Non-selective beta-blockers in cirrhosis: Current concepts and controversies

Figure 2 Extended - “window hypothesis” adapted and revised from Krag et al[21]. The window hypothesis illustrates that in early portal hypertension when low risk of bacterial translocation and adequate cardiac compensatory reserve, NSBBs have no effect on survival[25,67]. As disease progresses and varices enlarge there is clear benefit of NSBB in primary and secondary prophylaxis in improving mortality and also reducing rebleeding rates. The original widow hypothesis[21] commented that the window for benefit of NSBBs then may indeed close in decompensated cirrhosis (e.g., patients with refractory ascites[20]) however the data from Leithead et al[22] would suggest the window may indeed remain open even in such patients for a period of time. This window however may indeed close once patients have developed an episode of SBP[90]. SNS: Sympathetic nervous system activity; NSBB: Non-selective beta-blocker; SBP: Spontaneous bacterial peritonitis.