title: Patients whose first episode of bleeding occurs while taking a β-blocker have high long-term risks of rebleeding and death.
abstract: OBJECTIVE
  Patients who have their first episode of variceal bleeding despite primary prophylaxis with a nonselective β-adrenergic receptor antagonist (also called a nonselective β-blocker [NSBB]) receive additional treatment by endoscopic band ligation to prevent further bleeding. However, little is known about their long-term outcomes.
  
  
  METHODS
  We collected data on 89 consecutive patients with cirrhosis who were admitted to the Liver Unit of Hospital Clínic, Barcelona, with acute esophageal variceal bleeding between June 2007 and February 2011. Thirty-four patients were receiving primary prophylaxis with NSBBs when they had their first episode of variceal bleeding, whereas 55 were not receiving NSBBs (controls). All patients were subsequently treated with a combination of endoscopic band ligation and NSBBs. Patients were examined after 1, 3, and 6 months and every 6 months thereafter until 2 years.
  
  
  RESULTS
  After 2 years, a greater proportion of patients who had their first episode of bleeding while on NSBBs had further bleeding, compared with controls (48% vs 24%; P = .01). Primary prophylaxis with NSBBs and serum levels of bilirubin were independent predictors of rebleeding. Overall, 11 patients died, and 5 underwent liver transplantation. Liver transplantation-free survival was lower among patients who had their first episode of bleeding while taking NSBBs (66% vs 88% for controls; P = .02). Primary prophylaxis with NSBBs and Child-Pugh class were independently associated with liver transplantation-free survival.
  
  
  CONCLUSIONS
  Patients who have their first episode of variceal bleeding while on primary prophylaxis with a β-blocking agent have an increased risk of further bleeding and death, despite adding endoscopic band ligation. These patients possibly require alternative treatment approaches.
authors.affiliation: Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic-IDIBAPS, University of Barcelona and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (Ciberehd), Barcelona, Spain.
authors.forename: Andrea Ribeiro
authors.initials: AR
authors.lastname: de Souza
authors.forename: Vincenzo
authors.initials: V
authors.lastname: La Mura
authors.forename: Enric
authors.initials: E
authors.lastname: Reverter
authors.forename: Susana
authors.initials: S
authors.lastname: Seijo
authors.forename: Annalisa
authors.initials: A
authors.lastname: Berzigotti
authors.forename: Eyal
authors.initials: E
authors.lastname: Ashkenazi
authors.forename: Eyal
authors.initials: E
authors.lastname: Askenazhi
authors.forename: Juan Carlos
authors.initials: JC
authors.lastname: García-Pagán
authors.forename: Juan G
authors.initials: JG
authors.lastname: Abraldes
authors.forename: Jaime
authors.initials: J
authors.lastname: Bosch
mesh_terms: D000319:Adrenergic beta-Antagonists / Q000008:administration & dosage* / Q000009:adverse effects*; D000328:Adult; D004935:Esophageal Diseases / Q000453:epidemiology* / Q000401:mortality*; D005260:Female; D006470:Hemorrhage / Q000453:epidemiology* / Q000401:mortality*; D006801:Humans; D008103:Liver Cirrhosis / Q000150:complications*; D008297:Male; D008875:Middle Aged; D012008:Recurrence; D018570:Risk Assessment; D013030:Spain / Q000453:epidemiology; D016019:Survival Analysis; D016896:Treatment Outcome
chemical_list: D000319:Adrenergic beta-Antagonists