Nonselective beta blockers not recommended for cirrhosis patients with weak cardiac performance

The risks outweigh the benefits of nonselective beta blockers (NSBBs) in cirrhosis patients with compromised cardiac performance, argues a new study.

The study included 584 consecutive cirrhosis patients (median age, 54 years; 78 percent male) scheduled for liver transplantation; half were given NSBBs. Cardiac performance was evaluated through the left ventricular stroke work index (LVSWI). The outcome was waitlist mortality without ever receiving liver transplantation.

A total of 102 died while on the waiting list, yielding a mortality rate of 17 percent. Seventy-five percent of the participants were able to receive their transplants while the remaining 8 percent were removed from the waitlist due to improvements in liver function, worsening of the condition or patient decision.

Multivariate analysis found that the use of NSBBs in patients with LVSWI <64.1 g.m/m² was a significant risk factor for waitlist mortality (subdistribution hazard ratio [SHR], 1.96, 95 percent confidence interval [CI], 1.32–2.90; p=0.0008), along with the presence of refractory ascites (SHR, 1.52, 95 percent CI, 1.01–2.28; p=0.04).

Notably, without taking into account LVSWI values, NSBBs showed no significant relationship with waiting list mortality.

“[T]his study shows that not all patients with cirrhosis and refractory ascites are at higher risk of mortality when receiving NSBBs,” said the researchers. “However, in a subgroup of patients with impaired left ventricular reserve, NSBBs should not be initiated or should be discontinued as they have a deleterious impact on the outcome, independent of the [model for end-stage liver disease] score.

“Noninvasive tools are needed to assess cardiac reserve and to optimize the management of patients with end-stage cirrhosis,” they added.