Remote Ischemic Conditioning in Emergency Medicine—Clinical Frontiers and Research Opportunities

Abstract

Time-critical acute ischemic conditions such as ST-elevation myocardial infarction and acute ischemic stroke are staples in Emergency Medicine practice. While timely reperfusion therapy is a priority, the resultant acute ischemia/reperfusion injury contributes to significant mortality and morbidity. Among therapeutics targeting ischemia/reperfusion injury (IRI), remote ischemic conditioning (RIC) has emerged as the most promising. RIC, which consists of repetitive inflation and deflation of a pneumatic cuff on a limb, was first demonstrated to have protective effect on IRI through various neural and humoral mechanisms. Its attractiveness stems from its simplicity, low-cost, safety, and efficacy, while at the same time it does not impede reperfusion treatment. There is now good evidence for RIC as an effective adjunct to reperfusion in ST-elevation myocardial infarction patients for improving clinical outcomes. For other applications such as acute ischemic stroke, subarachnoid hemorrhage, traumatic brain injury, cardiac arrest, and spinal injury, there is varying level of evidence. This review aims to describe the RIC phenomenon, briefly recount its historical development, and appraise the experimental and clinical evidence for RIC in selected emergency conditions. Finally, it describes the practical issues with RIC clinical application and research in Emergency Medicine.

Regulation of STAT3 and its role in cardioprotection by conditioning: focus on non-genomic roles targeting mitochondrial function

“…Remote ischemic conditioning is performed by applying brief cycles of IR in a remote organ or tissue from the heart; it was demonstrated to protect the heart against subsequent ischemic events, not only in animal models, but also in humans and it is currently under studies in the clinic [33,85,171].…”

Remote Ischemic Conditioning in Ischemic Stroke and Myocardial Infarction: Similarities and Differences

“…Once again, an automatic device can relieve both manpower and cognitive resources in the emergency setting, as it can be left in place once a pre-programmed protocol has been set. Interestingly, RIC can also be given in the emergency department, and even in the catheterization laboratory ( 88 ).…”

Effect of remote ischemic preConditioning on liver injury in patients undergoing liver resection: the ERIC-LIVER trial

“…The presence of a hepatoprotective effect from RIPC has been postulated based on the demonstrated protection from IRI in many other organs, ranging from the heart, kidneys, brain, soft tissue grafts and lungs in a variety of experimental and clinical settings. 14,25 At the same time, local (non-remote) IPC (such as from portal triad clamping) have demonstrated benefits in liver surgery, with a 2016 Bayesian network meta-analysis suggesting reduced blood transfusion requirement and lesser operative time, but too few trials and patients to make conclusions on patient-oriented outcomes such as mortality, hospital stay or Intensive Therapy Unit (ITU) stay. 11 The mechanism of hepatoprotection by RIPC is not fully understood.…”

“…11 Remote ischemic preconditioning (RIPC) describes the phenomenon in which the application of brief episodes of non-lethal ischemia and reperfusion to an organ (such as the kidney, liver or small intestine) or tissue (such as the skeletal muscle) is protective against acute lethal IRI. 12,13 RIPC is non-invasive, low-cost, and has been shown to reduce organ injury in acute ischemic conditions 14,15 including myocardial injury from coronary bypass graft surgery 16,17 , and has the potential to reduce liver injury after liver surgery.…”