Publication Date:
2017-01-20
Description:
Monitoring the hemodynamic response of portal pressure to drug therapy accurately stratifies the risk of variceal rebleeding. We assessed whether guiding therapy with HVPG-monitoring may improve survival in the prevention of variceal rebleeding. Cirrhotic patients with controlled variceal bleeding were randomized to a HVPG-guided-therapy group (N= 84) or to a control group (N= 86). In both groups, HVPG and acute β-blocker response were evaluated at baseline and HVPG measurements were repeated at 2-4-weeks to determine chronic response. In the HVPG-guided group, acute responders were treated with nadolol and acute non-responders with nadolol+nitrates. Chronic non-responders received nadolol+prazosin and had a third HVPG study. Ligation sessions were repeated until response was achieved. The control group was treated with nadolol+nitrates+ligation. Between-group baseline characteristics were similar. During long-term follow-up (median of 24 months) mortality was lower in the HVPG-guided-therapy group than in the control group (29% vs 43%; HR= 0.59, 95%CI= 0.35-0.99). Rebleeding occurred in 19% vs 31% of patients, respectively (HR= 0.53, 95%CI= 0.29-0.98), and further decompensation of cirrhosis occurred in 52% vs 72% (HR= 0.68, 95%CI= 0.46-0.99). The survival probability was higher with HVPG-guided-therapy than in controls, both in acute (HR= 0.59, 95%CI= 0.32-1.08) and chronic non-responders (HR= 0.48, 95%CI= 0.23-0.99). HVPG-guided patients had a greater reduction of HVPG and a lower final value than controls (P〈 0.05). Conclusion : HVPG-monitoring, by stratifying risk and targeting therapy, improves the survival achieved with currently recommended treatment to prevent variceal rebleeding using β-blockers and ligation. HVPG-guided-therapy achieved a greater reduction in portal pressure, which may have contributed to reduce the risk of rebleeding and of further decompensation of cirrhosis, thus contributing to a better survival. This article is protected by copyright. All rights reserved.
Print ISSN:
0270-9139
Electronic ISSN:
1527-3350
Topics:
Medicine
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