Abstract
Remote ischemic conditioning (RIC) confers cardioprotection in patients with ST-segment elevation myocardial infarction (STEMI). Despite intense research, the translation of RIC into clinical practice remains a challenge. This may, at least partly, be due to confounding factors that may modify the efficacy of RIC. The present review focuses on cardiovascular risk factors, comorbidities, medication use and procedural variables which may modify the efficacy of RIC in patients with STEMI. Findings of such efficacy modifiers are based on subgroup and post-hoc analyses and thus hold risk of type I and II errors. Although findings from studies evaluating influencing factors are often ambiguous, some but not all studies suggest that smoking, non-statin use, infarct location, area-at-risk of infarction, pre-procedural Thrombolysis in Myocardial Infarction (TIMI) flow, ischemia duration and coronary collateral blood flow to the infarct-related artery may influence on the cardioprotective efficacy of RIC. Results from the on-going CONDI2/ERIC-PPCI trial will determine any clinical implications of RIC in the treatment of patients with STEMI and predefined subgroup analyses will give further insight into influencing factors on the efficacy of RIC.
Highlights
Even though the relative incidence of ST-segment elevation myocardial infarction (STEMI) is decreasing [1], the mortality is high with in-hospital mortality varying from 4% to 12% across European countries [2]
In a post-hoc analysis of the CONDI trial, we found no cardioprotective of Pre-infarction angina (PIA) per se on myocardial salvage in patients with STEMI treated with primary percutaneous coronary intervention (PPCI) [26]
Compatible with the findings on myocardial salvage in the parent trial, the authors demonstrated that Remote ischemic conditioning (RIC) improved left ventricular ejection fraction (LVEF) by an absolute 5% but that this effect was preserved the subset of patients with extensive AAR of infarction or patients presenting with anterior myocardial infarction
Summary
Even though the relative incidence of ST-segment elevation myocardial infarction (STEMI) is decreasing [1], the mortality is high with in-hospital mortality varying from 4% to 12% across European countries [2]. Effect modification from LAD artery infarction, AAR, pre-procedural TIMI flow, ischemia duration [25] and CCBF [26]. No observed effect modification from sex, age, infarct location, AAR, pre-procedural TIMI flow, ischemia duration, Killip class, thrombectomy, direct stenting or GP IIb/IIIa inhibitor administration. No observed effect modification from smoking, LAD artery infarction, pre-procedural TIMI flow or ischemia duration. RIC, Remote ischemic conditioning; I-R, Ischemia-reperfusion; PPCI, Primary percutaneous coronary intervention; MSI, Myocardial salvage index; SPECT, Single-photon emission computed tomography; LAD, Left anterior descending; AAR, Area-at-risk; TIMI, Thrombolysis in myocardial infarction; RCA, Right coronary artery; CCBF, Coronary collateral blood flow; PIA, Pre-infarction angina; NSTEMI, Non-ST-segment elevation myocardial infarction; MI, Myocardial infarct; CK-MB, Creatine kinase-myocardial band; CMR, Cardiac magnetic resonance; LVEF, Left ventricular ejection fraction; HF, Heart failure; MI, Myocardial infarction; GP, Glycoprotein; N/A, Not applicable
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