Clinical vs haemodynamic response to drugs in portal hypertension.
OBJECTIVE
The combination of non-selective beta-blockers and nitrates is an effective therapy for the prevention of rebleeding from oesophageal varices. However, a significant number of patients fail to respond and have further haemorrhage. It has been suggested that measurement of the hepatic venous pressure gradient response to long-term drug therapy may allow early selection of non-responders. We aimed to test this hypothesis in 63 patients with cirrhosis and variceal bleeding treated with propranolol+/-isosorbide mononitrate.


METHODS
Hepatic venous pressure gradient was measured before and during treatment. Response was defined as a reduction of 20% or more in hepatic venous pressure gradient, or a fall in hepatic venous pressure gradient to 12 mmHg or less.


RESULTS
Forty-four patients were evaluable: 28 responders and 16 non-responders. Hepatic venous pressure gradient fell significantly in the responder group (17.5+/-0.5 mmHg vs 12.2+/-0.5 mmHg; p<0.01) but not in the non-responders (18.0+/-1.0 vs 17.9+/-1.2 mmHg; p=n.s.). Overall, there was no difference in rebleeding rates between the two groups: responders 43%, non-responders 25%. However, rebleeding was uncommon in compliant patients with alcoholic cirrhosis, in whom the hepatic venous pressure gradient fell to less than 12 mmHg (9%).


CONCLUSIONS
In this study a fall in hepatic venous pressure gradient of 20% was not a reliable predictor of clinical response. A threshold value of 12 mmHg was useful, but applied to relatively few patients.
Liver Unit, St Vincent's Hospital, Dublin, Ireland.
P A
PA
McCormick
D
D
Patch
L
L
Greenslade
J
J
Chin
N
N
McIntyre
A K
AK
Burroughs
D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use*; D001794:Blood Pressure / Q000187:drug effects*; D004932:Esophageal and Gastric Varices / Q000188:drug therapy* / Q000503:physiopathology* / Q000628:therapy; D005260:Female; D005500:Follow-Up Studies; D006439:Hemodynamics / Q000187:drug effects; D006801:Humans; D006975:Hypertension, Portal / Q000188:drug therapy / Q000503:physiopathology; D007548:Isosorbide Dinitrate / Q000031:analogs & derivatives* / Q000627:therapeutic use; D008103:Liver Cirrhosis / Q000150:complications; D008104:Liver Cirrhosis, Alcoholic / Q000150:complications / Q000503:physiopathology; D008297:Male; D008875:Middle Aged; D015282:Octreotide / Q000627:therapeutic use; D011433:Propranolol / Q000627:therapeutic use*; D012008:Recurrence; D015911:Sclerotherapy; D013997:Time Factors; D016896:Treatment Outcome; D014665:Vasodilator Agents / Q000627:therapeutic use*
D000319:Adrenergic beta-Antagonists; D014665:Vasodilator Agents; D011433:Propranolol; D007548:Isosorbide Dinitrate; C030397:isosorbide-5-mononitrate; D015282:Octreotide