Observational Study
Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jun 7, 2019; 25(21): 2665-2674
Published online Jun 7, 2019. doi: 10.3748/wjg.v25.i21.2665
Management of betablocked patients after sustained virological response in hepatitis C cirrhosis
Marta Abadía, María Luisa Montes, Dolores Ponce, Consuelo Froilán, Miriam Romero, Joaquín Poza, Teresa Hernández, Rubén Fernández-Martos, Antonio Olveira, on behalf of the “La Paz Portal Hypertension” Study Group Investigators
Marta Abadía, Consuelo Froilán, Miriam Romero, Joaquín Poza, Rubén Fernández-Martos, Antonio Olveira, Servicio de Aparato Digestivo, Hospital Universitario La Paz, Madrid 28046, Spain
María Luisa Montes, Unidad VIH, Servicio de Medicina Interna, Hospital Universitario La Paz, Madrid 28046, Spain
Dolores Ponce, Teresa Hernández, Servicio de Radiología, Hospital Universitario La Paz, Madrid 28046, Spain
Author contributions: Abadía M, Montes ML, and Olveira A designed the research; Abadía M, Montes ML, Ponce D, Froilán C, Romero M, Poza J, Hernández T, Fernández-Martos R, Olveira A and the remaining “La Paz Portal Hypertension” Study Group Investigators (Castillo P, Erdozain JC, García-Samaniego J, González J, Gonzalo N, García A, Marín E, Martín-Carbonero L, Mora P, Novo J, Fernández-Rodríguez L, Valencia E) performed the research; Abadía M, Montes ML, Froilán C, and Olveira A analyzed the data; Abadía M, Montes ML, and Olveira A wrote the paper.
Supported by RIS (Red Temática de Investigación Cooperativa en SIDA) RD16/0025/0018 (translation and statistical analysis);the RIS is funded by the Instituto de Salud Carlos III as part of the Plan Nacional R + D + I and cofinanced by ISCIII-Subdirección General de Evaluación and the Fondo Europeo de Desarrollo Regional (FEDER).
Institutional review board statement: The study was reviewed and approved by the Human Research and Ethics Committee at Hospital Universitario La Paz (Madrid).
Informed consent statement: Written informed consent was obtained from each patient included in the study.
Conflict-of-interest statement: The authors have no conflict of interest to declare.
STROBE statement: The authors have read the STROBE Statement—checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Marta Abadía, MD, Doctor, Servicio de Aparato Digestivo, Hospital Universitario La Paz, Paseo de La Castellana 261, Madrid 28046, Spain. mabadiab@gmail.com
Telephone: +34-646388528 Fax: +34-912071466
Received: February 17, 2019
Peer-review started: February 18, 2019
First decision: March 5, 2019
Revised: March 13, 2019
Accepted: March 24, 2019
Article in press: March 25, 2019
Published online: June 7, 2019

Current guidelines do not address the post–sustained virological response management of patients with baseline hepatitis C virus (HCV) cirrhosis and oesophageal varices taking betablockers as primary or secondary prophylaxis of variceal bleeding. We hypothesized that in some of these patients portal hypertension drops below the bleeding threshold after sustained virological response, making definitive discontinuation of the betablockers a safe option.


To assess the evolution of portal hypertension, associated factors, non-invasive assessment, and risk of stopping betablockers in this population.


Inclusion criteria were age > 18 years, HCV cirrhosis (diagnosed by liver biopsy or transient elastography > 14 kPa), sustained virological response after direct-acting antivirals, and baseline oesophageal varices under stable, long-term treatment with betablockers as primary or secondary bleeding prophylaxis. Main exclusion criteria were prehepatic portal hypertension, isolated gastric varices, and concomitant liver disease. Blood tests, transient elastography, and upper gastrointestinal endoscopy were performed. Hepatic venous pressure gradient (HVPG) was measured five days after stopping betablockers. Betablockers could be stopped permanently if gradient was < 12 mmHg, at the discretion of the attending physician.


Sample comprised 33 patients under treatment with propranolol or carvedilol: median age 64 years, men 54.5%, median Model for End-Stage Liver Disease (MELD) score 9, Child-Pugh score A 77%, median platelets 77.000 × 103/µL, median albumin 3.9 g/dL, median baseline transient elastography 24.8 kPa, 88% of patients received primary prophylaxis. Median time from end of antivirals to gradient was 67 wk. Venous pressure gradient was < 12 mmHg in 13 patients (39.4%). In univariate analysis the only associated factor was a MELD score decrease from baseline. On endoscopy, variceal size regressed in 19/27 patients (70%), although gradient was ≥ 12 mmHg in 12/19 patients. The elastography area under receiver operating characteristic for HVPG ≥ 12 mmHg was 0.62. Betablockers were stopped permanently in 10/13 patients with gradient < 12 mmHg, with no bleeding episodes after a median follow-up of 68 wk.


Portal hypertension dropped below the bleeding threshold in 39% of patients more than one year after antiviral treatment. Endoscopy and transient elastography are inaccurate for reliable detection of this change. Stopping betablockers permanently seems uneventful in patients with a gradient < 12 mmHg.

Keywords: Hepatitis C virus, Oesophageal varices, Portal hypertension, Betablocker, Variceal bleeding

Core tip: Approximately 1/3 of the patients with baseline cirrhosis and bleeding-risk oesophageal varices, satisfactorily evolve below the bleeding-risk threshold, after curation of chronic hepatitis C. In these patients, the definitive interruption of the preventive medication taken to avoid bleeding seems to be safe.