Are Beta-Blockers Safe in Cirrhotic Patients With Refractory Ascites?
SAN FRANCISCO, CA—Treatment with non-selective beta-blockers in cirrhotic patients with refractory ascites may further deteriorate cardiac function, researchers reported at The Liver Meeting® 2015.
"This study shows for the first time that non-selective beta-blocker therapy in refractory ascites reduces the cardiac compensation to hyperkinetic circulation," noted Valerio Giannelli, from Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Clichy, France, and INSERM, and colleagues.
Earlier data have shown non-selective beta-blockers may be harmful in cirrhotic patients with refractory ascites by increasing transplant-free mortality. One possible mechanism may be "a worse cardiac adaptation to the hyperdynamic syndrome, which characterizes patients with refractory ascites," the study team noted.
The investigators retrospectively explored the impact of non-selective beta-blockers on systemic and splanchnic hemodynamics in 583 patients with refractory ascites evaluated for liver transplantation.
Alcohol was the primary cause of cirrhosis in 42% among those without refractory ascites and 61% of those with refractory ascites (P=0.001). Thirty-four percent of the study population had refractory ascites, of which 51% received non-selective beta-blockers. Physiological MELD score was similar in both groups, 16 in those without refractory ascites (n=387) and 17.4 in those with refractory ascites (n=196; P=0.32).
Study results showed waiting list mortality was greater in patients with refractory ascites vs. patients without refractory ascites at one year (19% vs. 13%; P=0.001), "even though they were transplanted earlier," they reported. Median time on the waiting list was 16.8 weeks vs. 28.7 weeks, respectively (P<0.001).
Significantly lower mean arterial pressure and lower heart rate, as well as a higher hepatic venous pressure gradient (HVPG) was seen in patients with refractory ascites vs. patients without refractory ascites.
Independent risk factors for mortality before liver transplantation in patients with refractory ascites were MELD score (HR 1.1; 95% CI: 1-1.2; P=0.002) and LVSWI.
“Cardiac index as well as systemic vascular resistance were similar in both groups,” noted Giannelli, but “left and right ventricular stroke work index (LVSWI, RVSWI) were significantly lower in refractory ascites patients” when compared to patients without refractory ascites.
For both study groups, use of non-selective beta-blockers led to a significant decrease in heart rate, mean arterial pressure, and cardiac index.
Independent risk factors for mortality prior to liver transplantation in patients with refractory ascites were MELD score (HR 1.1; 95% CI: 1–1.2; P=0.002) and LVSWI <50 g·m/m2 (HR 1.7; 95% CI: 1–3.1; P=0.001), they reported.
Since reduced cardiac function increases the risk of mortality in cirrhotic patients with refractory ascites on a waiting list for liver transplantation, "careful thought should be given before continuing non-selective beta-blockers" in this population, they concluded.