title: Long-term follow-up of hemodynamic responders to pharmacological therapy after variceal bleeding.
abstract: Although it is assumed that hemodynamic responders to pharmacological therapy after a variceal hemorrhage are adequately protected from rebleeding, there is no evidence that either this response or its protective effect extend beyond the usual 2-year follow-up featured in available studies. We aimed to assess the maintenance of hemodynamic response and its impact on outcomes in a large cohort of hemodynamic responders during a long follow-up. One hundred three patients with cirrhosis admitted with acute variceal bleeding between 2001 and 2010 were prospectively evaluated. The hepatic venous pressure gradient (HVPG) was determined 5 days after the bleeding and repeated 5-7 days after maximal tolerated doses of nadolol and nitrates. Hemodynamic responders (HVPG ≤ 12 mm Hg or ≥ 20% decrease from baseline) were maintained on drugs and followed up with annual HVPG measurements. Forty-eight patients (47%) were hemodynamic responders. The median follow-up was 48 months (range, 2-108 months). Long-term HVPG evaluations could not be performed in eight patients (four deaths, two rebleedings, two follow-ups <1 year). Among the remaining 40 patients, hemodynamic response was maintained in 26 (65%) and lost in 14 (35%). There were no baseline differences between the two subgroups. However, 100% of alcoholic patients who remained abstinent maintained long-term response, compared with 36% of nonabstinent alcoholics and 50% of patients with viral cirrhosis. Patients with loss of hemodynamic response rebled more during follow-up and showed a higher incidence of death or liver transplantation.
  
  
  CONCLUSIONS
  After variceal bleeding, long-term maintenance of hemodynamic response to drug therapy is mainly restricted to patients with alcoholic cirrhosis who remain abstinent. The loss of this long-term response carries worse clinical outcomes.
authors.affiliation: Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebron, Institut de Recerca, Universitat Autónoma de Barcelona, Barcelona, Spain. saugustin@vhebron.net
authors.forename: Salvador
authors.initials: S
authors.lastname: Augustin
authors.forename: Antonio
authors.initials: A
authors.lastname: González
authors.forename: Laia
authors.initials: L
authors.lastname: Badia
authors.forename: Laura
authors.initials: L
authors.lastname: Millán
authors.forename: Aranzazu
authors.initials: A
authors.lastname: Gelabert
authors.forename: Alejandro
authors.initials: A
authors.lastname: Romero
authors.forename: Antoni
authors.initials: A
authors.lastname: Segarra
authors.forename: María
authors.initials: M
authors.lastname: Martell
authors.forename: Rafael
authors.initials: R
authors.lastname: Esteban
authors.forename: Jaime
authors.initials: J
authors.lastname: Guardia
authors.forename: Joan
authors.initials: J
authors.lastname: Genescà
mesh_terms: D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use*; D000328:Adult; D000368:Aged; D004932:Esophageal and Gastric Varices / Q000188:drug therapy* / Q000401:mortality / Q000503:physiopathology; D005260:Female; D005500:Follow-Up Studies; D006471:Gastrointestinal Hemorrhage / Q000188:drug therapy* / Q000401:mortality / Q000503:physiopathology; D006439:Hemodynamics / Q000187:drug effects* / Q000502:physiology*; D006801:Humans; D017093:Liver Failure / Q000401:mortality / Q000601:surgery; D016031:Liver Transplantation; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D009566:Nitrates / Q000627:therapeutic use*; D011379:Prognosis; D016016:Proportional Hazards Models; D011446:Prospective Studies; D055502:Secondary Prevention; D014690:Venous Pressure / Q000502:physiology
chemical_list: D000319:Adrenergic beta-Antagonists; D009566:Nitrates