Beta-Blocker Therapy in Cirrhosis: A Paradigm Shift

Summary and Comment |
March 18, 2014

Beta-Blocker Therapy in Cirrhosis: A Paradigm Shift

  1. Atif Zaman, MD, MPH

Their use should mostly be limited to the middle stages of disease.

  1. Atif Zaman, MD, MPH

Emerging data show that arterial pressure is an independent predictor of survival in patients with cirrhosis. Patients with a mean arterial pressure (MAP) >80 mmHg have a 1-year survival of 70% compared with only 40% in patients with a MAP ≤80 mmHg. Therefore, drugs that lower the MAP, such as beta-blockers, should be avoided or used with caution (NEJM JW Gastroenterol May 10 2013). The current review covers the use of beta-blockers — commonly used in the primary and secondary prevention of variceal hemorrhage — in patients with cirrhosis.

The authors conclude that beta-blockers improve survival only in a narrow clinical window during the course of cirrhosis. As such, they suggest the following with regard to timing of beta-blocker therapy:

  • Do not use beta-blocker therapy early in cirrhosis when there is no significant portal hypertension (i.e., no evidence of varices). Studies demonstrate that during this phase, beta-blocker therapy does not prevent varices formation or increase survival and is associated with increased drug-related adverse effects.

  • Consider use of beta-blocker therapy during the middle stages of cirrhosis when portal hypertension becomes significant and medium-to-large varices and ascites develop but systemic hemodynamics are still preserved.

  • Avoid beta-blocker therapy in the late stages of cirrhosis when cardiovascular reserve is compromised, refractory ascites and systemic hypotension are usually present, and end-organ perfusion (mainly renal perfusion) is compromised.


This high-quality review outlines the paradigm shift that has occurred in the use of beta-blocker therapy in patients with cirrhosis. The latest data now provide convincing evidence that in late-stage cirrhosis, beta-blocker therapy for management of varices should be avoided in favor of endoscopic band ligation.

Editor Disclosures at Time of Publication

  • Disclosures for Atif Zaman, MD, MPH at time of publication Speaker’s bureau Bristol-Myers Squibb; Genentech; Gilead; Kadmon; Merck; Salix; Vertex


Reader Comments (2)


It's about time.

SARA LEVIN Physician

The increase in 1 year mortality in patients with MAP<80 referred to in this study as the reason to discontinue beta-blockers indicated for primary or secondary prevention of variceal hemmorhage (a major cause of mortality in advanced cirrhosis) seems to miss a step. It would seem to me that you have to prove that the mortality that is prevented by the variceal hemmorhage is negated by the increased contribution to mortality of the beta-blocker lowering the MAP. The decrease in MAP seems to me to be more of an indication of disease severity progression rather than an outcome of beta-blocker therapy per se. That being said, it would be good to go back to original studies of non-selective beta-blockers in preventing varicael hemmorhage and see who was excluded from study group based on MAP/SBP measurments to make sure we are not overapplying this therapy based on the best evidence to date

Your Comment

(will not be published)

Filtered HTML

  • Allowed HTML tags: <a> <em> <strong> <cite> <blockquote> <code> <ul> <ol> <li> <dl> <dt> <dd>
  • Web page addresses and e-mail addresses turn into links automatically.
  • Lines and paragraphs break automatically.

Plain text

  • No HTML tags allowed.
  • Web page addresses and e-mail addresses turn into links automatically.
  • Lines and paragraphs break automatically.
Do you have any conflict of interest to disclose?
This question is for testing whether you are a human visitor and to prevent automated spam submissions.

Vertical Tabs

* Required

Reader comments are intended to encourage lively discussion of clinical topics with your peers in the medical community. We ask that you keep your remarks to a reasonable length, and we reserve the right to withhold publication of remarks that do not meet this standard.

PRIVACY: We will not use your email address, submitted for a comment, for any other purpose nor sell, rent, or share your e-mail address with any third parties. Please see our Privacy Policy.