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Remote Ischemic Preconditioning and Cardiac Surgery
Study Questions:
What is the impact of remote ischemic preconditioning on clinical outcomes in patients undergoing coronary-artery bypass graft (CABG) surgery?
Methods:
The ERICCA trial investigators conducted a multicenter, sham-controlled trial involving adults at increased surgical risk who were undergoing on-pump CABG (with or without valve surgery) with blood cardioplegia. After anesthesia induction and before surgical incision, patients were randomly assigned to remote ischemic preconditioning (four 5-minute inflations and deflations of a standard blood-pressure cuff on the upper arm) or sham conditioning (control group). Anesthetic management and perioperative care were not standardized. The combined primary endpoint was death from cardiovascular causes, nonfatal myocardial infarction, coronary revascularization, or stroke, assessed 12 months after randomization.
Results:
The ERICCA trial investigators enrolled a total of 1,612 patients (811 in the control group and 801 in the ischemic-preconditioning group) at 30 cardiac surgery centers in the United Kingdom. There was no significant difference in the cumulative incidence of the primary endpoint at 12 months between the patients in the remote ischemic preconditioning group and those in the control group (212 patients [26.5%] and 225 patients [27.7%], respectively; hazard ratio with ischemic preconditioning, 0.95; 95% confidence interval, 0.79-1.15; p = 0.58). Furthermore, there were no significant between-group differences in either adverse events or the secondary endpoints of perioperative myocardial injury (assessed on the basis of the area under the curve for the high-sensitivity assay of serum troponin T at 72 hours), inotrope score (calculated from the maximum dose of the individual inotropic agents administered in the first 3 days after surgery), acute kidney injury, duration of stay in the intensive care unit and hospital, distance on the 6-minute walk test, and quality of life.
Conclusions:
The authors concluded that remote ischemic preconditioning did not improve clinical outcomes in patients undergoing elective on-pump CABG.
Perspective:
This study reports that in higher-risk patients undergoing on-pump CABG (with or without valve surgery) with blood cardioplegia, remote ischemic preconditioning did not affect the incidence of major adverse cardiac and cerebral events at 12 months, as compared with sham preconditioning. Furthermore, remote ischemic preconditioning had no effect on any of the major secondary endpoints, as compared with sham preconditioning. Given there was a suggestion of an increased risk of death from cardiovascular causes in association with remote ischemic preconditioning, its routine use is not recommended.
Keywords: Acute Kidney Injury, Anesthesia, Cardiac Surgical Procedures, Coronary Artery Bypass, Heart Arrest, Induced, Ischemic Preconditioning, Myocardial Infarction, Perioperative Care, Stroke, Troponin T
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