Is carvedilol superior to propranolol in patients with cirrhosis with portal hypertension: a systematic and meta-analysis

Background: Carvedilol has shown greater potency than propranolol as a β-blocker in managing cardiac conditions. However, its efficacy in reducing portal hypertension (PHTN) in patients with cirrhosis remains unclear. This study evaluates the efficacy and safety of carvedilol compared with propranolol in managing PHTN. Methods: A systematic review and meta-analysis were conducted using PubMed, Scopus and Embase databases. Randomized controlled trials comparing carvedilol and propranolol were included. Primary outcomes were changes in hepatic venous pressure gradient, wedge hepatic venous pressure and free hepatic venous pressure. Secondary outcomes included heart rate, cardiac output and mean arterial pressure. Tertiary outcomes assessed adverse event incidences. Results: Six randomized controlled trials involving 336 patients (171 carvedilol, 165 propranolol) were analysed. Carvedilol significantly reduced hepatic venous pressure gradient (mean difference (MD): 2.22 (95% CI 1.82- 2.62); p<0.00001) and wedge hepatic venous pressure (MD: 2.38 (95% CI 1.92-2.84); p<0.00001). Propranolol significantly reduced cardiac output (MD: -0.60 (95% CI -0.74 to -0.45); p<0.00001). Mean arterial pressure was significantly lower in the carvedilol group (MD: 1.79 (95% CI 0.38-3.20); p=0.01). Adverse events, such as orthostatic hypotension and increased diuretic use, were more frequent in the carvedilol group but were manageable. Conclusion: Carvedilol demonstrates superior efficacy in reducing PHTN compared with propranolol, with a slightly higher but tolerable adverse event profile. It may be considered the first-line treatment for PHTN. Further research is needed to validate long-term benefits and safety.