Beta-blockers have no effect on outcomes in patients with cirrhosis and severe infections
Authors: Arnaud Galbois, Vincent Das, Dominique Thabut, Eric Maury, Hafid Ait-Oufella, Chantal Housset, Bertrand Guidet
Journal: Hepatology (2010)

In a prospective, observational study, Sersté et al.1 reported a deleterious effect of beta-blockers on survival in patients with cirrhosis and refractory ascites, but they were unable to provide a clear explanation. However, Wong and Salerno2 highlighted that among the 97 patients who died, the first cause of death was sepsis (51.5%), and they raised the hypothesis of a deleterious effect of beta-blockers in patients with cirrhosis and sepsis. To address this hypothesis, we retrospectively analyzed a cohort of 68 patients with cirrhosis who were admitted to our medical intensive care unit (ICU) for severe sepsis or septic shock. Patients who were receiving beta-blockers and patients who were not receiving beta-blockers just before admission (beta-blockers were discontinued during the period of hemodynamic instability) were compared. The data were extracted from a database approved by the national committee (Commission Nationale de l'Informatique et des Libertés).3 The characteristics of the two groups on admission, depicted in Table 1, were not different except for esophageal varices, which were more frequent in the beta-blocker group (92.3% versus 38.1%, P < 0.001). There was no difference in the Child-Pugh, Model for End-Stage Liver Disease (MELD), or MELD-Na scores, in the general ICU-specific score [Simplified Acute Physiology Score II (SAPS II)],4 or in the Sequential Organ Failure Assessment (SOFA) score5 (Table 1). The two groups did not differ in their systemic arterial pressure on admission or in their vasopressor requirements during their ICU stay. A trend toward a lower heart rate was found in the group receiving beta-blockers [94 (78-117 bpm) versus 113 bpm (90-125 bpm), P = 0.07]. The ICU mortality rates were similar for the patients who had received beta-blockers and those who had not (57.7% versus 61.9%, P = 0.80), and these rates were also similar to those previously reported for critically ill patients with cirrhosis.3, 6 However, among ICU survivors, the mortality rate at 6 months was higher in patients who had received beta-blockers (54.5% versus 12.5%, P = 0.03), and this was in accordance with the results of Sersté et al.1 The fact that varices were more frequent in patients who had received beta-blockers is a limitation of both Sersté et al.'s study1 and ours. Despite this limitation, we could show that patients with cirrhosis who were admitted to the ICU for severe sepsis or septic shock and had been treated with beta-blockers before admission did not require vasopressors more often and had no increased ICU mortality. Our results suggest that there is no impact of beta-blockers on ICU mortality in patients with cirrhosis resulting from severe sepsis or septic shock. If a deleterious effect of beta-blockers in patients with refractory ascites is to be confirmed, it is unlikely that the underlying mechanism is increased mortality due to an inadequate hemodynamic response to severe sepsis. Arnaud Galbois M.D.* ¶, Vincent Das M.D**, Dominique Thabut M.D ¶ , Eric Maury M.D* ¶, Hafid Ait-Oufella M.D* § ¶, Chantal Housset M.D ¶, Bertrand Guidet M.D* ¶, * Service de Réanimation Médicale, Hôpital Saint-Antoine, Assistance Publique–Hôpitaux de Paris, Paris, France, Unités Mixtes de Recherche en Santé 938, Institut National de la Santé et de la Recherche Médicale, Paris, France, Unités Mixtes de Recherche en Santé 707, Institut National de la Santé et de la Recherche Médicale, Paris, France, § Unités Mixtes de Recherche 970, Institut National de la Santé et de la Recherche Médicale, Paris, France, ¶ Université Pierre et Marie Curie–Sorbonne Universités Paris, France, ** Service de Réanimation Polyvalente Adulte, Centre Hospitalier Intercommunal André Grégoire, Montreuil, France, Service d'Hépato-Gastroentérologie, Hôpital de la Pitié-Salpêtrière, Assistance Publique–Hôpitaux de Paris, Paris, France.