Carvedilol is associated with lower mortality than other nonselective beta-blockers in patients with cirrhosis.

Background: Recent guidelines have suggested that carvedilol should be first-line treatment in patients with cirrhosis and portal hypertension. This recommendation is based on data that rely on clinically impractical surrogates such as hepatic venous pressure gradient measurements. There is limited head-to-head data comparing carvedilol to other nonselective beta-blockers in the real-world setting.

Methods: This retrospective case-control study from a large health system compared patients with cirrhosis determined by ICD-10 algorithm and platelet count <150, who were treated with carvedilol versus nadolol or propranolol. Outcomes including hepatic decompensation (ascites, encephalopathy, variceal bleeding) and all-cause mortality were analyzed with adjustment for potential confounding using propensity score matching and time-dependent Cox regression.

Results: Among the 2302 cirrhosis patients meeting inclusion criteria, 1629 (70.8%) were on carvedilol and 673 (29.2%) were on nadolol or propranolol. In risk-adjusted analysis, patients on carvedilol had a lower hazard of hepatic decompensation (P < 0.001) and lower hazard of mortality (P = 0.03) compared to patients on propranolol/nadolol. The superiority of carvedilol applied equally to each decompensation type: ascites, encephalopathy, and variceal bleeding.

Conclusion: These findings support the use of carvedilol in patients with cirrhosis and clinically apparent portal hypertension, to decrease the risk of hepatic decompensation and improve survival.