Hepatic vein pressure gradient reduction and prevention of variceal bleeding in cirrhosis: A systematic review

Background & Aims: A reduction of the hepatic venous pressure gradient (HVPG) to <= 12 mm Hg or by >= 20% of baseline prevents variceal bleeding in cirrhosis. Because some inconsistent data have argued against the clinical application of these hemodynamic targets, we performed a systematic review of available studies from the Cochrane Library and MEDLINE. Methods: Hemodynamic targets were HVPG reduction (1) to : 12 mm Hg; (2) by >= 20% with final value > 12 mm Hg; (3) by >= 20% or to <= 12 turn Hg. Meta-regression analysis was used to explore heterogeneity. Results: Twelve studies were identified including 943 patients. Pooled odds ratios for bleeding for the 3 hemodynamic targets were, respectively, 0.21 (95% CI: 0.10-0.45; P=.0001), 0.25 (95% Cl: 0.11-0.56; P=.001), and 0.17 (95% Cl: 0.09-0.33; P=.001). A significant heterogeneity was found for the 2 last estimates, and meta-regression analysis showed that this was caused by an exceedingly long interval between HVPG measurements in I study. After exclusion of that study, heterogeneity disappeared, and the pooled odds ratios were, respectively, 0.19 (95% CI: 0.11-0.34; P=.0001) and 0.14 (95% CI: 0.09-0.21;P=.0001). The beneficial effect of HVPG reduction for first bleeding was similar to that for recurrent bleeding. Mortality was significantly reduced for HVPG reduction by >= 20% or to <= 12 mm Hg (pooled odds ratio, 0.39; 95% Cl: 0.19-0.81, P=.012). Conclusions: HVPG reduction to <= 12 mm Hg or by >= 20% significantly reduces the risk of bleeding, and a reduction of >= 20% significantly reduces mortality. These hemodynamic targets should be considered for clinical practice and for randomized controlled trials.