Non-selective beta blockers (NSBBs) are effective in advanced liver cirrhosis for several reasons: 1) They decrease portal pressure and the risk of bleeding from gastropathy by reducing cardiac output and portal blood flow through beta receptor blockade. 2) Several studies have shown that cirrhotic patients without NSBB treatment who have low mean arterial blood pressure (<82 mmHg) have lower transplantation-free survival. 3) NSBBs are most effective when started once varices are present but stopped once complications like refractory ascites, spontaneous bacterial peritonitis, or low mean arterial pressure develop.

1. Non-selective Beta blockers
(NSBB)
The Aspirin of Hepatologist
Ahmed Abdul Ghany

2. Why?
• Decrease portal pressure
• Decrease risk of bleeding from hypertensive
gastropathy
• Lower incidence of bacterial translocation
• Decrease development of spontaneous
bacterial peritonitis

3. NSBBs achieve their effects through
Reducing cardiac output via Beta 1 receptor
blockade
Reducing portal blood flow through splanchnic
vasoconstriction via Beta 2 receptor blockade

4. Several studies in cirrhotic patients without
NSBB treatment established a correlation
between BP and transplantation-free survival
As cirrhosis progress, cardiovascular system
looses it’s compensatory ability, thus patients
with low mean arterial Bp (< 82 mmHg) had
lower survival
Liach. Gastro 1988

5. Modified peripheral vasodilatation
hypothesis
Arroyo V, et al 2009

6. Predictors of worse survival
• Mean arterial Bp < 80 mmHg
• Cardiac index below 1.5 l/min/m2
Krag gut 2010

7. How effective are NSBBs in advanced
liver cirrhosis ?
Krag, et al,. 2012

8. Window of opportunity opened by
Presence of
varices
Start NSBB

9. Closed by
Refractory
ascites
SBP
HRS
Low MAP
STOP
NSBB

10. Paracentesis induced circulatory
dysfunction (PICD)
Refractory ascites is characterized by repeated
paracentsis, which has been shown to trigger
PICD.
PICD defined as increase in renin level at least
50% one week after paracentesis.

11. Lack of cardiac adaptation after paracentesis
under beta blockers may explain the increase in
PICD incidence.
Patients with PICD who are on NSBB
medications, have a higher incidence of acute
kidney injury (AKI) reaching 71%.
Serste et al., Liver International 2015

12. Transplantation-free survival with SBP
Mandofer M, et al., 2014

13. Mandofer M, et al., gastro 2014