Original article 507 Acute and chronic hemodynamic changes after propranolol in patients with cirrhosis under primary and secondary prophylaxis of variceal bleeding: a pilot study Enrique de-Madaria a , Jose ´ Marı ´a Palazo ´n a,f , Flavia Tamara Herna ´ ndez b , Jose ´ Sa ´ nchez-Paya c , Pedro Zapater b,f , Javier Irurzun d , Francisco de Espan ˜a d , Sonia Pascual a,f , Jose ´ Such a,f , Laura Sempere a , Fernando Carnicer a,f , Antonio Garcı ´a-Herola e , Jaime Valverde e and Miguel Pe ´ rez-Mateo a,f Background and aim Prophylactic treatment of variceal bleeding in cirrhotic patients with b-blockers is effective in only some patients. Our aim was to determine whether the response of the hepatic venous pressure gradient (HVPG) to the intravenous administration of propranolol predicts the response after chronic oral propranolol treatment. Patients and methods We included prospectively cirrhotic patients with esophageal varices under primary prophylaxis (PP) and secondary prophylaxis (SP). The HVPG was measured at baseline and after a propranolol bolus (0.15 mg/kg intravenous). A patient was considered a good-responder if HVPG decreased to 12 mmHg or 20% from baseline. Patients then received oral propranolol (heart rate titrated). Poor-responders under SP were also included in a variceal band ligation program. After at least 3 months, a second hemodynamic study was conducted. Results Fifty-six patients were included (36 SP and 20 PP). Response rate was similar (32.1 and 41.9%, P = 0.7) and the Pearson’s correlation coefficient was 0.61 (P = 0.001). In 81.4% patients, the first study predicted the response status of the second. Six patients rebled on follow-up between the studies, all of them were poor responders to intravenous propranolol. Conclusion A single hemodynamic study using intravenous propranolol seems to predict chronic response to propranolol. Eur J Gastroenterol Hepatol 22:507–512  c 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins. European Journal of Gastroenterology & Hepatology 2010, 22:507–512 Keywords: hepatic venous pressure gradient, hypertension, portal, propranolol, variceal bleeding a Unidad hepa ´ tica, b Farmacologı ´a clı ´nica, c Medicina preventiva, d Radiologı ´a intervencionista, Hospital General Universitario de Alicante, e Gastroenterologı ´a, Hospital Comarcal Marina Baixa, Villajoyosa, Alicante and f CIBERehd, Instituto de Salud Carlos III, Madrid, Spain Correspondence to Dr Jose ´ Marı ´a Palazo ´ n, MD, Unidad hepa ´ tica, Hospital General Universitario de Alicante, Pintor Baeza s/n, Alicante 03010, Spain Tel/fax: + 34 96 5938355; e-mail: palazon_jma@gva.es Received 8 February 2009 Accepted 7 April 2009 Introduction Variceal bleeding is an important cause of morbidity and mortality in cirrhotic patients. Patients with esophageal varices have a bleeding risk rate of 25–40%. After an episode of variceal bleeding, over 70% of patients will rebleed if no prophylactic treatment is administered [1,2]. Pharmacological treatment and endoscopic variceal band ligation to decrease the risk of first and recurrent variceal bleeding, and this has led to their widespread use [3,4]. Currently, the only approach to determine those patients who will respond to b-blocker treatment is the measurement of the hepatic venous pressure gradient (HVPG). A decrease of the HVPG to 12 mmHg or less, or a 20% decrease from basal value after chronic medical treatment, has been associated with a low probability of bleeding [5–11], better survival [7,11,12], and also a decrease in the rate of other complications related to portal hypertension, such as ascites, spontaneous bacter- ial peritonitis, hepatorenal syndrome, and hepatic ence- phalopathy [12,13]. Thirty-six to 64% of the patients respond to the chronic b-blocker treatment [8–12,14]. Some important issues of the key studies [5–8,15] that have shown the usefulness of target monitoring of the HVPG to guide therapy have been questioned [16,17]. Specifically, 17–65% of the patients in these studies did not have a baseline and/or a repeated HVPG measurement, mainly because of the presence of early rebleeding [16]. This is not surprising as the higher risk period of rebleeding is within the first 6 weeks [14]. Thus, an early evaluation of response to b-blockers by HVPG measurement would be a very useful method in discriminating those patients who will benefit from medical treatment very close to variceal bleeding. Poor-responding patients would be treated by esophageal variceal ligation, avoiding exposure to a futile medical treatment in the most dangerous period. 0954-691X  c 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins DOI: 10.1097/MEG.0b013e32832ca06b Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.