Efficacy of Remote Ischemic Conditioning (RIC) as an Adjunct to Percutaneous Coronary Intervention (PCI) in ST‑Elevation Myocardial Infarction (STEMI) Patients: A Meta‑Analysis of Randomised Controlled Trials
DOI:
https://doi.org/10.63682/jns.v14i32S.8762Keywords:
Remote ischemic conditioning, STEMI, PCI, myocardial infarction, left ventricular ejection fraction.Abstract
Background:Remote ischemic conditioning (RIC), involving intermittent ischemia-reperfusion cycles in a distant limb, has emerged as a promising adjunctive strategy to reduce myocardial reperfusion injury during primary percutaneous coronary intervention (PCI) in ST-elevation myocardial infarction (STEMI) patients. Despite promising findings from early-phase studies, larger trials have reported conflicting results, necessitating an updated evaluation of its efficacy.
Objective:To systematically assess the efficacy of RIC as an adjunct to PCI in reducing adverse clinical outcomes and improving cardiac function in STEMI patients.
Methods:This meta-analysis adhered to PRISMA guidelines and included randomized controlled trials (RCTs) comparing RIC plus PCI versus PCI alone in adult STEMI patients. Searches were conducted across PubMed, Scopus, Cochrane
CENTRAL, and Web of Science through June 2024. Primary outcomes included cardiac death and major adverse cardiac events (MACE); secondary outcomes were infarct size and left ventricular ejection fraction (LVEF). Data were pooled using a random-effects model, with relative risks (RR) and mean differences (MD) calculated alongside 95% confidence intervals (CI).
Results:Three RCTs comprising 2,735 patients (1,372 in RIC, 1,363 in control) were included. While RIC did not significantly reduce cardiac death (RR = 0.88, 95% CI: 0.75–1.03; p = 0.11) or MACE (RR = 0.91, 95% CI: 0.78–1.07; p = 0.24), it significantly improved LVEF (MD = +3.2%, 95% CI: 1.1–5.3; p = 0.004). A non-significant trend toward reduced infarct size was observed (MD = −2.4g, 95% CI: −5.1 to 0.3; p = 0.08). Subgroup analysis revealed that repeated RIC protocols yielded a significant reduction in adverse events (RR = 0.81, 95% CI: 0.66–0.99; p = 0.04), suggesting frequency and timing may influence therapeutic benefit.
Conclusion:Although RIC did not significantly impact mortality or MACE rates, it was associated with improved cardiac function as reflected by enhanced LVEF. Repeated RIC protocols may offer superior benefits compared to single-session strategies. These findings support the cardioprotective role of RIC as a non-invasive, cost-effective adjunct during PCI for STEMI patients. Further high-quality RCTs with standardised protocols and long-term follow-up are needed to confirm its clinical utility
Downloads
Metrics
References
. Yellon, D. M., & Hausenloy, D. J. (2007). Myocardial reperfusion injury. New England Journal of Medicine, 357(11), 1121–1135. https://doi.org/10.1056/NEJMra071667
Hausenloy, D. J., & Yellon, D. M. (2008). Remote ischaemic preconditioning: underlying mechanisms and clinical application. Cardiovascular Research, 79(3), 377–386. https://doi.org/10.1093/cvr/cvn114
Heusch, G. (2015). Molecular basis of cardioprotection: signal transduction in ischemic pre-, post-, and remote conditioning. Circulation Research, 116(4), 674–699. https://doi.org/10.1161/CIRCRESAHA.114.303686
Shimizu, M., & Russell, R. R. (2012). Mitochondrial effects of ischemic preconditioning. Circulation Journal, 76(11), 2593–2599. https://doi.org/10.1253/circj.CJ-12-0887
Tapuria, N., Kumar, Y., Habib, M. M., Amara, M. A., & Seifalian, A. M. (2008). Remote ischemic preconditioning: a novel protective method from ischemia-reperfusion injury. Journal of Surgical Research, 150(2), 304–330. https://doi.org/10.1016/j.jss.2007.12.765
Bøtker, H. E., Kharbanda, R., Schmidt, M. R., et al. (2010). Remote ischaemic conditioning before hospital admission, as a complement to angioplasty, and effect on myocardial salvage in patients with acute myocardial infarction: a randomized trial. The Lancet, 375(9716), 727–734. https://doi.org/10.1016/S0140-6736(09)62001-8
Sloth, A. D., Schmidt, M. R., Munk, K., et al. (2014). Improved long-term clinical outcomes in patients with ST-elevation myocardial infarction undergoing remote ischemic conditioning as an adjunct to primary percutaneous coronary intervention. European Heart Journal, 35(3), 168–175. https://doi.org/10.1093/eurheartj/eht346
McLeod, S. L., Iansavichene, A., Cheskes, S., & Moher, D. (2017). Remote ischemic perconditioning to reduce reperfusion injury during acute ST-segment–elevation myocardial infarction: a systematic review and meta-analysis. Journal of the American Heart Association, 6(5), e005522. https://doi.org/10.1161/JAHA.117.005522
Hausenloy, D. J., Kharbanda, R. K., Møller, U. K., et al. (2019). Effect of remote ischaemic conditioning on clinical outcomes in patients with acute myocardial infarction (CONDI-2/ERIC-PPCI): a single-masked randomised controlled trial. The Lancet, 394(10207), 1415–1424. https://doi.org/10.1016/S0140-6736(19)32039-2
White, S. K., Frohlich, G. M., Sado, D. M., et al. (2015). Remote ischemic conditioning reduces myocardial infarct size and oedema in patients with ST-segment elevation myocardial infarction. JACC: Cardiovascular Imaging, 8(1), 42–49. https://doi.org/10.1016/j.jcmg.2014.07.014
Crimi, G., Pica, S., Raineri, C., et al. (2013). Remote ischemic post-conditioning of the lower limb during primary percutaneous coronary intervention safely reduces enzymatic infarct size in anterior myocardial infarction: a randomised controlled trial. JACC: Cardiovascular Interventions, 6(10), 1055–1063. https://doi.org/10.1016/j.jcin.2013.05.015
Verouhis, D., Koul, S., Henareh, L., et al. (2016). Effect of remote ischemic conditioning on infarct size in patients with anterior ST-elevation myocardial infarction. American Heart Journal, 181, 66–73. https://doi.org/10.1016/j.ahj.2016.07.021
Chen, S., Li, S., Feng, X., & Wang, G. (2022). Cardioprotection of repeated remote ischemic conditioning in patients with ST-segment elevation myocardial infarction. Frontiers in Cardiovascular Medicine, 9, 899302. https://doi.org/10.3389/fcvm.2022.899302
Gong, R., & Wu, Y. Q. (2019). Remote ischemic conditioning during primary percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction: a systematic review and meta-analysis. Journal of Cardiothoracic Surgery, 14(1), 14. https://doi.org/10.1186/s13019-019-0834-x
Li, S., Wang, Y., Zhou, X., et al. (2021). Repeated remote ischemic postconditioning improves cardiac remodelling and mitochondrial function in acute myocardial infarction. Scientific Reports, 11(1), 12342. https://doi.org/10.1038/s41598-021-91892-0
Eitel, I., Stiermaier, T., Rommel, K. P., et al. (2015). Cardioprotection by combined intrahospital remote ischaemic perconditioning and postconditioning in ST-elevation myocardial infarction: the randomised LIPSIA CONDITIONING trial. European Heart Journal, 36(46), 3049–3057. https://doi.org/10.1093/eurheartj/ehv294
Chen, S., Li, S., Feng, X., & Wang, G. (2022). Cardioprotection of repeated remote ischemic conditioning in patients with ST-segment elevation myocardial infarction. Frontiers in Cardiovascular Medicine, 9, 899302. https://doi.org/10.3389/fcvm.2022.899302
Hausenloy, D. J., Kharbanda, R. K., Møller, U. K., et al. (2019). Effect of remote ischaemic conditioning on clinical outcomes in patients with acute myocardial infarction (CONDI-2/ERIC-PPCI): a single-masked randomised controlled trial. The Lancet, 394(10207), 1415–1424. https://doi.org/10.1016/S0140-6736(19)32039-2
Heusch, G. (2015). Molecular basis of cardioprotection: signal transduction in ischemic pre-, post-, and remote conditioning. Circulation Research, 116(4), 674–699. https://doi.org/10.1161/CIRCRESAHA.114.303686.
Downloads
Published
How to Cite
Issue
Section
License
This work is licensed under a Creative Commons Attribution 4.0 International License.
You are free to:
- Share — copy and redistribute the material in any medium or format
- Adapt — remix, transform, and build upon the material for any purpose, even commercially.
Terms:
- Attribution — You must give appropriate credit, provide a link to the license, and indicate if changes were made. You may do so in any reasonable manner, but not in any way that suggests the licensor endorses you or your use.
- No additional restrictions — You may not apply legal terms or technological measures that legally restrict others from doing anything the license permits.
