Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, , Vienna, Austria.
Gut. 2013 Nov;62(11):1634-41. doi: 10.1136/gutjnl-2012-304038. Epub 2012 Dec 18.
Non-selective β-blockers or endoscopic band ligation (EBL) are recommended for primary prophylaxis of variceal bleeding in patients with oesophageal varices. Additional α-adrenergic blockade (as by carvedilol) may increase the number of patients with haemodynamic response (reduction in hepatic venous pressure gradient (HVPG) of ≥ 20% or to values <12 mm Hg).
Patients with oesophageal varices undergoing measurement of HVPG before and under propranolol treatment (80-160 mg/day) were included. HVPG responders were kept on propranolol (PROP group), while non-responders were placed on carvedilol (6.25-50 mg/day). Carvedilol responders continued treatment (CARV group), while non-responders to carvedilol underwent EBL. The primary aim was to assess haemodynamic response rates to carvedilol in propranolol non-responders.
36% (37/104) of patients showed a HVPG response to propranolol. Among the propranolol non-responders 56% (38/67) eventually achieved a haemodynamic response with carvedilol, while 44% (29/67) patients were finally treated with EBL. The decrease in HVPG was significantly greater with carvedilol (median 12.5 mg/day) than with propranolol (median 100 mg/day): -19 ± 10% versus -12 ± 11% (p<0.001). During a 2 year follow-up bleeding rates for PROP were 11% versus CARV 5% versus EBL 25% (p=0.0429). Fewer episodes of hepatic decompensation (PROP 38%/CARV 26% vs EBL 55%; p=0.0789) and significantly lower mortality (PROP 14%/CARV 11% vs EBL 31%; p=0.0455) were observed in haemodynamic responders compared to the EBL group.
Carvedilol leads to a significantly greater decrease in HVPG than propranolol. Using carvedilol for primary prophylaxis a substantial proportion of non-responders to propranolol can achieve a haemodynamic response, which is associated with improved outcome with regard to prevention of variceal bleeding, hepatic decompensation and death.
非选择性β受体阻滞剂或内镜套扎（EBL）被推荐用于食管静脉曲张患者的静脉曲张出血的一级预防。额外的α肾上腺素能阻断（如卡维地洛）可能会增加血液动力学反应（肝静脉压力梯度（HVPG）降低≥20％或至<12mmHg）的患者数量。
纳入接受普萘洛尔治疗（80-160mg/天）前和治疗下测量 HVPG 的食管静脉曲张患者。HVPG 反应者继续服用普萘洛尔（PROP 组），而无反应者服用卡维地洛（6.25-50mg/天）。卡维地洛反应者继续治疗（CARV 组），而卡维地洛无反应者接受 EBL。主要目的是评估普萘洛尔无反应者对卡维地洛的血液动力学反应率。
36％（104 例中的 37 例）的患者对普萘洛尔有 HVPG 反应。在普萘洛尔无反应者中，56％（67 例中的 38 例）最终通过卡维地洛实现血液动力学反应，而 44％（67 例中的 29 例）患者最终接受 EBL 治疗。卡维地洛的 HVPG 降低幅度明显大于普萘洛尔（中位数 12.5mg/天）：-19±10％与-12±11％（p<0.001）。在 2 年的随访期间，PROP 的出血率为 11％，CARV 为 5％，EBL 为 25％（p=0.0429）。肝功能失代偿（PROP 38％/CARV 26％vs EBL 55％；p=0.0789）和死亡率（PROP 14％/CARV 11％vs EBL 31％；p=0.0455）明显降低。
卡维地洛导致 HVPG 的降低明显大于普萘洛尔。使用卡维地洛进行一级预防，普萘洛尔无反应者中有相当一部分可以实现血液动力学反应，这与预防静脉曲张出血、肝功能失代偿和死亡方面的改善结果相关。
