Carvedilol Versus Propranolol for the Prevention of Decompensation and Mortality in Patients with Compensated and Decompensated Cirrhosis
Clinical question: Is carvedilol more effective than the classical non-selective beta-blockers (cNSBBs) propranolol or nadolol in preventing first decompensation and in reducing mortality in patients with clinically significant portal hypertension (CSPH) and both compensated and decompensated cirrhosis?
Background: The study addressed a gap in the lack of direct comparative data to determine the optimal beta-blocker choice in patients with cirrhosis and CSPH.
Study design: Multicenter, retrospective, comparative effectiveness, cohort study for patients with cirrhosis referred for a baseline hemodynamic study before initiating non-selective beta-blockers from January 1, 2008, to July 1, 2021, in six hospitals across Europe.
Synopsis: Patients with compensated or decompensated cirrhosis underwent hepatic venous pressure gradient (HVPG) measurement to assess acute hemodynamic response to IV propranolol before starting primary prophylaxis for variceal bleeding. Outcomes were analyzed using an inverse-probability-of-treatment weighting in a competing-risk framework. The study included 540 patients from multiple centers, with 256 (cNSBBs, n=111; carvedilol, n=145) patients in the compensated cohort and 284 (cNSBBs, n=134; carvedilol, n=150) in the decompensated cohort. Median follow-up was approximately 36.3 and 30.7 months, respectively. After covariate balancing, compared to cNSBBs, carvedilol significantly reduced the risk of decompensation in compensated patients (hazard ratio [HR], 0.61; 95% CI, 0.41-0.92) and a combined endpoint of further decompensation or death in decompensated patients (HR, 0.57; 95% CI, 0.42-0.77). A second HVPG was conducted in approximately two-thirds of the cohort, and among initial non-responders, carvedilol was associated with a higher likelihood of achieving a chronic hemodynamic response.
Bottom line: In this study, carvedilol was superior to cNSBBs for preventing first and further decompensation and mortality in patients with compensated and selected decompensated cirrhosis with CSPH, with similar safety. These findings support the preferential use of carvedilol in these populations, consistent with the evolving consensus and recommendations from the American Association for the Study of Liver Diseases. However, caution is advised in patients with decompensated cirrhosis and circulatory dysfunction or recurrent or refractory ascites.
Citation: Fortea JI, et al. Carvedilol vs. propranolol for the prevention of decompensation and mortality in patients with compensated and decompensated cirrhosis. J Hepatol. 2025;83(1):70-80. doi:10.1016/j.jhep.2024.12.017.
Dr. Vura is an academic hospitalist in the division of hospital medicine at UT Health San Antonio and a clinical assistant professor in the department of internal medicine at the Joe R. & Teresa Long School of Medicine in San Antonio.