🔴 BAVENO VIII – Portal Hypertension: What Changes Clinical Practice? 📌 Baveno VIII – Advancing Consensus in Portal Hypertension The Baveno VIII consensus, developed across 9 expert panels, achieved strong consensus on 272 statements/recommendations and proposes 153 research priorities. The central message continues the paradigm shift from simply preventing variceal bleeding to identifying clinically significant portal hypertension (CSPH) early and preventing first and further hepatic decompensation. 🔑 1. CSPH remains the pivotal therapeutic threshold CSPH = HVPG ≥10 mmHg, but invasive HVPG is no longer necessary for routine risk stratification in many compensated patients. 👉 Liver stiffness measurement (LSM), platelet count and increasingly spleen stiffness form the backbone of non-invasive assessment. Clinical pearl: Do not wait for varices to appear before thinking about portal-hypertension-directed treatment. 🔑 2. The “Rule of Five” remains clinically powerful Think progressively: LSM 5 → 10 → 15 → 20 → 25 kPa Increasing liver stiffness reflects progressively increasing probability of advanced liver disease, CSPH and clinical events. The well-validated Baveno framework remains: ✅ LSM ≤15 kPa + platelets ≥150 ×10⁹/L → CSPH can generally be ruled out. ✅ LSM ≥25 kPa → strongly supports CSPH in appropriate populations. But an important caveat is MASLD with obesity: an isolated LSM ≥25 kPa is less reliable for ruling in CSPH. Recent individual-patient meta-analysis showed that obesity materially reduces the reliability of this simple rule-in threshold. 🔑 3. The old 15–25 kPa “grey zone” is becoming smaller Patients falling between the classical rule-out and rule-in thresholds should not automatically undergo invasive testing. Additional tools such as: ➡️ platelet count ➡️ spleen stiffness measurement (SSM) ➡️ ANTICIPATE/ANTICIPATE-NASH probability models ➡️ selected biochemical algorithms can further refine CSPH probability. This is particularly relevant in steatotic liver disease and obesity, where a one-size-fits-all LSM threshold performs less well. 🔑 4. Carvedilol is not merely an “anti-variceal” drug This is one of the most important conceptual messages for physicians. In a compensated patient with CSPH, a non-selective β-blocker is used not only to prevent bleeding but to prevent hepatic decompensation, particularly ascites. Carvedilol remains particularly important because of its additional α1-blocking action and greater portal-pressure reduction. Thus the clinical thinking becomes: CSPH identified → ask whether NSBB/carvedilol is appropriate, rather than waiting for large varices. Baveno VII established this paradigm, and subsequent evidence has strengthened non-invasive identification of the patients most likely to benefit. 🔑 5. Endoscopy becomes more selective A major evolution of Baveno guidance is: Not every compensated patient with cirrhosis needs screening endoscopy solely to decide whether to start an NSBB. If CSPH is established and the patient is an appropriate candidate for an NSBB, treatment may be initiated on the basis of the portal-hypertension risk assessment. Endoscopy assumes greater importance when: ➡️ NSBBs are contraindicated/intolerable ➡️ the non-invasive assessment is uncertain ➡️ endoscopic therapy would alter management. This represents a move from “find varices and treat them” toward “identify portal hypertension and prevent decompensation.” 🔑 6. MASLD changes the portal-hypertension equation Baveno VIII gives increased importance to steatotic liver disease and its modifiers. ⚠️ Obesity can alter the diagnostic performance of VCTE. Therefore: LSM ≥25 kPa should not be interpreted mechanically in an obese MASLD patient. BMI, platelets and other NITs may need to be integrated. 📖Next .....journal-of-hepatology.eu/art…