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Beta-blockers for the prevention of variceal haemorrhage in patients with cirrhosis: an updated meta-analysis of randomized controlled trials.

Bleeding from oesophageal or gastric varices is a major complication of portal hypertension, and a leading cause of death in patients with liver cirrhosis. The efficacy of oral beta-blockers in preventing recurrence of gastrointestinal haemorrhage in these patients is debatable. A recent meta-analysis showed benefits in reducing bleeding risk, but results on mortality were inconclusive. We combined results from all available randomized controlled trials to evaluate treatment with beta-blockers in the prevention of the first bleeding episode, or recurrent haemorrhage, in patients with cirrhosis and varices. Scrutiny of the data from all 13 available randomized trials, in which 1154 patients were entered, suggests that treatment (4 trials, 589 patients) may decrease the rate of the first bleeding episode (p less than 0.001), but not of death in the same patients. Results from the analysis of 9 trials (565 patients) for the prevention of recurrent haemorrhage suggest a beneficial effect of treatment on bleeding (p less than 0.0001), and a slight efficacy on survival (p less than 0.05) by the DerSimonian and Laird method. The implications of this analysis are that (i) updating of meta-analyses is useful to overcome the problem of negative results of undersized trials and previous meta-analyses; and (ii) treatment with beta-blockers, for the prevention of the first bleeding episode or recurrent haemorrhage, appears to be promising, but its effects on an important end point, such as death, still need to be reliably assessed.