Cardioprotective and prognostic effects of remote ischaemic preconditioning in patients undergoing coronary artery bypass surgery: a single-centre randomised, double-blind, controlled trial
Selected in Lancet by R. Dworakowski
Thielmann M, Kottenberg E, Kleinbongard P, Wendt D, Gedik N, Pasa S, Price V, Tsagakis K, Neuhäuser M, Peters J, Jakob H, Heusch G.
Lancet. 2013 Aug 17;382(9892):597–604
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It has been shown that remote ischaemic preconditioning (RIPC) by brief episodes of ischaemia and reperfusion (IR) in a remote organ or vascular territory provides myocardial protection. In coronary artery bypass graft (CABG) surgery clinical outcomes relate to myocardial injury but it has not been shown if reduction of perioperative myocardial injury by RIPC translates into better clinical outcomes.
Theilmann et al randomized 326 patients with three vessel coronary artery disease undergoing on pump CABG to two groups (RIPC group and control group) to test the effect of RIPC on myocardial injury and clinical outcomes including mortality. RIPC was associated with significant reduction of perioperative myocardial injury, which was expressed as area under the curve for troponin I (266ng/mL vs 321 ng/mL). More importantly all-cause mortality at 1 year (1.9% vs 6.9%), major adverse cardiac and cerebrovascular events (2.6% vs 12%) were less frequent in the RIPC group, although the rate of coronary revascularization did not differ. This difference in mortality was no more significant after excluding deaths from sepsis.
RIPC was described for the first time in 1983. The idea of remote myocardial protection is very attractive as RIPC can be quite easily achieved by repeated inflation of a blood-pressure cuff on the arm to achieve ischaemia followed by reperfusion with deflated cuff. Hence, RIPC was tested in clinical settings during cardiac surgery and coronary intervention. In most published studies significant cardioprotection was observed but they failed to show difference in clinical outcomes. It can be because of difference in tolerance to myocardial injury and/or cardioprotection confounded by age, gender, comorbidities (such as diabetes, LVH, hypercholesterolemia) and drugs (such as statins, ACEI).
This is the first study, which showed mortality benefit post cardiac surgery by using RIPC. Unfortunately the study was not powered for clinical outcomes and mortality was not a primary endpoint.
We still need to wait for larger randomized study to get a more definite answer about effect of RIPC on clinical outcomes. Nevertheless this study shows once more time that myocardial protection can be achieved with RIPC.