Elsevier

International Journal of Cardiology

Volume 178, 15 January 2015, Pages 136-141
International Journal of Cardiology

Remote ischemic preconditioning reduces contrast-induced acute kidney injury in patients with ST-elevation myocardial infarction: A randomized controlled trial

https://doi.org/10.1016/j.ijcard.2014.10.135Get rights and content

Highlights

  • RIPC reduced acute kidney injury after emergency percutaneous coronary intervention.

  • RIPC was safe and was an easy strategy in real clinical settings.

  • RIPC is a promising strategy in patients with ST-elevation myocardial infarction.

Abstract

Background

Contrast medium-induced acute kidney injury (CI-AKI) is a cardiovascular complication after myocardial infarction treated with emergency percutaneous coronary intervention. The aim of this randomized, sham-controlled trial was to evaluate the impact of remote ischemic preconditioning (RIPC) on CI-AKI in patients with ST-elevation myocardial infarction who received emergency primary percutaneous coronary intervention.

Methods and results

Patients with a suspected ST-elevation myocardial infarction were randomly assigned at a 1:1 ratio to receive percutaneous coronary intervention either with (n = 63) or without (n = 62) RIPC (intermittent arm ischemia through three cycles of 5 min of inflation and 5 min of deflation of a blood pressure cuff). A total of 47 RIPC patients and 47 control patients met all study criteria. The primary endpoint was the incidence of CI-AKI, which was defined as an increase in serum creatinine > 0.5 mg/dL or > 25% over the baseline value 48–72 h after administration of contrast medium. The incidence of CI-AKI was 10% (n = 5) in the RIPC group and 36% (n = 17) in the control group (p = 0.003). The odds ratio of CI-AKI in patients who received RIPC was 0.18 (95% confidence interval: 0.05–0.64; p = 0.008).

Conclusions

In patients with ST-elevation myocardial infarction, RIPC before percutaneous coronary intervention reduced the incidence of CI-AKI.

Introduction

ST-elevation myocardial infarction (STEMI) is a leading cause of mortality and morbidity. The reduction of myocardial injury is the mainstay of therapy for STEMI and is best achieved by early reperfusion through emergency percutaneous coronary intervention (PCI) [1]. Patients receiving such treatment achieve infarct-related vessel patency and reperfusion, but risk sustaining clinically significant myocardial infarction, even when the procedure is done soon after symptom onset [2]. Cardiac complications after emergency PCI with STEMI, such as heart failure and cardiac rupture, are potentially lethal and lead to an impaired prognosis [3]. Additionally, contrast medium-induced acute kidney injury (CI-AKI), a cardiovascular complication after myocardial infarction, is a frequent complication of emergency PCI and is associated with an increased mortality rate and persistent renal dysfunction [4], [5].

Remote ischemic preconditioning (RIPC) is the phenomenon in which transient nonlethal ischemia and reperfusion applied to one organ or tissue protects another organ or tissue from a subsequent episode of lethal ischemia and reperfusion [6]. A previous study showed that RIPC applied before PCI in patients with evolving STEMI was able to increase myocardial salvage [7]. Additionally, a recent study demonstrated that RIPC performed before administration of contrast medium prevented CI-AKI in moderate- to high-risk patients [8], [9], [10]. The role of RIPC in reducing CI-AKI in STEMI patients undergoing emergency PCI is not clear. In this prospective, randomized, sham-controlled pilot study, we evaluated the impact of RIPC on CI-AKI in patients with STEMI who received emergency primary PCI, and hypothesized that RIPC applied before PCI would reduce the incidence of CI-AKI in patients with STEMI.

Section snippets

Methods

This study was a prospective, single-blind, multicenter, randomized, sham-controlled parallel-group study conducted from 2012 to 2013 at Saiseikai Imabari Hospital, Ehime Prefectural Central Hospital, and Okayama University Hospital, in Japan. The study was approved by the ethics committees of all three hospitals, and written informed consent was obtained from all participants before beginning the protocol. This study was conducted according to the principles expressed in the Declaration of

Study flow and patient characteristics

A flow diagram is shown in Fig. 1. One hundred twenty-five STEMI patients were randomized to receive RIPC before PCI (n = 63) or primary PCI alone (n = 62). Twenty-nine patients (15 in the RIPC group and 14 in the control group) were excluded because of no enzymatic evidence of infarction (n = 13), greater than 24-hour symptom-to-balloon time (n = 5), severe heart failure requiring percutaneous cardiopulmonary support (n = 8), receiving hemodialysis (n = 3), and withdrawal of informed consent (n = 2). Thus,

Discussion

The main finding of this prospective, multicenter, randomized study was that RIPC induced by intermittent upper-arm ischemia before emergency PCI dramatically reduced the incidence of CI-AKI in patients with STEMI. Multivariate logistic analysis revealed that this protective effect was independent of other risk factors. Additionally, the reduction in CI-AKI was accompanied by a reduction in infarct size and dysrhythmic events within 24 h after PCI.

To date, there is no effective prophylactic drug

References (29)

  • H.R. Andersen et al.

    A comparison of coronary angioplasty with fibrinolytic therapy in acute myocardial infarction

    N. Engl. J. Med.

    (2003)
  • H. Ito

    No-reflow phenomenon and prognosis in patients with acute myocardial infarction

    Nat. Clin. Pract. Cardiovasc. Med.

    (2006)
  • M.W. Rich et al.

    Incidence, risk factors, and clinical course of acute renal insufficiency after cardiac catheterization in patients 70 years of age or older. A prospective study

    Arch. Intern. Med.

    (1990)
  • K. Przyklenk et al.

    Regional ischemic ‘preconditioning’ protects remote virgin myocardium from subsequent sustained coronary occlusion

    Circulation

    (1993)
  • Cited by (0)

    Conflict of interest: The authors declare that they have no conflicts of interest.

    View full text