Hepatic Venous Pressure Gradient Response in Non-Selective Beta-Blocker Treatment—Is It Worth Measuring?

To review the evidence supporting the assessment of hepatic venous pressure gradient (HVPG) response to non-selective beta-blockers (NSBB). HVPG response to NSBB reduces the risks of variceal bleeding, hepatic decompensation due to ascites and its complications, and, finally, mortality. In hemodynamic non-responders to NSBB, their effectiveness is suboptimal, although there is increasing evidence for non-hemodynamic effects. Carvedilol may be a good treatment option for patients with non-response to conventional NSBB, as it is more potent in decreasing HVPG. Furthermore, hemodynamic non-responders may also benefit from (the addition of) other HVPG-lowering drugs that are in clinical development, and, depending on the setting, complimentary or alternative treatment strategies. Clinical benefits of HVPG response have been established throughout a broad spectrum of advanced chronic liver disease (ACLD) severity, ranging from compensated patients without varices but with clinically significant portal hypertension (CSPH) to subjects with a history of bleeding and/or non-bleeding hepatic decompensation. HVPG-guided NSBB therapy facilitates personalized medicine in patients with ACLD and portal hypertension. Since the clinical use of HVPG measurement is limited by its invasiveness and its availability is mostly restricted to academic centers, the development of non-invasive surrogates of HVPG response is of high clinical relevance.