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 mm 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% CI: 0.11-0.56; P = .001), and 0.17 (95% CI: 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 1 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% CI: 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.