Remote ischemic preconditioning reduces contrast-induced acute kidney injury in patients with ST-elevation myocardial infarction: A randomized controlled trial☆
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
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Conflict of interest: The authors declare that they have no conflicts of interest.