The beta-blocker window hypothesis postulates that the use of non-selective beta-blockers in patients with chronic liver disease is associated with improved survival rates only if certain criteria are met and if they are used outside that window period, they may be associated with increased mortality and morbidity.

Patients who are candidates to benefit from using beta-blockers include:

• Those patients who are in the second stage of the disease. Patients in the early stage of their disease do not have large varices and beta-blockers may not exert sufficient beneficial effects to prevent the progression of development of varices or prevent variceal bleeding. 
• patients who are stage 2 of cirrhosis can benefit from beta-blockers when used for primary or secondary prophylaxis of variceal bleeding. These patients have RAAS system and sympathetic system activation and their cardiac reserve are declining.
• The clinical window of beta-blockers use closes once the patient enters stage 3 of cirrhosis which is characterized by maximum CNS stimulation and RAAS activation. These patients have critically low cardiac index and the use of beta-blockers may further impair the cardiac reserves.

It is thus recommended to avoid using beta-blockers in patients who have advanced cirrhosis with refractory ascites and the following clinical parameters:

1. systolic blood pressure of less than 90 mm Hg,
2. mean arterial pressure of 82 mm Hg or less,
3. serum sodium levels of less than 120 mEq/L,
4. acute kidney injury,
5. hepatorenal syndrome,
6. spontaneous bacterial peritonitis,
7. sepsis,
8. severe alcoholic hepatitis,
9. non-compliance to treatment and poor follow-up.

Clinical scenarios where Beta-Blockers should not be used include:

• Child-Pugh Turcotte (CPT) - C or Model for End-stage Liver Disease (MELD) score of 25 or more, and

  • Diuretic-refractory or diuretic intolerant ascites as in patients with renal dysfunction, hyponatremia, and hepatic encephalopathy,

  • Cardiac index of 1.5 L/min/m² or less,

  • Systolic blood pressure less than or equal to 90 mm Hg,

  • Within six months after the first episode of spontaneous bacterial peritonitis.