The Impact of Heart Rate Reduction From Individual Baseline With Propranolol for Primary and Secondary Prophylaxis of Variceal Hemorrhage in Cirrhosis

A target heart rate of 55-60 beats per minute is a goal for propranolol in both primary and secondary prophylaxis of variceal hemorrhage (VH). However, dose adjustments are often needed based on baseline heart rates. This study analyzed the effect of heart rate reduction from baseline with propranolol therapy on VH in patients with cirrhosis. A retrospective study was conducted on cirrhotic patients receiving propranolol for primary and secondary prophylaxis, 2008-2023. Patients were categorized as responders or non-responders based on the achievement of a heart rate reduction of ≥ 25% from baseline. The primary outcome was the incidence of VH. A survival analysis with propensity score-inverse probability treatment weighting was performed to associate heart rate reduction and the outcome. Among the 215 patients treated with propranolol for primary prophylaxis, 72 (33.5%) were responders and 143 (66.5%) non-responders. In secondary prophylaxis, 157 patients were included, with 52 (33.1%) classified as responders and 105 (66.9%) as non-responders. The median Child-Pugh score was 6 (range 5-12) for primary and 7 (range 5-12) for secondary prophylaxis. Responders and non-responders showed a similar incidence of VH in both primary (adjusted hazard ratio (HR) 1.70, 95% CI: 0.82-3.49) and secondary prophylaxis (adjusted HR 1.00, 95% CI: 0.34-2.90). Our analysis did not support achieving a heart rate reduction of ≥ 25% from baseline as a response to propranolol for the primary and secondary prophylaxis of VH in cirrhosis.