How do you decide between empiric carvedilol versus obtaining HVPG to confirm CSPH when noninvasive markers suggest CSPH but there is limited hemodynamic/renal reserve (borderline MAP and/or CKD)?

May be reasonable to consider EGD to assess for varices and/or band high risk especially if the patient ultimately cannot tolerate carvedilol.

I’m not sure how HVPG measurement would change your management other than confirming presence of CSPH, which you already have signs of noninvasively. I would consider low dose carvedilol trial with a low threshold to stop if not tolerated and screen for varices.