ERRICA: Remote ischemic preconditioning fails to improve CABG outcomes

Issue: May 2015

SAN DIEGO — Remote ischemic preconditioning did not improve long-term clinical outcomes in high-risk patients undergoing on-pump CABG with blood cardioplegia compared with a simulated conditioning protocol.

Perspective from John A. Jarcho, MD

“Remote ischemic preconditioning is a simple, noninvasive, low-cost intervention that has no obvious downsides. But although it has been shown to help reduce injury to the heart during surgery and in other medical contexts, unfortunately it showed no benefit on long-term clinical outcomes in our study of patients undergoing cardiac bypass surgery,” Derek J. Hausenloy, MD, PhD, professor in cardiovascular medicine at University College London and at Duke-National University in Singapore, said in a press release.

Hausenloy and colleagues for the ERRICA study investigated the impact of remote ischemic preconditioning on major adverse cardiac and cerebrovascular events in 1,612 patients who were undergoing on-pump CABG at 30 hospitals in the United Kingdom. Half of the patients (n = 811) were randomly assigned remote ischemic preconditioning, which included four 5-minute inflations/deflations of a cuff placed on the upper arm, and the other half to simulated remote ischemic preconditioning. The procedure was performed after anesthesia was administered, but before the first surgical incision was made.

The primary endpoint was a composite of CV death, nonfatal MI, stroke and coronary revascularization at 1 year. After 1 year, major adverse cardiac and cerebrovascular events occurred in 26.6% of patients assigned remote ischemic preconditioning vs. 27.7% of patients assigned the control procedure (HR = 0.96; 95% CI, 0.8-1.16). There was no significant difference in this outcome between the two groups, Hausenloy reported at the American College of Cardiology Scientific Sessions.

“Importantly, most of the events occurred during surgery or immediately following surgery,” Hausenloy said during a presentation.

In addition, the two groups had similar rates of individual components of the primary endpoint: CV death (P = .08), MI (P = .43), stroke (P = .82) and coronary revascularization (P = .68).

The researchers reported no differences in other secondary endpoints, including inotrope score, ICU and hospital stay, acute kidney injury, postoperative atrial fibrillation and quality of life.

“In other settings of ischemia/reperfusion injury such as STEMI and organ transplantation, the effect of remote ischemic preconditioning on major clinical outcomes remains to be investigated,” Hausenloy said. – by Rob Volansky

Reference:

Hausenloy DJ, et al. Late Breaker IV Session. Presented at: American College of Cardiology Scientific Sessions; March 14-16, 2015; San Diego.

Disclosure: Hausenloy reports no relevant financial disclosures.

Perspective

John A. Jarcho, MD

I don't think that ERRICA disproves the concept of remote conditioning, but this clearly was a disappointing result. Many of us retain hope that it will turn out to be beneficial, but it is certainly not ready for clinical application at this point.

There are probably better clinical settings to test it in, such as patients who undergo primary PCI in the setting of STEMI. This is a well-defined population of patients that we know gets ischemia and reperfusion. If it were possible to do the remote conditioning procedure either at the time they were taken to the cath lab for primary PCI or even potentially afterward, since there's evidence that post-conditioning may be beneficial, then that may be a setting where you might expect to see a benefit.

John A. Jarcho, MD

Assistant professor, cardiovascular medicine, Harvard Medical School

Deputy editor, The New England Journal of Medicine

Disclosures: Jarcho reports no relevant financial disclosures.