The hemodynamic response to medical treatment of portal hypertension as a predictor of clinical effectiveness in the primary prophylaxis of variceal bleeding in cirrhosis

In the prevention of variceal rebleeding, it is already established that he modynamic response to drug treatment (decrease in hepatic venous pressure g radient [HVPG] to 12 mm Hg or by >20%) is predictive of clinical effectiven ess. In primary prophylaxis very few clinical data are available. We assess ed the role of the hemodynamic response to beta-blockers or beta-blockers p lus nitrates in predicting clinical efficacy of prophylaxis. A total of 49 cirrhotic patients with varices at risk of bleeding, without prior variceal bleeding, were investigated by hepatic vein catheterization before and aft er 1 to 3 months of chronic treatment with nadolol or nadolol plus isosorbi de mononitrate, and were followed during treatment for up to 5 years. A tot al of 30 patients (61%) were good hemodynamic responders, and among them in 12 (24%) HVPG was less than or equal to 12 mm Hg during treatment. During treatment 9 patients had variceal bleeding: 7 were poor responders and 2 we re good responders. The probability of bleeding at 3 years of follow-up was significantly higher in poor responders (41%) than in good responders (7%; P =.0008). No patient reaching an HVPG of 12 mm Hg or less during treatmen t had variceal bleeding during follow-up. Cox's regression analysis showed that poor hemodynamic response was the main factor predicting bleeding (bet a = 1.91; SE(beta) = 0.80; P =.01). During follow-up 11 patients died of he patic causes. Survival was related to Child-Pugh class and to initial value of HVPG, according to Cox's analysis. In conclusion, the assessment of hem odynamic response to drugs in terms of HVPG is the best predictor of effica cy of prophylaxis of variceal bleeding in patients treated with beta-blocke rs or beta-blockers plus nitrates.