Efficacy of Remote Ischemic Preconditioning in Myocardial Protection for On-pump CABG Patients: A Systematic Review_Chinese Journal of Evidence-Based Medicine

Authors：

 LIUYi-dan , PANGYun , WANGJang ,  ZHENGHong

Anesthesiology Department, The First Affiliated Hospital of Xinjiang Medical University, Urumqi 510180, China;

Corresponding author：

ZHENGHong, Email: xjzhenghong@aliyun.com

Keywords：

Remote ischemic preconditioning; Cardiopulmonary bypass; Coronary artery bypass grafting; Meta-analysis; Systematic review; Randomized controlled trial

DOI：

10.7507/1672-2531.20160163

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Objective To systematically review the efficacy of remote ischemic preconditioning in myocardial protection for on-pump CABG patients. Methods Databases including PubMed, EMbase, The Cochrane Library (Issue 1, 2015), WanFang Data, CBM and CNKI were searched from inception to January 2015 to collect randomized controlled trials (RCTs) about remote ischemic preconditioning on coronary artery bypass grafting under extracorporeal circulation. Two reviewers independently screened literature, extracted data and assessed the risk of bias of included studies. Then, meta-analysis was conducted using RevMan 5.2 software. Results A total of 11 RCTs involving 1 128 patients were included. The results of meta-analysis showed that, compared with patients in the control, the RIPC (remote ischemic preconditioning) patients had lower levels of troponin T (MD=-0.22, 95%CI -0.24 to -0.20, P < 0.000 01) and troponin I (MD=-1.91, 95%CI -2.43 to -1.38, P < 0.000 01). However, there were no statistical differences between the two groups in CK-MB, mortality at 30 days, inotropic support, length of stay in ICU or in hospital. Conclusion Current evidence indicates that RIPC myocardial protection has little impact on patients undergoing CABG surgery. Due to the quantity and quality limitations of included studies, more high quality studies are needed to verify the above conclusion.

Citation： LIUYi-dan, PANGYun, WANGJang, ZHENGHong. Efficacy of Remote Ischemic Preconditioning in Myocardial Protection for On-pump CABG Patients: A Systematic Review. Chinese Journal of Evidence-Based Medicine, 2016, 16(9): 1064-1071. doi: 10.7507/1672-2531.20160163 Copy

1.	Cameron A, Davis KB, Green G, et al. Coronary bypass surgery with internal-thoracic-artery grafts--effects on survival over a 15-year period. N Engl J Med, 1996, 334(4): 216-219.
2.	Günaydin B, Cakici I, Soncul H, et al. Does Remote Organ Ischaemia Trigger Cardiac Preconditioning During Coronary Artery Surgery? Pharmacol Res, 2000, 41(4): 493-496.
3.	Higgins JPT, Green S. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Available at: www.cochrane-handbook.org.
4.	Ali N, Rizwi F, Iqbal A, et al. Induced remote ischemic pre-conditioning on ischemia-reperfusion injury in patients undergoing coronary artery bypass. J Coll Physicians Surg Pak, 2010, 20(7): 427-431.
5.	Hausenloy DJ, Mwamure PK, Venugopal V, et al. Effect of remote ischaemic preconditioning on myocardial injury in patients undergoing coronary artery bypass graft surgery: a randomised controlled trial. Lancet, 2007, 370(9587): 575-579.
6.	Karuppasamy P, Chaubey S, Dew T, et al. Remote intermittent ischemia before coronary artery bypass graft surgery: a strategy to reduce injury and inflammation? Basic Res Cardiol, 2011, 106(4): 511-519.
7.	Kottenberg E, Thielmann M, Bergmann L, et al. Protection by remote ischemic preconditioning during coronary artery bypass graft surgery with isoflurane but not propofol -a clinical trial. Acta Anaesthesiol Scand, 2012, 56(1): 30-38.
8.	Lomivorotov VV, Shmyrev VA, Nepomnyaschih VA, et al. Remote ischaemic preconditioning does not protect the heart in patients undergoing coronary artery bypass grafting. Interact Cardiovasc Thorac Surg, 2012, 15(1): 18-22.
9.	Rahman IA, Mascaro JG, Steeds RP, et al. Remote ischemic preconditioning in human coronary artery bypass surgery: from promise to disappointment? Circulation, 2010, 122(11): S53-59.
10.	Thielmann M, Kottenberg E, Boengler K, et al. Remote ischemic preconditioning reduces myocardial injury after coronary artery bypass surgery with crystalloid cardioplegic arrest. Basic Res Cardiol, 2010, 105(5): 657-664.
11.	Venugopal V, Hausenloy DJ, Ludman A, et al. Remote ischaemic preconditioning reduces myocardial injury in patients undergoing cardiac surgery with cold-blood cardioplegia: a randomised controlled trial. Heart, 2009, 95(19): 1567-1571.
12.	Kleinbongard P, Thielmann M, Jakob H, et al. Nitroglycerin does not Interfere with Protection by Remote Ischemic Preconditioning in Patients with Surgical Coronary Revascularization under Isoflurane Anesthesia. Cardiovasc Drugs Ther, 2013, 27(4): 359-361.
13.	Thielmann M, Kottenberg E, Kleinbongard P, et al. Cardioprotective and prognostic effects of remote ischaemic preconditioning in patients undergoing coronary artery bypass surgery: a single-centre randomised, double-blind, controlled trial. Lancet, 2013, 382(9892): 597-604.
14.	Yellon DM, Hausenloy DJ. Myocardial reperfusion injury. N Engl J Med, 2007, 357(11): 1121-1235.
15.	Lønborg J, Engstrøm T. Determining the optimal time to introduce ischemic postconditioning. Expert Rev Cardiovasc Ther, 2011, 9(5): 541-543.
16.	Murry CE, Jennings RB, Reimer KA. Preconditioning with ischemia: a delay of lethal cell injury in ischemic myocardium. Circulation, 1986, 74(5): 1124-1136．.
17.	Botker HE, Kharbanda R, Schmidt MR, et al. Remote ischaemic conditioning before hospital admission, as a complement to angioplasty, and effect on myocardial salvage in patients with acute myocardial infarction: a randomised trial. Lancet, 2010, 375(9716): 727-734.
18.	Gho BC, Schoemaker RG, van den Doel MA, et al. Myocardial protection by brief ischemia in noncardiac tissue. Circulation, 1999, 94(9): 2193-2200.
19.	Verdouw PD, Gho BC, Koning MM, et al. Cardioprotection by Ischemic and Nonischemic Myocardial Stress and Ischemia in Remote Organs Implications for the Concept of Ischemic Preconditioning. Ann N Y Acad Sci, 1996, 793(1): 27-42.
20.	Maynard SJ, Menown IB, Adgey AA. Troponin T or Troponin I as cardiac markers in ischaemic heart disease. Heart, 2000, 83(4): 371-373.
21.	Lehrke S, Steen H, Sievers HH, et al. Cardiac troponin T for prediction of short-and long-term morbidity and mortality after elective open heart surgery. Clin Chem, 2004, 50(9): 1560-1567.
22.	Bignami E, Landoni G, Crescenzi G, et al. Role of cardiac biomarkers (troponin I and CK-MB) as predictors of quality of life and long-term outcome after cardiac surgery. Ann Card Anaesth, 2009, 12(1): 22-26.
23.	Olatidoye AG, Wu AH, Feng YJ, et al. Prognostic role of troponin T versus troponin I in unstable angina pectoris for cardiac events with meta-analysis comparing published studies. Am J Cardiol, 1998, 81(12): 1405-1410.

1. Cameron A, Davis KB, Green G, et al. Coronary bypass surgery with internal-thoracic-artery grafts--effects on survival over a 15-year period. N Engl J Med, 1996, 334(4): 216-219.
2. Günaydin B, Cakici I, Soncul H, et al. Does Remote Organ Ischaemia Trigger Cardiac Preconditioning During Coronary Artery Surgery? Pharmacol Res, 2000, 41(4): 493-496.
3. Higgins JPT, Green S. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Available at: www.cochrane-handbook.org.
4. Ali N, Rizwi F, Iqbal A, et al. Induced remote ischemic pre-conditioning on ischemia-reperfusion injury in patients undergoing coronary artery bypass. J Coll Physicians Surg Pak, 2010, 20(7): 427-431.
5. Hausenloy DJ, Mwamure PK, Venugopal V, et al. Effect of remote ischaemic preconditioning on myocardial injury in patients undergoing coronary artery bypass graft surgery: a randomised controlled trial. Lancet, 2007, 370(9587): 575-579.
6. Karuppasamy P, Chaubey S, Dew T, et al. Remote intermittent ischemia before coronary artery bypass graft surgery: a strategy to reduce injury and inflammation? Basic Res Cardiol, 2011, 106(4): 511-519.
7. Kottenberg E, Thielmann M, Bergmann L, et al. Protection by remote ischemic preconditioning during coronary artery bypass graft surgery with isoflurane but not propofol -a clinical trial. Acta Anaesthesiol Scand, 2012, 56(1): 30-38.
8. Lomivorotov VV, Shmyrev VA, Nepomnyaschih VA, et al. Remote ischaemic preconditioning does not protect the heart in patients undergoing coronary artery bypass grafting. Interact Cardiovasc Thorac Surg, 2012, 15(1): 18-22.
9. Rahman IA, Mascaro JG, Steeds RP, et al. Remote ischemic preconditioning in human coronary artery bypass surgery: from promise to disappointment? Circulation, 2010, 122(11): S53-59.
10. Thielmann M, Kottenberg E, Boengler K, et al. Remote ischemic preconditioning reduces myocardial injury after coronary artery bypass surgery with crystalloid cardioplegic arrest. Basic Res Cardiol, 2010, 105(5): 657-664.
11. Venugopal V, Hausenloy DJ, Ludman A, et al. Remote ischaemic preconditioning reduces myocardial injury in patients undergoing cardiac surgery with cold-blood cardioplegia: a randomised controlled trial. Heart, 2009, 95(19): 1567-1571.
12. Kleinbongard P, Thielmann M, Jakob H, et al. Nitroglycerin does not Interfere with Protection by Remote Ischemic Preconditioning in Patients with Surgical Coronary Revascularization under Isoflurane Anesthesia. Cardiovasc Drugs Ther, 2013, 27(4): 359-361.
13. Thielmann M, Kottenberg E, Kleinbongard P, et al. Cardioprotective and prognostic effects of remote ischaemic preconditioning in patients undergoing coronary artery bypass surgery: a single-centre randomised, double-blind, controlled trial. Lancet, 2013, 382(9892): 597-604.
14. Yellon DM, Hausenloy DJ. Myocardial reperfusion injury. N Engl J Med, 2007, 357(11): 1121-1235.
15. Lønborg J, Engstrøm T. Determining the optimal time to introduce ischemic postconditioning. Expert Rev Cardiovasc Ther, 2011, 9(5): 541-543.
16. Murry CE, Jennings RB, Reimer KA. Preconditioning with ischemia: a delay of lethal cell injury in ischemic myocardium. Circulation, 1986, 74(5): 1124-1136．.
17. Botker HE, Kharbanda R, Schmidt MR, et al. Remote ischaemic conditioning before hospital admission, as a complement to angioplasty, and effect on myocardial salvage in patients with acute myocardial infarction: a randomised trial. Lancet, 2010, 375(9716): 727-734.
18. Gho BC, Schoemaker RG, van den Doel MA, et al. Myocardial protection by brief ischemia in noncardiac tissue. Circulation, 1999, 94(9): 2193-2200.
19. Verdouw PD, Gho BC, Koning MM, et al. Cardioprotection by Ischemic and Nonischemic Myocardial Stress and Ischemia in Remote Organs Implications for the Concept of Ischemic Preconditioning. Ann N Y Acad Sci, 1996, 793(1): 27-42.
20. Maynard SJ, Menown IB, Adgey AA. Troponin T or Troponin I as cardiac markers in ischaemic heart disease. Heart, 2000, 83(4): 371-373.
21. Lehrke S, Steen H, Sievers HH, et al. Cardiac troponin T for prediction of short-and long-term morbidity and mortality after elective open heart surgery. Clin Chem, 2004, 50(9): 1560-1567.
22. Bignami E, Landoni G, Crescenzi G, et al. Role of cardiac biomarkers (troponin I and CK-MB) as predictors of quality of life and long-term outcome after cardiac surgery. Ann Card Anaesth, 2009, 12(1): 22-26.
23. Olatidoye AG, Wu AH, Feng YJ, et al. Prognostic role of troponin T versus troponin I in unstable angina pectoris for cardiac events with meta-analysis comparing published studies. Am J Cardiol, 1998, 81(12): 1405-1410.

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Efficacy of Remote Ischemic Preconditioning in Myocardial Protection for On-pump CABG Patients: A Systematic Review

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