title: Remote ischemic post-conditioning of the lower limb during primary percutaneous coronary intervention safely reduces enzymatic infarct size in anterior myocardial infarction: a randomized controlled trial.
abstract: OBJECTIVE
  This study sought to evaluate whether remote ischemic post-conditioning (RIPC) could reduce enzymatic infarct size in patients with anterior ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention (pPCI).
  
  
  BACKGROUND
  Myocardial reperfusion injury may attenuate the benefit of pPCI. In animal models, RIPC mitigates myocardial reperfusion injury.
  
  
  METHODS
  One hundred patients with anterior ST-segment elevation myocardial infarction and occluded left anterior descending artery were randomized to pPCI + RIPC (n = 50) or conventional pPCI (n = 50). RIPC consisted of 3 cycles of 5 min/5 min ischemia/reperfusion by cuff inflation/deflation of the lower limb. The primary endpoint was infarct size assessed by the area under the curve of creatinine kinase-myocardial band release (CK-MB). Secondary endpoints included the following: infarct size assessed by cardiac magnetic resonance delayed enhancement volume; T2-weighted edema volume; ST-segment resolution >50%; TIMI (Thrombolysis In Myocardial Infarction) frame count; and myocardial blush grading.
  
  
  RESULTS
  Four patients (2 RIPC, 2 controls) were excluded due to missing samples of CK-MB. A total of 96 patients were analyzed; median area under the curve CK-MB was 8,814 (interquartile range [IQR]: 5,567 to 11,325) arbitrary units in the RIPC group and 10,065 (IQR: 7,465 to 14,004) arbitrary units in control subjects (relative reduction: 20%, 95% confidence interval: 0.2% to 28.7%; p = 0.043). Seventy-seven patients underwent a cardiac magnetic resonance scan 3 to 5 days after randomization, and 66 patients repeated a second scan after 4 months. T2-weighted edema volume was 37 ± 16 cc in RIPC patients and 47 ± 22 cc in control subjects (p = 0.049). ST-segment resolution >50% was 66% in RIPC and 37% in control subjects (p = 0.015). We observed no significant differences in TIMI frame count, myocardial blush grading, and delayed enhancement volume.
  
  
  CONCLUSIONS
  In patients with anterior ST-segment elevation myocardial infarction, RIPC at the time of pPCI reduced enzymatic infarct size and was also associated with an improvement of T2-weighted edema volume and ST-segment resolution >50%. (Remote Postconditioning in Patients With Acute Myocardial Infarction Treated by Primary Percutaneous Coronary Intervention [PCI] [RemPostCon]; NCT00865722).
authors.affiliation: Struttura Complessa Cardiologia, Fondazione Istituto Di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo, Pavia, Italy; SC Cardiologia, Azienda Sanitaria Locale 3 Ospedale Villa Scassi, Genova, Italy. Electronic address: gabrielecrimi@gmail.com.
authors.forename: Gabriele
authors.initials: G
authors.lastname: Crimi
authors.forename: Silvia
authors.initials: S
authors.lastname: Pica
authors.forename: Claudia
authors.initials: C
authors.lastname: Raineri
authors.forename: Ezio
authors.initials: E
authors.lastname: Bramucci
authors.forename: Gaetano M
authors.initials: GM
authors.lastname: De Ferrari
authors.forename: Catherine
authors.initials: C
authors.lastname: Klersy
authors.forename: Marco
authors.initials: M
authors.lastname: Ferlini
authors.forename: Barbara
authors.initials: B
authors.lastname: Marinoni
authors.forename: Alessandra
authors.initials: A
authors.lastname: Repetto
authors.forename: Maurizio
authors.initials: M
authors.lastname: Romeo
authors.forename: Vittorio
authors.initials: V
authors.lastname: Rosti
authors.forename: Margherita
authors.initials: M
authors.lastname: Massa
authors.forename: Arturo
authors.initials: A
authors.lastname: Raisaro
authors.forename: Sergio
authors.initials: S
authors.lastname: Leonardi
authors.forename: Paolo
authors.initials: P
authors.lastname: Rubartelli
authors.forename: Luigi
authors.initials: L
authors.lastname: Oltrona Visconti
authors.forename: Maurizio
authors.initials: M
authors.lastname: Ferrario
mesh_terms: D000368:Aged; D056988:Anterior Wall Myocardial Infarction / Q000097:blood / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy*; D019540:Area Under Curve; D015415:Biomarkers / Q000097:blood; D052279:Creatine Kinase, MB Form / Q000097:blood; D005260:Female; D006801:Humans; D057775:Ischemic Postconditioning / Q000379:methods*; D007558:Italy; D035002:Lower Extremity / Q000098:blood supply*; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D015428:Myocardial Reperfusion Injury / Q000097:blood / Q000175:diagnosis / Q000503:physiopathology / Q000517:prevention & control*; D009206:Myocardium / Q000201:enzymology / Q000473:pathology; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects; D011237:Predictive Value of Tests; D012372:ROC Curve; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D015415:Biomarkers; D052279:Creatine Kinase, MB Form
keywords: CI; CK-MB; DE; IQR; LAD; LV; MBG; RIPC; ST-segment elevation myocardial infarction; ST-segment resolution; STEMI; STR; T(2)-weighted; T2W; TIMI; Thrombolysis In Myocardial Infarction; anti-GP IIb/IIIa; cardiac magnetic resonance imaging; ce-CMR; confidence interval; contrast enhanced cardiac magnetic resonance; creatine kinase-myocardial band; delayed enhancement; inhibitors of glycoprotein IIb/IIIa; interquartile range; left anterior descending; left ventricle/ventricular; myocardial blush grading; myocardial conditioning; myocardial infarction; myocardial reperfusion injury; pPCI; primary angioplasty; primary percutaneous coronary intervention; remote ischemic post-conditioning