背景:在英国,晚期慢性肝病是导致过早发病率和死亡率增加的原因。门脉高压是代偿失调的主要驱动因素,包括腹水的发展,肝性脑病和静脉曲张出血。非选择性β受体阻滞剂(NSBB)可降低门静脉压力,并且在预防静脉曲张出血方面已得到公认。卡维地洛,一个新的NSBB,由于额外的α-肾上腺素能阻滞,在降低门静脉压力方面更有效,并且具有额外的抗氧化剂,抗炎和抗纤维化作用。
目的:总结使用β受体阻滞剂的现有证据,特别是卡维地洛,在肝硬化中,关注何时以及为什么开始方法:我们对PubMed进行了全面的文献检索,以获取相关出版物。
结果:国际指南建议使用NSBB预防高风险静脉曲张患者的静脉曲张出血。与内镜下绑带结扎术(EBL)相当的疗效证据。NSBB在二级预防中也很成熟,结合EBL。更有争议的是它们在没有大静脉曲张的患者中的使用,但有临床意义的门静脉高压.然而,有证据表明NSBB,尤其是卡维地洛,降低失代偿风险,提高生存率。尽管晚期肝硬化和难治性腹水患者应谨慎行事,最近的证据表明,NSBB可以继续安全使用,过早停药可能是有害的。
结论:随着独立于静脉曲张出血的获益证据的增加,即失代偿的延迟和生存的改善,现在是时候考虑是否应该向所有晚期慢性肝病患者提供卡维地洛。
Advanced chronic liver disease is an increasing cause of premature morbidity and mortality in the UK. Portal hypertension is the primary driver of decompensation, including the development of ascites, hepatic encephalopathy and variceal haemorrhage. Non-selective beta blockers (NSBB) reduce portal pressure and are well established in the prevention of variceal haemorrhage. Carvedilol, a newer NSBB, is more effective at reducing portal pressure due to additional α-adrenergic blockade and has additional anti-oxidant, anti-inflammatory and anti-fibrotic effects.
To summarise the available evidence on the use of beta blockers, specifically carvedilol, in cirrhosis, focussing on when and why to start METHODS: We performed a comprehensive literature search of PubMed for relevant publications.
International guidelines advise the use of NSBB in primary prophylaxis against variceal haemorrhage in those with high-risk
varices, with substantial evidence of efficacy comparable with endoscopic band ligation (EBL). NSBB are also well established in secondary prophylaxis, in combination with EBL. More controversial is their use in patients without large
varices, but with clinically significant portal hypertension. However, there is gathering evidence that NSBB, particularly carvedilol, reduce the risk of decompensation and improve survival. While caution is advised in patients with advanced cirrhosis and refractory ascites, recent evidence suggests that NSBB can continue to be used safely, and that premature discontinuation may be detrimental.
With increasing evidence of benefit independent of variceal bleeding, namely retardation of decompensation and improvement in survival, it is time to consider whether carvedilol should be offered to all patients with advanced chronic liver disease.