Carvedilol Versus Endoscopic Variceal Ligation for Prophylaxis of Esophageal Variceal Bleeding in Patients With Liver Cirrhosis

Background: Esophageal variceal bleeding (EVB) is a life-threatening complication of liver cirrhosis. Carvedilol, a nonselective β-blocker with α1-blocking properties, and endoscopic variceal ligation (EVL) are both recommended for prophylaxis, but their comparative performance remains uncertain. Methods: A systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted, searching PubMed, Web of Science, and Embase to July 2025. Trials comparing carvedilol with EVL in adults with cirrhosis were included. Outcomes included all-cause and bleeding-related mortality, variceal bleeding, hepatic complications, and adverse events. Results: Nine RCTs enrolling 1385 patients were included. Carvedilol and EVL showed no significant differences in all-cause mortality (RR: 1.00, 95% CI: 0.64-1.54), variceal bleeding (RR: 1.04, 95% CI: 0.75-1.45), or bleeding-related mortality (RR: 1.71, 95% CI: 0.83-3.50). Rates of ascites (new or worsening), hepatocellular carcinoma, spontaneous bacterial peritonitis, hepatorenal syndrome/acute kidney injury, and TIPS requirement were also comparable. Treatment-related adverse event rates did not differ significantly (RR: 1.43, 95% CI: 0.65-3.11). Conclusion: Carvedilol and EVL provide similar prophylactic efficacy and safety profiles for EVB prevention in cirrhosis. Carvedilol represents a viable, noninvasive alternative, particularly in settings where endoscopy is impractical.