From the Guidelines
The target heart rate for managing esophageal varices should be around 50-55 bpm, but this should be approached with caution in decompensated patients, considering the risk of systemic circulatory dysfunction and the need for a critical risk/benefit evaluation. Treatment of esophageal varices focuses on reducing portal hypertension, which is the underlying cause of these dilated veins in the esophagus. Non-selective beta-blockers (NSBBs) such as propranolol or nadolol are the primary medications used, with the goal of reducing the heart rate by 25% from baseline or to about 50-55 beats per minute, while maintaining systolic blood pressure above 90mmHg 1. The dose should be gradually increased until the target heart rate reduction is achieved or the maximum tolerated dose is reached. These medications work by decreasing cardiac output and causing splanchnic vasoconstriction, which reduces portal pressure and the risk of variceal bleeding.
- Key considerations in managing esophageal varices include:
- Monitoring for side effects such as fatigue, dizziness, and hypotension
- Regular follow-up with a gastroenterologist to assess treatment effectiveness and adjust medication dosages as needed
- Considering alternative treatments such as endoscopic variceal ligation if beta-blockers are contraindicated or not tolerated
- Being cautious when using NSBBs in patients with refractory ascites and signs of systemic circulatory dysfunction, as they may be more vulnerable to the adverse effects of these medications 1.
- In patients with refractory ascites, the use of NSBBs should be based on a critical risk/benefit evaluation, and parameters such as severe hyponatraemia, low mean arterial pressure or cardiac output, and increasing SCr should be considered to identify more vulnerable patients 1.
- The recent BAVENO VI consensus proposed that in patients with refractory ascites and certain conditions, such as systolic blood pressure <90 mmHg, or SCr >1.5 mg/dl, or hyponatraemia <130 mmol/L, the NSBB dose should be reduced or even temporarily discontinued 1.
From the Research
Target Heart Rate for Esophageal Varicose
There is no direct information available on the target heart rate for esophageal varicose. However, the following information is available on the treatment and management of esophageal varices:
- Medical prophylaxis consists of non-selective beta-blockers like propranolol or carvedilol 2
- The hemodynamic response to medical treatment of portal hypertension as a predictor of clinical effectiveness in the primary prophylaxis of variceal bleeding in cirrhosis is established 3
- The assessment of hemodynamic response to drugs in terms of hepatic venous pressure gradient (HVPG) is the best predictor of efficacy of prophylaxis of variceal bleeding in patients treated with beta-blockers or beta-blockers plus nitrates 3
- Beta-blockers have a significant impact in the treatment of portal hypertension, but the question of how long they should be continued for prevention of variceal hemorrhage remains unknown 4
- Indefinite administration of beta blockers for primary prevention of variceal bleeding has become standard practice 4
Treatment Options
Some treatment options for esophageal varices include:
- Endoscopic variceal banding 5
- Sclerotherapy 5
- Treatment with Sengstaken-Blakemore tube or self-expanding covered metallic esophageal stent for acute variceal bleeding refractory to standard pharmacologic and endoscopic therapy 5
- Non-selective beta-blockers like propranolol or carvedilol for medical prophylaxis 2
- Variceal endoscopic band ligation, which is equally effective as medical prophylaxis but has the drawback of procedure-related morbidity 2
Hemodynamic Response
The hemodynamic response to medical treatment is an important factor in predicting the clinical effectiveness of prophylaxis: