S1355 Carvedilol Equals Endoscopic Band Ligation for Preventing First Variceal Bleed and Death: An Updated Systematic Review and Meta-Analysis of 8 Randomized Controlled Trials

Introduction: Acute oesophageal-variceal hemorrhage remains one of the deadliest decompensation events in cirrhosis, driving substantial global mortality and rehospitalisation costs. Although current guidelines endorse either non-selective β-blockers (NSBBs) or endoscopic variceal band ligation (EVBL) for primary prophylaxis, direct comparative data are limited. Carvedilol—a vasodilatory NSBB that achieves greater portal-pressure reduction than propranolol—has been elevated to preferred status in the Baveno VII recommendations, yet its relative efficacy and safety versus EVBL have not been systematically synthesised. Methods: A systematic search of PubMed, Embase, Scopus, and Cochrane Library identified randomized controlled trials (RCTs) comparing carvedilol with Band Ligation in managing variceal bleeding through May 2025. Data were analyzed using RevMan 4.2.1. Pooled risk ratios (RRs) with 95% confidence intervals (CIs) were calculated using Mantel-Haenszel methods. Random- or fixed-effects models were applied based on heterogeneity (Higgins’ I²). Statistical significance was set at P < 0.05. Risk of bias was assessed using RoB 2.0. Results: Across 8 RCTs enrolling 1,481 cirrhotic patients, first-bleed rates were 11.6% (85/736) vs 12.1% (90/745), giving RR 0.92 (95% CI 0.60–1.41; P = 0.72; I² = 47%). Five trials (n = 832) found no difference in all-cause mortality (16.6% vs 14.4%; RR 1.15, 95% CI 0.84–1.58; P = 0.39; I² = 0%). Safety was comparable: Six trials (n = 1,025) showed numerically fewer adverse events with carvedilol (23.8% vs 29.0%; RR 0.85, 95% CI 0.64–1.13; P = 0.26; I² = 56%), and 4 trials (n = 592) reported similar bleed-related mortality (6.8% vs 5.4%; RR 1.26, 95% CI 0.67–2.37; P = 0.47; I² = 0%). Conclusion: Carvedilol prevented first variceal bleeding, all-cause death and bleed-related mortality as effectively as EVBL, while showing a non-significant trend toward fewer adverse events. The lack of superiority for EVBL, coupled with carvedilol’s oral administration, low cost and capacity to reduce portal pressure systemically, supports its use as a pragmatic first-line option—particularly where endoscopic resources are constrained or patients prefer to avoid repeated procedures. These findings strengthen the guideline momentum toward β-blocker-based prophylaxis and highlight the need for implementation studies that integrate quality-of-life and cost-effectiveness.