/or cardiac function may offset the benefit of reducing portal pressure. Herein, we show that in patients with decompensated cirrhosis the potentially detrimental systemic effects of beta-blockers are greater than in compensated patients, while the beneficial pressure lowering effects are reduced. The short-term effect of beta-blockers on cardiac output may adversely influence survival in patients with decompensated cirrhosis. (C) 2020 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.
Filiaciones:
Alvarado-Tapias, E:
Hosp Santa Creu & Sant Pau, Dept Gastroenterol, Mas Casanovas 90, Barcelona 08041, Spain
Hosp Santa Creu & Sant Pau, Inst Recerca, Barcelona, Spain
Inst Salud Carlos III, Ctr Invest Biomed Red Enfermedades Hepat & Digest, Madrid, Spain
Univ Autonoma Barcelona, Barcelona, Spain
Ardevol, A:
Hosp Santa Creu & Sant Pau, Dept Gastroenterol, Mas Casanovas 90, Barcelona 08041, Spain
Inst Salud Carlos III, Ctr Invest Biomed Red Enfermedades Hepat & Digest, Madrid, Spain
Univ Autonoma Barcelona, Barcelona, Spain
Garcia-Guix, M:
Hosp Santa Creu & Sant Pau, Dept Gastroenterol, Mas Casanovas 90, Barcelona 08041, Spain
Hosp Santa Creu & Sant Pau, Inst Recerca, Barcelona, Spain
Montanes, R:
Hosp Santa Creu & Sant Pau, Dept Gastroenterol, Mas Casanovas 90, Barcelona 08041, Spain
Hosp Santa Creu & Sant Pau, Inst Recerca, Barcelona, Spain
Pavel, O:
Hosp Santa Creu & Sant Pau, Dept Gastroenterol, Mas Casanovas 90, Barcelona 08041, Spain
Hosp Santa Creu & Sant Pau, Inst Recerca, Barcelona, Spain
Cuyas, B:
Hosp Santa Creu & Sant Pau, Dept Gastroenterol, Mas Casanovas 90, Barcelona 08041, Spain
Hosp Santa Creu & Sant Pau, Inst Recerca, Barcelona, Spain
Graupera, I:
Hosp Santa Creu & Sant Pau, Dept Gastroenterol, Mas Casanovas 90, Barcelona 08041, Spain
Hosp Santa Creu & Sant Pau, Inst Recerca, Barcelona, Spain
Brujats, A:
Hosp Santa Creu & Sant Pau, Dept Gastroenterol, Mas Casanovas 90, Barcelona 08041, Spain
Hosp Santa Creu & Sant Pau, Inst Recerca, Barcelona, Spain
Vilades, D:
Hosp Santa Creu & Sant Pau, Inst Recerca, Barcelona, Spain
Univ Autonoma Barcelona, Barcelona, Spain
Hosp Santa Creu & Sant Pau, Cardiac Imaging Unit, Barcelona, Spain
Colomo, A:
Hosp Santa Creu & Sant Pau, Dept Gastroenterol, Mas Casanovas 90, Barcelona 08041, Spain
Hosp Santa Creu & Sant Pau, Inst Recerca, Barcelona, Spain
Poca, M:
Hosp Santa Creu & Sant Pau, Dept Gastroenterol, Mas Casanovas 90, Barcelona 08041, Spain
Hosp Santa Creu & Sant Pau, Inst Recerca, Barcelona, Spain
Torras, X:
Hosp Santa Creu & Sant Pau, Dept Gastroenterol, Mas Casanovas 90, Barcelona 08041, Spain
Hosp Santa Creu & Sant Pau, Inst Recerca, Barcelona, Spain
Inst Salud Carlos III, Ctr Invest Biomed Red Enfermedades Hepat & Digest, Madrid, Spain
Univ Autonoma Barcelona, Barcelona, Spain
Guarner, C:
Hosp Santa Creu & Sant Pau, Dept Gastroenterol, Mas Casanovas 90, Barcelona 08041, Spain
Hosp Santa Creu & Sant Pau, Inst Recerca, Barcelona, Spain
Inst Salud Carlos III, Ctr Invest Biomed Red Enfermedades Hepat & Digest, Madrid, Spain
Univ Autonoma Barcelona, Barcelona, Spain
Concepcion, M:
Hosp Santa Creu & Sant Pau, Dept Gastroenterol, Mas Casanovas 90, Barcelona 08041, Spain
Hosp Santa Creu & Sant Pau, Inst Recerca, Barcelona, Spain
Aracil, C:
Hosp Arnau Vilanova, Inst Recerca Biomed IRBLleida, Lleida, Spain
Torres, F:
Hosp Clin Barcelona, IDIBAPS, Med Stat Core Facil, Barcelona, Spain
Univ Autonoma Barcelona, Fac Med, Biostat Unit, Barcelona, Spain
Villanueva, C:
Hosp Santa Creu & Sant Pau, Dept Gastroenterol, Mas Casanovas 90, Barcelona 08041, Spain
Hosp Santa Creu & Sant Pau, Inst Recerca, Barcelona, Spain
Inst Salud Carlos III, Ctr Invest Biomed Red Enfermedades Hepat & Digest, Madrid, Spain
Univ Autonoma Barcelona, Barcelona, Spain
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