Effects of remote ischemic preconditioning in high-risk patients undergoing cardiac surgery (Remote IMPACT): a randomized controlled trial

Walsh, Michael; Whitlock, Richard; Garg, Amit X.; Légaré, Jean‐François; Duncan, Andra E.; Zimmerman, Robert F.; Miller, Scott; Fremes, Stephen E.; Karthikeyan, Ganesan; Chan, Matthew T. V.; Ho, Anthony D.; Nasr, Vivian; Vincent, Jessica; Ali, Imtiaz S.; Lavi, Ron; Sessler, Daniel I.; Kramer, Robert S.; Gardner, Jeff; Syed, Summer; VanHelder, Tomas; Guyatt, Gordon; Rao‐Melacini, Purnima; Thabane, Lehana; Devereaux, P.J.

doi:10.1503/cmaj.150632

Cited by 28 publications

(39 citation statements)

References 39 publications

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“…The ischemic protocol (cycles × I/R) was 3 × 5 min/5 min in 11 RCTs 17–19, 22, 26, 28, 29, 32, 35–37 , 4 × 5 min/5 min in 7 RCTs 24, 25, 27, 30, 31, 33, 34 , 3 × 10 min/10 min in 2 RCTs 20, 21 , and 2 × 5 min/5 min in 1 RCT 23 . The upper limb was used in 11 RCTs 17, 19, 22–29, 32, 35 , the lower limb in 3 RCTs 18, 20, 37 , the thigh in 6 RCTs 21, 30, 31, 33, 34, 36 , the combined of upper limb and thigh in 1 RCT 23 . The incidence of AKI was reported in 17 RCTs 17–27, 31–36 (AKI stage I in 11 RCTs 17–19, 22–27, 32, 36 ), the need for RRT in 19 RCTs 17–20, 22–33, 35–37 , mortality in 19 RCTs 17–19, 21–36 , MV duration in 13 RCTs 17, 20–22, 26–29, 31–35 , ICU stay in 16 RCTs 17, 20–23, 25–29, 31, 33–37 , and hospital length of stay (LOS) in 16 RCTs 17–23, 25–28, 31, 33, 34, 36, 37 .…”

Section: Resultsmentioning

confidence: 99%

Age and Surgical Complexity impact on Renoprotection by Remote Ischemic Preconditioning during Adult Cardiac Surgery: A Meta analysis

Zhou

Bulluck

Fang

et al. 2017

Sci Rep

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We aimed to conduct an up-to-date meta-analysis to comprehensively assess the renoprotective effect of remote ischemic preconditioning (RIPC) in patients undergoing adult cardiac surgery. 21 randomized controlled trials (RCTs) with a total of 6302 patients were selected and identified. Compared with controls, RIPC significantly reduced the incidence of acute kidney injury (AKI) [odds ratio (OR) = 0.79; P = 0.02; I2 = 38%], and in particular, AKI stage I (OR = 0.65; P = 0.01; I2 = 55%). RIPC significantly shortened mechanical ventilation (MV) duration [weighted mean difference (WMD) = −0.79 hours; P = 0.002; I2 = 53%), and reduced intensive care unit (ICU) stay (WMD = −0.23 days; P = 0.07; I2 = 96%). Univariate meta-regression analyses showed that the major sources of heterogeneity for AKI stage I were age (coefficient = 0.06; P = 0.01; adjusted R2 = 0.86) and proportion of complex surgery (coefficient = 0.02; P = 0.03; adjusted R2 = 0.81). Subsequent multivariate regression and subgroup analyses also confirmed these results. The present meta-analysis suggests that RIPC reduces the incidence of AKI in adults undergoing cardiac surgery and this benefit was more pronounced in younger patients undergoing non-complex cardiac surgery. RIPC may also shorten MV duration and ICU stay. Future RCTs tailored for those most likely to benefit from RIPC warrants further investigation.

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Section: Resultsmentioning

confidence: 99%

Age and Surgical Complexity impact on Renoprotection by Remote Ischemic Preconditioning during Adult Cardiac Surgery: A Meta analysis

Zhou

Bulluck

Fang

et al. 2017

Sci Rep

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“…Only 2 studies, one of them with only 4 patients per group, reported an increased infarct size with remote ischemic preconditioning. 127,128 Other studies were either neutral 36,38,[129][130][131][132][133][134][135][136][137][138] or had significantly reduced infarct size, as reflected by reduced biomarker release 37,139-149 ( Figure 3). Only one study each found improved clinical outcome at short-term 149 or more long-term follow-up.…”

Section: Remote Ischemic Conditioningmentioning

confidence: 99%

“…Propofol is known to abrogate protection by remote ischemic conditioning, which is seen with volatile anesthesia, 153,[162][163][164] and volatile anesthesia is the recommended anesthesia for patients at cardiac risk. 233,234 As seen from Figure 3, the only study with a significant increase of infarct size 128 and all neutral studies where information on the anesthetic regime is available 36,38,[130][131][132][133][135][136][137][138]150,155 had used propofol anesthesia, which, therefore, appears as the major denominator of all neutral/negative studies on remote ischemic conditioning in cardiovascular surgery.…”

Section: Current State Of Translation For Remote Ischemic Conditioningmentioning

confidence: 99%

Time to Give Up on Cardioprotection?

Heusch

Rassaf

2016

Circulation Research

174

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Abstract:The mortality from acute myocardial infarction (AMI) remains significant, and the prevalence of postmyocardial infarction heart failure is increasing. Therefore, cardioprotection beyond timely reperfusion is needed. Conditioning procedures are the most powerful cardioprotective interventions in animal experiments. However, ischemic preconditioning cannot be used to reduce infarct size in patients with AMI because its occurrence is not predictable; several studies in patients undergoing surgical coronary revascularization report reduced release of creatine kinase and troponin. Ischemic postconditioning reduces infarct size in most, but not all, studies in patients undergoing interventional reperfusion of AMI, but may require direct stenting and exclusion of patients with >6 hours of symptom onset to protect. Remote ischemic conditioning reduces infarct size in patients undergoing interventional reperfusion of AMI, elective percutaneous or surgical coronary revascularization, and other cardiovascular surgery in many, but not in all, studies. Adequate dose-finding phase II studies do not exist. There are only 2 phase III trials, both on remote ischemic conditioning in patients undergoing cardiovascular surgery, both with neutral results in terms of infarct size and clinical outcome, but also both with major problems in trial design. We discuss the difficulties in translation of cardioprotection from animal experiments and proof-ofconcept trials to clinical practice. Given that most studies on ischemic postconditioning and all studies on remote ischemic preconditioning in patients with AMI reported reduced infarct size, it would be premature to give up on cardioprotection. (Circ Res. 2016;119:676-695.

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“…* we recommend giving aspirin independent of (and in addition to) thrombosis prophylaxis under consideration of the bleeding risk For MINS prevention, two smaller studies seem interesting: the Prevention of Myocardial Injury in Non-cardiac Surgery trial is set to finish in 2017, which will examine whether or not remote ischemic preconditioning can reduce the number of patients with MINS in 540 patients undergoing hip fracture repair (however given the existing data in cardiac surgery [94][95][96], it seems unlikely that remote ischemic preconditioning is likely to significantly reduce MINS) and the Biomarkers, Blood Pressure, BIS: Risk Stratification/Management of Patients at Cardiac Risk in Major Noncardiac Surgery (BBB) study, set to finish in 2019 which will randomize 458 at-risk patients to a liberal or tight blood pressure control for influencing postoperative troponin.…”

Section: Direction and Outlookmentioning

confidence: 99%

Myocardial injury after noncardiac surgery

Mauermann

Puelacher²,

Buse³

2016

Current Opinion in Anaesthesiology

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Currently, we are limited to appreciating the vast extent of the MINS problem and applying recommendations based on observational data or derived from the nonoperative setting. Routine troponin measurements after noncardiac surgery and the increasing use of high-sensitivity troponins have revealed the larger underwater iceberg of perioperative myocardial injury and ischemia. Clinicians should be sensitized for this important complication and search for it using a perioperative troponin screening.

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Effects of remote ischemic preconditioning in high-risk patients undergoing cardiac surgery (Remote IMPACT): a randomized controlled trial

Cited by 28 publications

References 39 publications

Age and Surgical Complexity impact on Renoprotection by Remote Ischemic Preconditioning during Adult Cardiac Surgery: A Meta analysis

Age and Surgical Complexity impact on Renoprotection by Remote Ischemic Preconditioning during Adult Cardiac Surgery: A Meta analysis

Time to Give Up on Cardioprotection?

Myocardial injury after noncardiac surgery

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