Cardioprotection by combined intrahospital remote ischaemic perconditioning and postconditioning in ST-elevation myocardial infarction
Selected in European Heart Journal by G.G. Toth
Eitel I, Stiermaier T, Rommel KP, Fuernau G, Sandri M, Mangner N, Linke A, Erbs S, Lurz P, Boudriot E, Mende M, Desch S, Schuler G, Thiele H
Eur Heart J. 2015 Nov 21;36(44):3049-57
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The randomized LIPSIA CONDITIONING trial
Although prompt reopening of the culprit vessel is crucially important for patients with acute ST-elevation myocardial infarction, myocardial reperfusion injury is a known phenomenon with potential deleterious effects. Mainly animal experiments suggest beneficial effect of remote ischemic conditioning (RIC) and postconditioning (PostC), while human data are rather limited. The combination of the two methods mentioned above have never been investigated before in a large randomized fashion.
- This single center study enrolled patients with acute STEMI (<12h) and randomized 1:1:1 to RIC+PostC+PCI vs PostC+PCI vs PCI alone.
- RIC was performed as follows: three cycles of 5 min inflation to 200 mmHg and 5 min deflation of an upper arm blood pressure cuff, started prior to PCI.
- PostC was performed as follows: within 1 min of reopening the infarct-related coronary artery, the angioplasty balloon was reinflated four times with low pressure (4–6 atm) ensuring complete occlusion, with each inflation lasting 30s and separated by 30s for reflow.
- Primary endpoint was defined as myocardial salvage index by cardiac magnet resonance tomography 2-5 days after index procedure. Secondary outcome parameters were infarct size and microvascular obstruction and composite clinical endpoint defined as death, reinfarction and occurrence of new congestive heart failure within 6 months after randomization.
- 696 patients were randomized in the study.
- Peak CK was the lowest in the RIC+PostC+PCI group with a trend for statistical significance as compared to PCI alone group (p=0.06). ST-segment resolution was significantly greater in RIC+PostC+PCI group when compared with the PCI alone group (p=0.046). Difference between PostC+PCI group and PCI alone group was not significant for both.
- Myocardial salvage index was significantly greater in the RIC+PostC+PCI group (median 49; IQR 30 to 72) when compared with the PCI alone group (median 40; IQR 16 to 68) (p=0.020), whereas no significant difference between PostC+PCI group (median 44; IQR 21 to 71) and PCI alone group was observed (p=0.39). The secondary endpoints including infarct size and microvascular obstruction and the composite clinical endpoint showed no significant differences between groups.
RIC and PostC have been in the focus of experiments for many years now, showing really promising results from animal data. Being very simple and practically ‘no-cost’ methods, their application in humans has been considered to be very attractive, if clinical benefit is achievable.
This was the first study investigating the application of combined RIC and PostC on a large patient population. The study achieved to show significant beneficial effect in terms of increased myocardial salvage when combining RIC and PostC in addition to PCI as compared to conventional primary PCI alone. However, disappointingly this result could not be translated to outcome advantage in any clinical endpoints. Still, considering the promising results it might be worth to further investigate the clinical potentials and best application of the methods.