The protective effect of ischaemic postconditioning (short cycles of reperfusion and reocclusion of a previously occluded vessel) was identified over a decade ago commanding intense interest as an approach for modifying reperfusion injury which contributes to infarct size in acute myocardial infarction. Elucidation of the major mechanisms of postconditioning has identified potential pharmacological targets for limitation of reperfusion injury. These include ligands for membrane-associated receptors, activators of phosphokinase survival signalling pathways and inhibitors of the mitochondrial permeability transition pore. In experimental models, numerous agents that target these mechanisms have shown promise as postconditioning mimetics. Nevertheless, clinical studies of ischaemic postconditioning and pharmacological postconditioning mimetics are equivocal. The majority of experimental research is conducted in animal models which do not fully portray the complexity of risk factors and comorbidities with which patients present and which we now know modify the signalling pathways recruited in postconditioning. Cohort size and power, patient selection, and deficiencies in clinical infarct size estimation may all represent major obstacles to assessing the therapeutic efficacy of postconditioning. Furthermore, chronic treatment of these patients with drugs like ACE inhibitors, statins and nitrates may modify signalling, inhibiting the protective effect of postconditioning mimetics, or conversely induce a maximally protected state wherein no further benefit can be demonstrated. Arguably, successful translation of postconditioning cannot occur until all of these issues are addressed, that is, experimental investigation requires more complex models that better reflect the clinical setting, while clinical investigation requires bigger trials with appropriate patient selection and standardization of clinical infarct size measurements.
LINKED ARTICLESThis article is part of a themed section on Conditioning the Heart -Pathways to Translation. To view the other articles in this section visit http://dx.doi.org/10.1111/bph.2015.172.issue-8 Abbreviations AMI, acute myocardial infarction; CK, creatine kinase; CK-MB, creatine kinase assay; CYP-D, cyclophilin-D; Cys-A, cyclosporine-A; eNOS, endothelial NOS; EPO, erythropoietin; GSK-3β, glycogen synthase-3β; MKATP, ATP-sensitive mitochondrial potassium channel; MPTP, mitochondrial permeability transition pore; PCI, percutaneous coronary intervention; RISK, reperfusion injury salvage kinase; ROS, reactive oxygen species; SAFE, survivor activating factor enhancement
Development of the postconditioning paradigm for cardioprotectionDeath due to acute myocardial infarction (AMI) has declined steadily in the economically developed countries during the last 50 years. Since the 1980s, the development of reperfusion therapies as the 'standard of care' for AMI has contributed markedly to the decline in early mortality. However, while case fatality rate has declined, there is evidence of an in...