American Board of Internal Medicine (ABIM) Certification Practice Exam

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What is the primary medication recommended for the prevention of variceal hemorrhage in patients with cirrhosis?

Propranolol
Metoprolol
Enalapril
Atenolol

The correct answer is: Propranolol

Propranolol is recognized as the primary medication for preventing variceal hemorrhage in patients with cirrhosis. This non-selective beta-blocker reduces portal hypertension by decreasing cardiac output and splenic blood flow, ultimately lowering the pressure in the portal venous system. By effectively lowering portal pressure, propranolol helps to reduce the risk of bleeding from esophageal varices, which are dilated veins that can rupture and lead to significant bleeding in patients with advanced liver disease. Non-selective beta-blockers like propranolol are preferred over selective beta-blockers, such as metoprolol, for this specific indication. Although metoprolol can also be used, it is primarily a selective beta-1 blocker with less effect on portal pressure compared to propranolol. Enalapril, an ACE inhibitor, and atenolol, a selective beta-1 blocker, are not indicated for the prevention of variceal hemorrhage and do not significantly address the problem of portal hypertension in the same way as the non-selective agents. Therefore, propranolol emerges as the most effective choice for this preventive measure in patients with cirrhosis.