I read with interest the article by Serste et al.,1 who showed that beta-blockers are deleterious to the survival of patients with cirrhosis and refractory ascites. Because the study was performed with two groups of patients with cirrhosis with striking differences in their characteristics, it should be interpreted with caution. As indicated in the editorial by Wong and Salerno,2 the patients on beta-blockers were indeed sicker: they had higher bilirubin levels, lower albumin levels, lower arterial pressures, and lower serum sodium levels, and more patients had hepatic encephalopathy, hepa-tocellular carcinoma, and Child-Pugh class C cirrhosis. In addition, the patients receiving beta-blockers were taking them for the prevention of variceal hemorrhaging, but only 4% of the patients not receiving beta-blockers had esophageal varices. I do not know whether the patients received beta-blockers mainly for primary or secondary prevention of variceal bleeding. If patients had episodes of variceal bleeding with concomitant refractory ascites and hepato-cellular carcinoma, the outcome was naturally very dismal.
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