How to prevent varices from bleeding:: Shades of grey -: The case for nonselective β blockers

Nonselective beta blockers have been shown to reduce the risk of variceal hemorrhage in primary and secondary prophylaxis in patients with cirrhosis. Target reduction of hepatovenous pressure gradient after initiation of pharmacologic therapy identifies a group of patients who are unlikely to experience this complication ("hemodynamic responders"). However, a large proportion of patients who do not achieve this pressure reduction ("hemodynamic nonresponders"') also do not bleed or rebleed and seem to experience a protective effect from beta blockade. Nonselective beta blockade appears to prevent other complications of cirrhosis, independent of liver dysfunction. We discuss the available clinical evidence for predicting variceal hemorrhage in hemodynamic nonresponders and for protective mechanisms of nonselective beta blockade other than reduction of portal pressure. Nonselective beta blockers could become the "aspirin" of hepatologists.