Systemic arterial blood pressure determines the therapeutic window of non‐selective beta blockers in decompensated cirrhosis

Summary Background The safety of non‐selective β‐blockers in patients with advanced cirrhosis has been questioned in recent years. It was hypothesised that there is a particular therapeutic window. However, the specific limits still need to be determined. Aim To evaluate potential limits of the therapeutic window of non‐selective β‐blocker therapy in patients with cirrhosis and ascites Methods The impact of non‐selective β‐blockers on 28‐day transplant‐free survival was analysed in a cohort of 624 consecutive patients with decompensated cirrhosis and ascites. Three potential limits were investigated: spontaneous bacterial peritonitis, acute‐on‐chronic liver failure, mean arterial blood pressure ≤ 82 and < 65 mm Hg. Results Treatment with non‐selective β‐blockers was associated with a higher 28‐day transplant‐free survival in the overall cohort (hazard ratio: 0.621; P = .035) as well as in patients with acute‐on‐chronic liver failure (hazard ratio: 0.578; P = .031) and those with spontaneous bacterial peritonitis (hazard ratio: 0.594; P = .073). In contrast, survival benefits were markedly attenuated in patients with a mean arterial blood pressure ≤ 82 mm Hg and completely lost in those with mean arterial blood pressure < 65 mm Hg ( P = .536). In spontaneous bacterial peritonitis patients with a mean arterial blood pressure < 65 mm Hg non‐selective β‐blocker treatment was associated with renal impairment. Of note, among those with a mean arterial blood pressure ≥ 65 mm Hg non‐selective β‐blocker intake was consistently associated with superior transplant‐free survival (hazard ratio: 0.582; P = .029) irrespective of the presence of spontaneous bacterial peritonitis (hazard ratio: 0.435; P = .028) or acute‐on‐chronic liver failure (hazard ratio: 0.480 P = .034). Conclusions Ascites, acute‐on‐chronic liver failure and spontaneous bacterial peritonitis do not limit the safe use of non‐selective β‐blockers in patients with cirrhosis. Mean arterial blood pressure might represent a better indicator to determine the therapeutic window of non‐selective β‐blocker treatment.