HVPG-Guided Prophylaxis

Portal hypertension is defined as an increase of the pressure in the portal vein system. Nowadays portal hypertension is generally assessed using HVPG measurement. 10 mmHg is the threshold for clinically significant portal hypertension when complications of portal hypertension (i.e., esophageal variceal bleeding, ascites) can arise. HVPG measurement, if performed properly, can give important prognostic information and guide the treatment of patients in primary and secondary prophylaxis and in case of acute variceal bleeding. Several studies have shown that the decrease of HVPG to ≤12 mmHg by chronic treatment, in primary and secondary prophylaxis completely prevents variceal bleeding. In case of a reduction ≥20 % from baseline, even though not below 12 mmHg, there is still a protection from variceal bleeding. About 30–40 % of patients in primary prophylaxis and 40–50 % in secondary prophylaxis achieve a reduction in HVPG to ≤12 mmHg or ≥20 % during chronic medical treatment for portal hypertension and can be considered good hemodynamic responders. Those patients who do not achieve an hemodynamic response are considered nonresponders and their risk of bleeding is about 30–40 % at 2–3 years in primary prophylaxis and 46–65 % in secondary prophylaxis. In the setting of acute variceal bleeding, the finding of HVPG values ≥20 mmHg was a predictor of high risk of treatment failure; these “high risk” patients may benefit from treatment with “early TIPS” placement.