Predictive value of the variceal pressure response to continued pharmacological therapy in patients with cirrhosis and portal hypertension

Noninvasive measurements of variceal pressure adequately reflect the hemody namic effects of propranolol on portal hypertension. However, the prognosti c value of variceal pressure responses during continued propranolol therapy has not been evaluated, and it is unclear whether this may substitute inva sive measurements of portal pressure response. Fifty-five portal hypertensi ve patients with cirrhosis were studied before and at 4 months of continued propranolol therapy. Variceal pressure was measured using an endoscopic pr essure gauge. Portal pressure was evaluated as the hepatic venous pressure gradient (HVPG). Over a 28 +/- 11 month follow-up, 16 patients experienced variceal bleeding. Baseline characteristics were similar in bleeders and no nbleeders, At 4 months, reduction in variceal pressure was less marked in b leeders than in nonbleeders (5% +/- 20% vs. -15% +/- 24%; P =.03). A fall i n variceal pressure 20% or greater of baseline was an independent predictor of absence of variceal bleeding; which occurred in 5% of patients with a 2 0% or greater fall in variceal pressure versus 42% of patients with less th an a 20% reduction (P =.004), The HVPG response had similar independent pro gnostic value (decrease greater than or equal to 20%: 6% bleeding; decrease < 20%: 45% bleeding; P = .004) but identified different patients. Achievin g a 20% decrease in either variceal pressure or HVPG was highly sensitive ( 85%) and specific (93%) identifying patients not bleeding on followup. Endo scopic measurements of variceal pressure response to continued pharmacother apy provide useful prognostic information on the risk of variceal bleeding. As with HVPG response, a fall in variceal pressure of 20% or greater is as sociated with a very low risk of variceal bleeding. The combination of both parameters allows almost optimal prognostication.