HVPG for Rebleeding Risk Stratification
HVPG for Rebleeding Risk Stratification
Background: In patients with cirrhosis on secondary prevention of variceal rebleeding with
 non-selective beta-blockers (NSBBs), the risk of rebleeding and death is markedly higher in
 those failing to achieve a good hemodynamic response (HVPG reduction ≥20% of baseline values
 or ≤12mmHg). However a substantial proportion of non-responders will never rebleed, thus
 appearing protected by NSBBs although non-detected by HVPG response. This low sensitivity
 hampers risk stratification and diminishes the cost-effectiveness of assessing the
 hemodynamic response to NSBBs. This is particularly relevant in prevention of rebleeding
 since in this scenario the risk of rebleeding and of other portal hypertension related
 complications is very high, which calls for early institution of effective therapy.

 Baseline HVPG bears prognostic significance with regards to risk of developing varices,
 decompensation, hepatocellular carcinoma and death1,2,7,8,18-27. However, no studies have
 investigated whether adding data from baseline HVPG may improve the sensitivity of the
 criteria defining a good or poor hemodynamic response.

 Hypothesis: Adding data from baseline HVPG may improve the sensitivity of the criteria
 defining a good or poor hemodynamic response.

 Objective: Exploring the prognostic value of basal HVPG that better discriminate those
 non-responders who do not re-bleed under prophylactic treatment with NSBBs.

 Methods: Observational cohort study. Training set: patients from two longitudinal studies
 conducted at the Hepatic Hemodynamic laboratory of the Hospital Clínic of Barcelona to assess
 the prognostic value of HVPG changes during continuous therapy with NSBBs for preventing
 variceal rebleeding. Validation set for chronic hemodynamic response: patients from two
 longitudinal studies conducted at the Hepatic Hemodynamic laboratory of the Hospital de Sant
 Pau of Barcelona to assess the prognostic value of HVPG changes during continuous therapy
 with NSBBs for preventing variceal rebleeding; a third cohort composed of patients undergoing
 acute hemodynamic response to intravenous propranolol will be studied.

 All patients received a preplanned follow-up in the outpatient clinic at 1, 3, and 6 months,
 and every 6 months thereafter in the original studies.

 End-point: bleeding from portal hypertensive sources (esophago-gastric varices or portal
 hypertensive gastropathy) (defined according to Baveno criteria 32), death or liver
 transplantation.

 Ethical aspects: All patients have given their written informed consent to use their data in
 the original studies.
Inclusion Criteria:

 Liver Cirrhosis Admission for bleeding from esophageal varices in the previous 7 days
 Baseline HVPG >12 mmHg Subsequent long-term treatment with NSBB (propranolol or nadolol)
 Second measurement of HVPG after 1-3 months of therapy

 Exclusion Criteria:

 Hepatocellular carcinoma Portal vein thrombosis Contraindications to beta-blockers
 Cholestatic liver disease