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Propranolol Compared with Propranolol plus Isosorbide-5-Mononitrate for Portal Hypertension in Cirrhosis

1991; American College of Physicians; Volume: 114; Issue: 10 Linguagem: Inglês

10.7326/0003-4819-114-10-869

1539-3704

Juan Carlos García‐Pagán, Faust Feu, Jaume Bosch, Joan Rodés,

Organ Transplantation Techniques and Outcomes

Article15 May 1991Propranolol Compared with Propranolol plus Isosorbide-5-Mononitrate for Portal Hypertension in CirrhosisA Randomized Controlled StudyJoan Carles GarcÍa-Pagán, MD, Faust Feu, MD, Jaume Bosch, MD, Joan Rodés, MDJoan Carles GarcÍa-Pagán, MD, Faust Feu, MD, Jaume Bosch, MD, Joan Rodés, MDAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-114-10-869 SectionsAboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail ExcerptObjective: To investigate whether isosorbide-5-mononitrate (Is5-Mn) given with propranolol reduces hepatic portal pressure more than does propranolol alone in patients with cirrhosis.Design: A randomized controlled trial.Patients: Fifty patients with cirrhosis and esophageal varices entered and 42 completed the study.Intervention: Twenty-one patients received oral propranolol at increasing doses until their resting heart rate was reduced by 25%, and 21 patients received oral propranolol (on the same schedule) plus oral Is-5-Mn, 40 mg twice a day.Measurements: Hepatic vein pressure gradient, liver function, and splanchnic and systemic hemodynamics before and after 3 months of continuous therapy.Main Results: At 3 months, the hepatic venous pressure gradient decreased more (P < 0.01) in patients given propranolol plus Is-5-Mn (19%, from 18.4 ± 3.9 to 14.9 ± 3.8 mm Hg; 95% CI, - 2.4 to -4.5 mm Hg) than in those given propranolol alone (10%, from 18.2 ±3.5 to 16.3 ±3.1 mm Hg; CI, - 1.1 to - 2.7 mm Hg). The hepatic venous pressure gradient decreased by more than 20% of the baseline value in 10% of patients receiving propranolol, but in 50% of patients receiving combined therapy (P < 0.02). There were statistically significant decreases in hepatic blood flow and the intrinsic clearance of indocyanine green after propranolol therapy, but not after combined therapy. The treatments caused similar reductions in azygos blood flow and cardiac output.Conclusions:The long-term combined administration of propranolol plus Is-5-Mn reduces portal pressure more than propranolol alone without adverse effects on hepatic perfusion and liver function. Whether this greater hemodynamic effect translates into better clinical efficacy should be determined in randomized controlled trials....References1. Lebrec D, Poynard T, Hillon P, and Benhamou J. Propranolol for prevention of recurrent gastrointestinal bleeding in patients with cirrhosis. N Engl J Med. 1981;305:1371-4. CrossrefMedlineGoogle Scholar2. 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Nitroglycerin improves the hemodynamic response to vasopressin in portal hypertension. Hepatology. 1982;2:757-62. CrossrefMedlineGoogle Scholar21. Bosch J, Groszmann R, and Garcia-Pagán J. Association of transdermal nitroglycerin to vasopressin infusion in the treatment of variceal hemorrhage: a placebo-controlled clinical trial. Hepatology. 1989;10:962-8. CrossrefMedlineGoogle Scholar22. Gimson A, Westaby D, Hegarty J, Watson A, and Williams R. A randomized trial of vasopressin and vasopressin plus nitroglycerin in the control of acute variceal hemorrhage. Hepatology. 1986;6: 410-3. CrossrefMedlineGoogle Scholar This content is PDF only. To continue reading please click on the PDF icon. Author, Article, and Disclosure InformationAuthors: Joan Carles GarcÍa-Pagán, MD; Faust Feu, MD; Jaume Bosch, MD; Joan Rodés, MDFrom the Hospital Clinic i Provincial, University of Barcelona, Barcelona, Spain. For current author addresses, see end of text. 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