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Wu YK, Wecht JM, Bloom OE, Panza GS, Harel NY. Remote Ischemic conditioning as an emerging tool to improve corticospinal transmission in individuals with chronic spinal cord injury. Curr Opin Neurol 2023; 36:523-530. [PMID: 37865833 DOI: 10.1097/wco.0000000000001216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2023]
Abstract
PURPOSE OF REVIEW Remote ischemic conditioning (RIC) involves transient blood flow restriction to one limb leading to systemic tissue-protective effects. RIC shares some potential underlying mechanisms with intermittent hypoxia (IH), in which brief bouts of systemic hypoxia trigger increases in growth factor expression and neural plasticity. RIC has shown promise in acute myocardial infarction and stroke but may be applicable toward chronic neuropathology as well. Consequently, this review discusses similarities and differences between RIC and IH and presents preliminary and ongoing research findings regarding RIC. RECENT FINDINGS Several publications demonstrated that combining RIC with motor training may enhance motor learning in adults with intact nervous systems, though the precise mechanisms were unclear. Our own preliminary data has found that RIC, in conjunction with task specific exercise, can increase corticospinal excitability in a subset of people without neurological injury and in those with chronic cervical spinal cord injury or amyotrophic lateral sclerosis. SUMMARY RIC is a low-cost intervention easy to deliver in a clinical or home setting. Its potential application to facilitate neural plasticity and motor learning during rehabilitation training for individuals with chronic neurological disorders is a novel concept requiring further investigation to characterize mechanisms, safety, and efficacy.
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Affiliation(s)
- Yu-Kuang Wu
- Icahn School of Medicine at Mount Sinai
- James J. Peters VA Medical Center
| | - Jill M Wecht
- Icahn School of Medicine at Mount Sinai
- James J. Peters VA Medical Center
| | - Ona E Bloom
- James J. Peters VA Medical Center
- The Feinstein Institute for Medical Research
- The Zucker School of Medicine at Hofstra Northwell
| | - Gino S Panza
- The Department of Healthcare Science Program of Occupational Therapy, Wayne State University
- John D. Dingell VA Medical Center, USA
| | - Noam Y Harel
- Icahn School of Medicine at Mount Sinai
- James J. Peters VA Medical Center
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Janfeshan S, Masjedi F, Karimi Z. Protective effects of limb remote ischemic per-conditioning on the heart injury induced by renal ischemic-reperfusion through the interaction of the apelin with the RAS/iNOS pathway. BIOIMPACTS : BI 2023; 14:27567. [PMID: 38505676 PMCID: PMC10945303 DOI: 10.34172/bi.2023.27567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 01/28/2023] [Accepted: 03/13/2023] [Indexed: 03/21/2024]
Abstract
Introduction Remote ischemic conditioning upregulates endogenous protective pathways in response to ischemia-reperfusion injury. This study tested the hypothesis that limb remote ischemic per- conditioning (RIPerC) exerts cardioprotective effects via the renin-angiotensin system (RAS)/inducible nitric oxide synthase (iNOS)/apelin pathway. Methods Renal ischemia-reperfusion injury (I/R) was induced by bilateral occlusion of the renal pedicles for 60 minutes, followed by 24 hours of reperfusion; sham-operated rats served as controls. RIPerC was induced by four cycles (5 minutes) of limb ischemia-reperfusion along with bilateral renal ischemia. The functional disturbance was evaluated by renal (BUN and creatinine) and cardiac (troponin I and lactate dehydrogenase) injury biomarkers. Results Renal I/R injury increased renal and cardiac injury biomarkers that were reduced in the RIPerC group. Histopathological findings of the kidney and heart were also suggestive of amelioration injury-induced changes in the RIPerC group. Assessment of cardiac electrophysiology revealed that RIPerC ameliorated the decline in P wave duration without significantly affecting other cardiac electrophysiological changes. Further, renal I/R injury increased the plasma (322.40±34.01 IU/L), renal (8.27±1.10 mIU/mg of Protein), and cardiac (68.28±10.28 mIU/mg of protein) angiotensin-converting enzyme (ACE) activities in association with elevations in the plasma and urine nitrite (25.47±2.01 & 16.62±3.05 μmol/L) and nitrate (15.47±1.33 & 5.01±0.96 μmol/L) levels; these changes were reversed by RIPerC. Further, renal ischemia-reperfusion injury significantly (P=0.047) decreased the renal (but not cardiac) apelin mRNA expression, while renal and cardiac ACE2 (P<0.05) and iNOS (P=0.043) mRNA expressions were significantly increased compared to the sham group; these effects were largely reversed by RIPerC. Conclusion Our results indicated that RIPerC protects the heart against renal ischemia- reperfusion injury, likely via interaction of the apelin with the RAS/iNOS pathway.
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Affiliation(s)
- Sahar Janfeshan
- Shiraz Nephro-Urology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Fatemeh Masjedi
- Shiraz Nephro-Urology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Zeinab Karimi
- Shiraz Nephro-Urology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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3
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Surkar SM, Willson JD, Cassidy JM, Kantak S, Patterson CG. Remote ischaemic conditioning combined with bimanual task training to enhance bimanual skill learning and corticospinal excitability in children with unilateral cerebral palsy: a study protocol of a single centre, phase II randomised controlled trial. BMJ Open 2023; 13:e076881. [PMID: 37770277 PMCID: PMC10546168 DOI: 10.1136/bmjopen-2023-076881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 07/22/2023] [Indexed: 09/30/2023] Open
Abstract
INTRODUCTION Children with unilateral cerebral palsy (UCP) have difficulty in bimanual coordination that restricts the child's independence in daily activities. Although several efficacious interventions to improve bimanual coordination exist, these interventions often require higher training doses and have modest effect sizes. Thus, there is a critical need to find an effective priming agent that, when paired with task-specific training, will facilitate neurobiological processes to enhance the magnitude of training effects and subsequently improve functional capabilities of children with UCP. The aim of this study is to determine the effects of a novel priming agent, remote ischaemic conditioning (RIC), combined with bimanual training on bimanual skill learning and corticospinal excitability in children with UCP. METHODS AND ANALYSES 46 children, aged 8-16 years, will be randomly assigned to receive RIC or sham conditioning combined with 5 days of bimanual skill (cup stacking) training (15 trials per session). RIC or sham conditioning will be performed with a standard conditioning protocol of five cycles of alternative inflation and deflation of a pressure cuff on the affected arm with the pressure of at least 20 mm Hg above systolic blood pressure for RIC and 25 mm Hg for sham conditioning. Primary outcomes will be movement time and corticospinal excitability measures determined with a single-pulse transcranial magnetic stimulation (TMS). Secondary outcomes include Assisting Hand Assessment, spatio-temporal kinematic variables and paired pulse TMS measures. All measures will be conducted before and immediately after the intervention. A mixed model analysis of variance will test the group×time interaction for all outcomes with group (RIC and sham) as between-subject and time (preintervention, postintervention) as within-subject factors. ETHICS AND DISSEMINATION The study has been approved by the University Medical Centre Institutional Review Board (UMCIRB #21-001913). We will disseminate the study findings via peer-reviewed publications and presentations at professional conferences. TRIAL REGISTRATION NUMBER NCT05777070.
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Affiliation(s)
- Swati M Surkar
- Physical Therapy, East Carolina University, Greenville, North Carolina, USA
| | - John D Willson
- Physical Therapy, East Carolina University, Greenville, North Carolina, USA
| | - Jessica M Cassidy
- Department of Health Sciences, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Shailesh Kantak
- Department of Physical Therapy, Arcadia University, Glenside, Pennsylvania, USA
- Department of Rehabilitation Medicine, Moss Rehabilitation Research Institute, Philadelphia, PA, USA
| | - Charity G Patterson
- Department of Physical Therapy and School of Health and Rehabilitation Sciences Data Center, University of Pittsburgh, Pittsburgh, PA, USA
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Liu Y, Ji X, Zhou Z, Zhang J, Zhang J. Myocardial ischemia-reperfusion injury; Molecular mechanisms and prevention. Microvasc Res 2023:104565. [PMID: 37307911 DOI: 10.1016/j.mvr.2023.104565] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/30/2023] [Accepted: 06/06/2023] [Indexed: 06/14/2023]
Abstract
Cardiovascular diseases are one of the leading causes of mortality in developed countries. Among cardiovascular disorders, myocardial infarction remains a life-threatening problem predisposing to the development and progression of ischemic heart failure. Ischemia/reperfusion (I/R) injury is a critical cause of myocardial injury. In recent decades, many efforts have been made to find the molecular and cellular mechanisms underlying the development of myocardial I/R injury and post-ischemic remodeling. Some of these mechanisms are mitochondrial dysfunction, metabolic alterations, inflammation, high production of ROS, and autophagy deregulation. Despite continuous efforts, myocardial I/R injury remains a major challenge in medical treatments of thrombolytic therapy, heart disease, primary percutaneous coronary intervention, and coronary arterial bypass grafting. The development of effective therapeutic strategies to reduce or prevent myocardial I/R injury is of great clinical significance.
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Affiliation(s)
- Yang Liu
- Department of Cardiology, The Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan 250011, China
| | - Xiang Ji
- Department of Integrative, The Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan 250011, China
| | - Zhou Zhou
- First Clinical Medical College, Shandong University of Traditional Chinese Medicine, Jinan 250011, China
| | - Jingwen Zhang
- Department of Cardiology, The Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan 250011, China
| | - Juan Zhang
- Department of Cardiology, The Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan 250011, China; First Clinical Medical College, Shandong University of Traditional Chinese Medicine, Jinan 250011, China.
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Myocardial Cell Preservation from Potential Cardiotoxic Drugs: The Role of Nanotechnologies. Pharmaceutics 2022; 15:pharmaceutics15010087. [PMID: 36678717 PMCID: PMC9865222 DOI: 10.3390/pharmaceutics15010087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 12/16/2022] [Accepted: 12/22/2022] [Indexed: 12/29/2022] Open
Abstract
Cardiotoxic therapies, whether chemotherapeutic or antibiotic, represent a burden for patients who may need to interrupt life-saving treatment because of serious complications. Cardiotoxicity is a broad term, spanning from forms of heart failure induction, particularly left ventricular systolic dysfunction, to induction of arrhythmias. Nanotechnologies emerged decades ago. They offer the possibility to modify the profiles of potentially toxic drugs and to abolish off-target side effects thanks to more favorable pharmacokinetics and dynamics. This relatively modern science encompasses nanocarriers (e.g., liposomes, niosomes, and dendrimers) and other delivery systems applicable to real-life clinical settings. We here review selected applications of nanotechnology to the fields of pharmacology and cardio-oncology. Heart tissue-sparing co-administration of nanocarriers bound to chemotherapeutics (such as anthracyclines and platinum agents) are discussed based on recent studies. Nanotechnology applications supporting the administration of potentially cardiotoxic oncological target therapies, antibiotics (especially macrolides and fluoroquinolones), or neuroactive agents are also summarized. The future of nanotechnologies includes studies to improve therapeutic safety and to encompass a broader range of pharmacological agents. The field merits investments and research, as testified by its exponential growth.
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Alloatti G, Penna C, Comità S, Tullio F, Aragno M, Biasi F, Pagliaro P. Aging, sex and NLRP3 inflammasome in cardiac ischaemic disease. Vascul Pharmacol 2022; 145:107001. [PMID: 35623548 DOI: 10.1016/j.vph.2022.107001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 05/01/2022] [Accepted: 05/20/2022] [Indexed: 10/18/2022]
Abstract
Experimentally, many strong cardioprotective treatments have been identified in different animal models of acute ischaemia/reperfusion injury (IRI) and coronary artery disease (CAD). However, the translation of these cardioprotective therapies for the benefit of the patients into the clinical scenario has been very disappointing. The reasons for this lack are certainly multiple. Indeed, many confounding factors we must deal in clinical reality, such as aging, sex and inflammatory processes are neglected in many experiments. Due to the pivotal role of aging, sex and inflammation in determining cardiac ischaemic disease, in this review, we take into account age as a modifier of tolerance to IRI in the two sexes, dissecting aging and myocardial reperfusion injury mechanisms and the sex differences in tolerance to IRI. Then we focus on the role of the gut microbiota and the NLRP3 inflammasome in myocardial IRI and on the possibility to consider NLRP3 inflammasome as a potential target in the treatment of CAD in relationship with age and sex. Finally, we consider the cardioprotective mechanisms and cardioprotective treatments during aging in the two sexes.
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Affiliation(s)
| | - Claudia Penna
- Department of Clinical and Biological Sciences, University of Turin, Regione Gonzole 10, Orbassano, 10043 Torino, TO, Italy; National Institute for Cardiovascular Research (INRC), Bologna, Italy
| | - Stefano Comità
- Department of Clinical and Biological Sciences, University of Turin, Regione Gonzole 10, Orbassano, 10043 Torino, TO, Italy
| | - Francesca Tullio
- Department of Clinical and Biological Sciences, University of Turin, Regione Gonzole 10, Orbassano, 10043 Torino, TO, Italy
| | - Manuela Aragno
- Department of Clinical and Biological Sciences, University of Turin, Regione Gonzole 10, Orbassano, 10043 Torino, TO, Italy
| | - Fiorella Biasi
- Department of Clinical and Biological Sciences, University of Turin, Regione Gonzole 10, Orbassano, 10043 Torino, TO, Italy
| | - Pasquale Pagliaro
- Department of Clinical and Biological Sciences, University of Turin, Regione Gonzole 10, Orbassano, 10043 Torino, TO, Italy; National Institute for Cardiovascular Research (INRC), Bologna, Italy.
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The Effects of Ischemic Preconditioning Supplementation on Endothelial Function: A Systematic Review and Meta-Analysis. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2021; 2021:6690691. [PMID: 34349827 PMCID: PMC8328691 DOI: 10.1155/2021/6690691] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 12/03/2020] [Accepted: 07/16/2021] [Indexed: 01/01/2023]
Abstract
Objective Ischemic preconditioning (IPC) has gradually been promoted in clinical practice to lower the risk of cardiovascular surgery and postoperative complications. We investigated the role of IPC on vascular endothelial function and the relationship between IPC, flow-mediated dilation (FMD), and brachial artery diameter (BAD). Methods Systematic searches were conducted in PubMed, Medline, Cochrane Library, Embase, and Scopus databases from their inception to March 20, 2020. This research included randomized controlled trials (RCTs) with adults, and the values of FMD and BAD were considered as the primary outcomes. Ten studies comprising 292 participants were included in the meta-analysis. Results Regarding FMD, we observed beneficial effects of IPC on endothelial function (standardized mean difference (SMD): 1.82; 95% confidence interval (CI): 0.64, 3.01; p < 0.001; I 2 = 89.9%). However, the available evidence did not indicate that IPC affected BAD (SMD: 0.08; 95% CI: -0.03, 0.18; p > 0.05; I 2 = 76.5%). Conclusions Our meta-analysis indicated a significant effect of IPC on the endothelial function of the blood vessels, affecting FMD but not BAD.
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8
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Querio G, Geddo F, Antoniotti S, Gallo MP, Penna C. Sex and Response to Cardioprotective Conditioning Maneuvers. Front Physiol 2021; 12:667961. [PMID: 34054579 PMCID: PMC8160310 DOI: 10.3389/fphys.2021.667961] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 03/30/2021] [Indexed: 12/02/2022] Open
Abstract
Ischemic heart disease (IHD) is a multifactorial pathological condition strictly related to genetic, dietary, and lifestyle factors. Its morbidity and mortality rate represent one of the most important pathological issues that today involve younger people in a stronger way than in the past. IHD clinical outcomes are difficult to treat and have a high economic impact on health care. So prevention of this pathological condition through cardioprotective maneuvers represents the first line of intervention, as already underlined by several animal and human studies. Even if the time of intervention is important to prevent severe outcomes, many studies highlight that sex-dependent responses are crucial for the result of cardioprotective procedures. In this scenario sexual hormones have revealed an important role in cardioprotective approach, as women seem to be more protected toward cardiac insults when compared to male counterparts. The aim of this mini review is to show the molecular pathways involved in cardioprotective protocols and to elucidate how sexual hormones can contribute in ameliorating or worsening the physiological responses to IHD.
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Affiliation(s)
- Giulia Querio
- Department of Life Sciences and Systems Biology, University of Turin, Turin, Italy
| | - Federica Geddo
- Department of Life Sciences and Systems Biology, University of Turin, Turin, Italy
| | - Susanna Antoniotti
- Department of Life Sciences and Systems Biology, University of Turin, Turin, Italy
| | - Maria Pia Gallo
- Department of Life Sciences and Systems Biology, University of Turin, Turin, Italy
| | - Claudia Penna
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
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Nazari-Shafti TZ, Exarchos V, Biefer HRC, Cesarovic N, Meyborg H, Falk V, Emmert MY. MicroRNA Mediated Cardioprotection - Is There a Path to Clinical Translation? Front Bioeng Biotechnol 2020; 8:149. [PMID: 32266222 PMCID: PMC7099408 DOI: 10.3389/fbioe.2020.00149] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 02/13/2020] [Indexed: 12/12/2022] Open
Abstract
In the past 20 years, there have been several approaches to achieve cardioprotection or cardiac regeneration using a vast variety of cell therapies and remote ischemic pre-conditioning (RIPC). To date, substantial proof that either cell therapy or RIPC has the potential for clinically relevant cardiac repair or regeneration of cardiac tissue is still pending. Preclinical trials indicate that the secretome of cells in situ (during RIPC) as well as of transplanted cells may exhibit cardioprotective properties in the acute setting of cardiac injury. The secretome generally consists of cell-specific cytokines and extracellular vesicles (EVs) containing microRNAs (miRNAs). It is currently hypothesized that a subset of known miRNAs play a crucial part in the facilitation of cardioprotective effects. miRNAs are small non-coding RNA molecules that inhibit post-transcriptional translation of messenger RNAs (mRNAs) and play an important role in gene translation regulation. It is also known that one miRNAs usually targets multiple mRNAs. This makes predictability of pharmacokinetics and mechanism of action very difficult and could in part explain the inferior performance of various progenitor cells in clinical studies. Identification of miRNAs involved in cardioprotection and remodeling, the composition of miRNA profiles, and the exact mechanism of action are important to the design of future cell-based but also cell-free cardioprotective therapeutics. This review will give a description of miRNA with cardioprotective properties and a current overview on known mechanism of action and potential missing links. Additionally, we will give an outlook on the potential for clinical translation of miRNAs in the setting of myocardial infarction and heart failure.
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Affiliation(s)
- Timo Z Nazari-Shafti
- Department for Cardiovascular and Thoracic Surgery, German Heart Center Berlin, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany.,Deutsches Zentrum für Herz-und Kreislauferkrankungen, Berlin, Germany
| | - Vasileios Exarchos
- Department for Cardiovascular and Thoracic Surgery, German Heart Center Berlin, Berlin, Germany.,Department of Health Sciences and Technology, ETH Zürich, Zurich, Switzerland
| | - Héctor Rodriguez Cetina Biefer
- Department for Cardiovascular and Thoracic Surgery, German Heart Center Berlin, Berlin, Germany.,Clinic for Cardiovascular Surgery, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Nikola Cesarovic
- Department for Cardiovascular and Thoracic Surgery, German Heart Center Berlin, Berlin, Germany.,Department of Health Sciences and Technology, ETH Zürich, Zurich, Switzerland
| | - Heike Meyborg
- Department for Cardiovascular and Thoracic Surgery, German Heart Center Berlin, Berlin, Germany
| | - Volkmar Falk
- Department for Cardiovascular and Thoracic Surgery, German Heart Center Berlin, Berlin, Germany.,Deutsches Zentrum für Herz-und Kreislauferkrankungen, Berlin, Germany.,Department of Health Sciences and Technology, ETH Zürich, Zurich, Switzerland.,Clinic for Cardiovascular Surgery, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Maximilian Y Emmert
- Department for Cardiovascular and Thoracic Surgery, German Heart Center Berlin, Berlin, Germany.,Deutsches Zentrum für Herz-und Kreislauferkrankungen, Berlin, Germany.,Clinic for Cardiovascular Surgery, Charité Universitätsmedizin Berlin, Berlin, Germany.,Institute for Regenerative Medicine, University of Zurich, Zurich, Switzerland.,Wyss Zurich, University of Zurich and ETH Zurich, Zurich, Switzerland
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Ischemia/Reperfusion Injury: Pathophysiology, Current Clinical Management, and Potential Preventive Approaches. Mediators Inflamm 2020; 2020:8405370. [PMID: 32410868 PMCID: PMC7204323 DOI: 10.1155/2020/8405370] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 12/18/2019] [Accepted: 01/03/2020] [Indexed: 12/21/2022] Open
Abstract
Myocardial ischemia reperfusion syndrome is a complex entity where many inflammatory mediators play different roles, both to enhance myocardial infarction-derived damage and to heal injury. In such a setting, the establishment of an effective therapy to treat this condition has been elusive, perhaps because the experimental treatments have been conceived to block just one of the many pathogenic pathways of the disease, or because they thwart the tissue-repairing phase of the syndrome. Either way, we think that a discussion about the pathophysiology of the disease and the mechanisms of action of some drugs may shed some clarity on the topic.
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Effects of remote ischemic conditioning on kidney injury in at-risk patients undergoing elective coronary angiography (PREPARE study): a multicenter, randomized clinical trial. Sci Rep 2019; 9:11985. [PMID: 31427688 PMCID: PMC6700075 DOI: 10.1038/s41598-019-47106-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 07/11/2019] [Indexed: 12/22/2022] Open
Abstract
The ability of remote ischemic preconditioning (RIPC) to prevent contrast-induced nephropathy (CIN) following percutaneous coronary angiography in at-risk patients is controversial. No evidence exists regarding potential RIPC positive effects on renal function and clinical outcomes in the long-term. The PREPARE study was a randomized, prospective, multicenter, and double-blinded trial. A total of 222 patients scheduled for coronary angiography and/or percutaneous transluminal coronary angioplasty with an estimated glomerular filtration rate (eGFR) < 40 mL/min/1.73 m2, or eGFR between 40 and 60 mL/min/1.73 m2 and two further risk factors were allocated to RIPC or control groups. Preventive measures were applied to all patients, including continuous intravenous saline infusion, withdrawal of nephrotoxic drugs, and limited volume of contrast medium. The primary endpoint, namely incidence of CIN, was 3.8% in the control group and 5.1% in the RIPC group (p = 0.74). The secondary endpoints, i.e., changes in serum creatinine and eGFR levels from baseline to 48 hours and from baseline to 12 months following contrast medium exposure, did not differ between both groups. The incidences of all major clinical events at 12 months were similar in both groups. In this population at risk of CIN, preventive strategies were associated with low CIN incidence. RIPC impacted neither the CIN incidence nor both the renal function and clinical outcomes at 1-year follow-up.
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12
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Deferrari G, Bonanni A, Bruschi M, Alicino C, Signori A. Remote ischaemic preconditioning for renal and cardiac protection in adult patients undergoing cardiac surgery with cardiopulmonary bypass: systematic review and meta-analysis of randomized controlled trials. Nephrol Dial Transplant 2019; 33:813-824. [PMID: 28992285 DOI: 10.1093/ndt/gfx210] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 04/28/2017] [Indexed: 12/20/2022] Open
Abstract
Background The main aim of this systematic review was to assess whether remote ischaemic preconditioning (RIPC) protects kidneys and the heart in cardiac surgery with cardiopulmonary bypass (CPB) and to investigate a possible role of anaesthetic agents. Methods Randomized clinical trials (RCTs) on the effects of RIPC through limb ischaemia in adult patients undergoing cardiac surgery with CPB were searched (1965-October 2016) in PubMed, Cochrane Library and article reference lists. A random effects model on standardized mean difference (SMD) for continuous outcomes and the Peto odds ratio (OR) for dichotomous outcomes were used to meta-analyse data. Subgroup analyses to evaluate the effects of different anaesthetic regimens were pre-planned. Results Thirty-three RCTs (5999 participants) were included. In the whole group, RIPC did not significantly reduce the incidence of acute kidney injury (AKI), acute myocardial infarction, atrial fibrillation, mortality or length of intensive care unit (ICU) and hospital stays. On the contrary, RIPC significantly reduced the area under the curve for myocardial injury biomarkers (MIBs) {SMD -0.37 [95% confidence interval (CI) -0.53 to - 0.21]} and the composite endpoint incidence [OR 0.85 (95% CI 0.74-0.97)]. In the volatile anaesthetic group, RIPC significantly reduced AKI incidence [OR 0.57 (95% CI 0.41-0.79)] and marginally reduced ICU stay. Conversely, except for MIBs, RIPC had fewer non-significant effects under propofol with or without volatile anaesthetics. Conclusions RIPC did not consistently reduce morbidity and mortality in adults undergoing cardiac surgery with CPB. In the subgroup on volatile anaesthetics only, RIPC markedly and significantly reduced the incidence of AKI and composite endpoint as well as myocardial injury.
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Affiliation(s)
- Giacomo Deferrari
- Department of Cardionephrology, Istituto Clinico Di Alta Specialità (ICLAS), Rapallo (GE), Italy.,Department of Internal Medicine (Di.MI), University of Genoa, Genoa, Italy
| | - Alice Bonanni
- Department of Cardionephrology, Istituto Clinico Di Alta Specialità (ICLAS), Rapallo (GE), Italy.,Division of Nephrology, Dialysis and Transplantation and Laboratory on Pathophysiology of Uremia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Maurizio Bruschi
- Division of Nephrology, Dialysis and Transplantation and Laboratory on Pathophysiology of Uremia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Cristiano Alicino
- Department of Health Science (Di.S.Sal), University of Genoa, Genoa, Italy
| | - Alessio Signori
- Department of Health Science (Di.S.Sal), University of Genoa, Genoa, Italy
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13
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Continuous remote ischemic conditioning attenuates cognitive and motor deficits from moderate traumatic brain injury. J Trauma Acute Care Surg 2019; 85:48-53. [PMID: 29443855 DOI: 10.1097/ta.0000000000001835] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND While studies show that single-dose remote ischemic conditioning (RIC) improves outcomes, the effect of continuous (daily) RIC is unknown. Thus, we aimed to investigate the role of continuous RIC on cognitive and motor function following traumatic brain injury (TBI). METHODS We subjected 24 male C57BL mice to a cortical-controlled TBI. Two hours after TBI, the animals were randomly allocated to the RIC group (n = 12) or the sham group (n = 12). Remote ischemic conditioning was induced by noninvasive external compression of the hind limb using an occlusive band (six 4-minute cycles/24 hours) for six consecutive days. Before TBI, a baseline rotarod test and novel object recognition were performed. Post-TBI rotarod and novel object recognition tests were performed on Days 1 to 5, 7, 14, and 21. After the animals were sacrificed on Day 21, brain sections were analyzed using hematoxylin and eosin and glial fibrillary acidic protein staining to evaluate the hippocampal CA1 area for neuronal injury. RESULTS Both the RIC and sham groups had lower latency to fall compared with the baseline post-TBI. The RIC animals had a higher latency to fall compared with the sham animals at all time points, statistically significant after Day 3, until Day 21 post-TBI. Both the RIC and sham groups had lower recognition index compared with the baseline post-TBI. The RIC animals had a significantly higher recognition index than the sham animals after Day 1, until Day 21 post-TBI. Hematoxylin and eosin and glial fibrillary acidic protein staining of the brain samples of the sham group revealed that more neurons in the hippocampal CA1 area appeared shrunken with eosinophilic cytoplasm and pyknotic nuclei compared with the brain samples of the RIC group. CONCLUSION Postinjury continuous RIC resulted in improved cognitive functions and motor coordination in a mouse model of moderate TBI. Further studies are required to determine optimum dosage and frequency of this novel therapy to maximize its beneficial effects following TBI.
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Zhang MH, Du X, Guo W, Liu XP, Jia X, Wu Y. Effect of Remote Ischemic Preconditioning on Complications After Elective Abdominal Aortic Aneurysm Repair: A Meta-Analysis With Randomized Control Trials. Vasc Endovascular Surg 2019; 53:387-394. [PMID: 30991903 DOI: 10.1177/1538574419840878] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE This meta-analysis was to evaluate the effect of remote ischemic preconditioning (RIP) on complications after abdominal aortic aneurysm repair. METHODS A literature search was conducted in Google scholar, PubMed, Embase, and Web of Science databases up to February 2019. The pooled risk difference (RD) as well as their 95% confidence interval (CI) were calculated by RevMan 5.3 software. RESULTS A total of 249 patients receiving abdominal aortic aneurysm repair with RIP and 248 receiving abdominal aortic aneurysm repair without RIP in 7 included studies were reanalyzed in this meta-analysis. The results showed that RIP cannot significantly reduce the postoperative mortality (RD = -0.01, 95% CI: -0.07 to 0.06, P = .87), myocardial infarction (RD = -0.01, 95% CI, -0.09 to 0.07, P = .79), and renal impairment (RD = 0.06, 95% CI: -0.41 to 0.30, P = .89) and renal failure (RD = 0.04, 95% CI: -0.03 to 0.10, P = .30). Moreover, the pooled estimate indicated that the RIP significantly increased the risk of arrhythmia after abdominal aortic aneurysm repair surgery (RD = 0.08, 95% CI: 0.01 to -0.16, P = .03). Nevertheless, sensitivity analyses indicated unreliable results for risk of arrhythmia. CONCLUSION There is no evidence that RIP reduces mortality after abdominal aortic aneurysm repair. Moreover, the current evidence is not robust enough to prove the effect of RIP on kidney- and cardiac-related complications.
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Affiliation(s)
- Min-Hong Zhang
- 1 Department of Vascular Surgery, General Hospital of People's Liberation Army, Beijing, China
| | - Xin Du
- 1 Department of Vascular Surgery, General Hospital of People's Liberation Army, Beijing, China
| | - Wei Guo
- 1 Department of Vascular Surgery, General Hospital of People's Liberation Army, Beijing, China
| | - Xiao-Ping Liu
- 1 Department of Vascular Surgery, General Hospital of People's Liberation Army, Beijing, China
| | - Xin Jia
- 1 Department of Vascular Surgery, General Hospital of People's Liberation Army, Beijing, China
| | - Ye Wu
- 1 Department of Vascular Surgery, General Hospital of People's Liberation Army, Beijing, China
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15
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Zhao JJ, Xiao H, Zhao WB, Zhang XP, Xiang Y, Ye ZJ, Mo MM, Peng XT, Wei L. Remote Ischemic Postconditioning for Ischemic Stroke: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Chin Med J (Engl) 2018; 131:956-965. [PMID: 29664057 PMCID: PMC5912063 DOI: 10.4103/0366-6999.229892] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background: Remote ischemic postconditioning (RIPostC) appears to protect distant organs from ischemia-reperfusion injury (IRI). However, cerebral protection results have remained inconclusive. In the present study, a meta-analysis was performed to compare stroke patients with and without RIPostC. Methods: CNKI, WanFang, VIP, CBM, PubMed, and Cochrane Library databases were searched up to July 2016. Data were analyzed using both fixed-effects and random-effects models by Review Manager. For each outcome, risk ratio (RR) and mean difference (MD) with 95% confidence interval (CI) were calculated. Results: A total of 13 randomized controlled trials that enrolled a total of 794 study participants who suffered from or are at risk for brain IRI were selected. Compared with controls, RIPostC significantly reduced the recurrence of stroke or transient ischemic attacks (RR = 0.37; 95% CI: 0.26–0.55; P < 0.00001). Moreover, it can reduce the levels of the National Institutes of Health Stroke Scale score (MD: 1.96; 95% CI: 2.18–1.75; P < 0.00001), modified Rankin Scale score (MD: 0.73; 95% CI: 1.20–0.25; P = 0.00300), and high-sensitivity C-reactive protein (MD: 4.17; 95% CI: 4.71–3.62; P < 0.00001) between the two groups. There was no side effect of RIPostC using tourniquet cuff around the limb on ischemic stroke treating based on different intervention duration. Conclusion: The present meta-analysis suggests that RIPostC might offer cerebral protection for stroke patients suffering from or are at risk of brain IRI.
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Affiliation(s)
- Jing-Jing Zhao
- Department of Nursing, Chongqing Medical and Pharmaceutical College, Chongqing 401331, China
| | - Hui Xiao
- Nursing Department, Guangdong Province Hospital of Chinese Medicine, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510120, China
| | - Wen-Bo Zhao
- Department of Nephrology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong 510632, China
| | - Xiao-Pei Zhang
- Department of Neurology, Guangdong Province Hospital of Chinese Medicine, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510120, China
| | - Yu Xiang
- Department of Neurology, Huaihua Hospital of Traditional Chinese Medicine, Huaihua, Hunan 418000, China
| | - Zeng-Jie Ye
- Department of Economics and Management, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510120, China
| | - Miao-Miao Mo
- Department of Neurology, Guangdong Province Hospital of Chinese Medicine, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510120, China
| | - Xue-Ting Peng
- The Second Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510120, China
| | - Lin Wei
- Department of Neurology, Guangdong Province Hospital of Chinese Medicine, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510120, China
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Abstract
Heart failure (HF) is a physiological state in which cardiac output is insufficient to meet the needs of the body. It is a clinical syndrome characterized by impaired ability of the left ventricle to either fill or eject blood efficiently. HF is a disease of multiple aetiologies leading to progressive cardiac dysfunction and it is the leading cause of deaths in both developed and developing countries. HF is responsible for about 73,000 deaths in the UK each year. In the USA, HF affects 5.8 million people and 550,000 new cases are diagnosed annually. Cardiac remodelling (CD), which plays an important role in pathogenesis of HF, is viewed as stress response to an index event such as myocardial ischaemia or imposition of mechanical load leading to a series of structural and functional changes in the viable myocardium. Protein kinase C (PKC) isozymes are a family of serine/threonine kinases. PKC is a central enzyme in the regulation of growth, hypertrophy, and mediators of signal transduction pathways. In response to circulating hormones, activation of PKC triggers a multitude of intracellular events influencing multiple physiological processes in the heart, including heart rate, contraction, and relaxation. Recent research implicates PKC activation in the pathophysiology of a number of cardiovascular disease states. Few reports are available that examine PKC in normal and diseased human hearts. This review describes the structure, functions, and distribution of PKCs in the healthy and diseased heart with emphasis on the human heart and, also importantly, their regulation in heart failure.
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Affiliation(s)
- Raphael M Singh
- School of Forensic and Applied Sciences, University of Central Lancashire, Preston, England, PR1 2HE, UK.
- Faculty of Medicine and Health Sciences, University of Guyana, Turkeyen, Georgetown, Guyana.
| | - Emanuel Cummings
- Faculty of Medicine and Health Sciences, University of Guyana, Turkeyen, Georgetown, Guyana
| | - Constantinos Pantos
- Department of Pharmacology, School of Medicine, University of Athens, Athens, Greece
| | - Jaipaul Singh
- School of Forensic and Applied Sciences, University of Central Lancashire, Preston, England, PR1 2HE, UK
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17
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Antonowicz SS, Cavallaro D, Jacques N, Brown A, Wiggins T, Haddow JB, Kapila A, Coull D, Walden A. Remote ischemic preconditioning for cardioprotection in elective inpatient abdominal surgery - a randomized controlled trial. BMC Anesthesiol 2018; 18:76. [PMID: 29945555 PMCID: PMC6020340 DOI: 10.1186/s12871-018-0524-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 05/24/2018] [Indexed: 11/10/2022] Open
Abstract
Background Perioperative myocardial injury (PMI) is common in elective inpatient abdominal surgery and correlates with mortality risk. Simple measures for reducing PMI in this cohort are needed. This study evaluated whether remote ischemic preconditioning (RIPC) could reduce PMI in elective inpatient abdominal surgery. Methods This was a double-blind, sham-controlled trial with 1:1 parallel randomization. PMI was defined as any post-operative serum troponin T (hs-TNT) > 14 ng/L. Eighty-four participants were randomized to receiving RIPC (5 min of upper arm ischemia followed by 5 min reperfusion, for three cycles) or a sham-treatment immediately prior to surgery. The primary outcome was mean peak post-operative troponin in patients with PMI, and secondary outcomes included mean hs-TnT at individual timepoints, post-operative hs-TnT area under the curve (AUC), cardiovascular events and mortality. Predictors of PMI were also collected. Follow up was to 1 year. Results PMI was observed in 21% of participants. RIPC did not significantly influence the mean peak post-operative hs-TnT concentration in these patients (RIPC 25.65 ng/L [SD 9.33], sham-RIPC 23.91 [SD 13.2], mean difference 1.73 ng/L, 95% confidence interval − 9.7 to 13.1 ng/L, P = 0.753). The treatment did not influence any secondary outcome with the pre-determined definition of PMI. Redefining PMI as > 5 ng/L in line with recent data revealed a non-significant lower incidence in the RIPC cohort (68% vs 81%, P = 0.211), and significantly lower early hs-TnT release (12 h time-point, RIPC 5.5 ng/L [SD 5.5] vs sham 9.1 ng/L [SD 8.2], P = 0.03). Conclusions RIPC did not at reduce the incidence or severity of PMI in these general surgical patients using pre-determined definitions. PMI is nonetheless common and effective cardioprotective strategies are required. Trial registration This trial was registered with Clinicaltrials.gov, NCT01850927, 5th July 2013. Electronic supplementary material The online version of this article (10.1186/s12871-018-0524-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Stefan Samad Antonowicz
- Department of Surgery, Royal Berkshire NHS Foundation Trust, Reading, UK.,London Surgical Research Group, Reading, UK
| | - Davina Cavallaro
- Department of Surgery, Royal Berkshire NHS Foundation Trust, Reading, UK
| | - Nicola Jacques
- Intensive Care and Anaesthetics, Royal Berkshire NHS Foundation Trust, London Road, Reading, RG1 5AN, UK
| | - Abby Brown
- Intensive Care and Anaesthetics, Royal Berkshire NHS Foundation Trust, London Road, Reading, RG1 5AN, UK
| | | | | | - Atul Kapila
- Intensive Care and Anaesthetics, Royal Berkshire NHS Foundation Trust, London Road, Reading, RG1 5AN, UK
| | - Dominic Coull
- Department of Surgery, Royal Berkshire NHS Foundation Trust, Reading, UK
| | - Andrew Walden
- Intensive Care and Anaesthetics, Royal Berkshire NHS Foundation Trust, London Road, Reading, RG1 5AN, UK.
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18
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Liang D, He X, Wang Z, Li C, Gao B, Wu J, Bai Y. Remote limb ischemic postconditioning promotes motor function recovery in a rat model of ischemic stroke via the up-regulation of endogenous tissue kallikrein. CNS Neurosci Ther 2018; 24:519-527. [PMID: 29399973 PMCID: PMC6489769 DOI: 10.1111/cns.12813] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 12/27/2017] [Accepted: 12/29/2017] [Indexed: 01/16/2023] Open
Abstract
AIMS Remote ischemic conditionings, such as pre- and per-conditioning, are known to provide cardioprotection in animal models of ischemia. However, little is known about the neuroprotection effect of postconditioning after cerebral ischemia. In this study, we aim to evaluate the motor function rescuing effect of remote limb ischemic postconditioning (RIPostC) in a rat model of acute cerebral stroke. METHODS Left middle cerebral artery occlusion (MCAO) was performed to generate the rat model of ischemic stroke, followed by daily RIPostC treatment for maximum 21 days. The motor function after RIPostC was assessed with foot fault test and balance beam test. Local infarct volume was measured through MRI scanning. Neuronal status was evaluated with Nissl's, HE, and MAP2 immunostaining. Lectin immunostaining was performed to evaluate the microvessel density and area. RESULTS Daily RIPostC for more than 21 days promoted motor function recovery and provided long-lasting neuroprotection after MCAO. Reduced infarct volume, rescued neuronal loss, and enhanced microvessel density and size in the injured areas were observed. In addition, the RIPostC effect was associated with the up-regulation of endogenous tissue kallikrein (TK) level in circulating blood and local ischemic brain regions. A TK receptor antagonist HOE-140 partially reversed RIPostC-induced improvements, indicating the specificity of endogenous TK mediating the neuroprotection effect of RIPostC. CONCLUSION Our study demonstrates RIPostC treatment as an effective rehabilitation therapy to provide motor function recovery and alleviate brain impairment in a rat model of acute cerebral ischemia. We also for the first time provide evidence showing that the up-regulation of endogenous TK from remote conditioning regions underlies the observed effects of RIPostC.
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Affiliation(s)
- Dan Liang
- Department of Rehabilitation MedicineHuashan HospitalFudan UniversityShanghaiChina
| | - Xi‐Biao He
- Shanghai University of Medicine & Health SciencesShanghaiChina
| | - Zheng Wang
- Department of NeurologyHuashan HospitalState Key Laboratory of Medical NeurobiologyFudan UniversityShanghaiChina
| | - Ce Li
- Department of Rehabilitation MedicineHuashan HospitalFudan UniversityShanghaiChina
| | - Bei‐Yao Gao
- Department of Rehabilitation MedicineHuashan HospitalFudan UniversityShanghaiChina
| | - Jun‐Fa Wu
- Department of Rehabilitation MedicineHuashan HospitalFudan UniversityShanghaiChina
| | - Yu‐Long Bai
- Department of Rehabilitation MedicineHuashan HospitalFudan UniversityShanghaiChina
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19
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Xu C, Liang C, Sun W, Chen J, Chen X. Glycyrrhizic acid ameliorates myocardial ischemic injury by the regulation of inflammation and oxidative state. DRUG DESIGN DEVELOPMENT AND THERAPY 2018; 12:1311-1319. [PMID: 29849452 PMCID: PMC5965375 DOI: 10.2147/dddt.s165225] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background Glycyrrhizic acid (GA), a bioactive triterpenoid saponin isolated from the roots of licorice plants (Glycyrrhiza glabra), has been shown to exert a variety of pharmacological activities and is considered to have potential therapeutic applications. The purpose of the present study was to investigate the cardioprotective effect of GA on myocardial ischemia (MI) injury rats induced by isoproterenol (ISO), and explore the potential mechanisms underlying these effects. Materials and methods The rats were randomized into five groups: control, ISO, ISO+diltiazem (10 mg/kg), ISO+GA (10 mg/kg), and ISO+GA (20 mg/kg). Electrocardiogram and histopathological examination were performed. Markers of cardiac marker enzymes (creatine kinase-MB, lactate dehydrogenase), oxidative stress (superoxide dismutase, malondialdehyde [MDA]), and inflammation (TNF-α, IL-1β, and IL-6) were also measured in each group. Proteins involved in NF-κB and Nrf-2/HO-1 pathway were detected by Western blot. Results GA decreased the ST elevation induced by MI, decreased serum levels of creatine kinase, lactate dehydrogenase, malondialdehyde, IL-6, IL-1β, and TNF-α, and increased serum superoxide dismutase and malondialdehyde activities. Furthermore, GA increased the protein levels of Nrf-2 and HO-1 and downregulated the phosphorylation of IκB, and NF-κB p65 in ISO-induced MI. Conclusion These observations indicated that GA has cardioprotective effects against MI, and these effects might be related to the activation of Nrf-2/HO-1 and inhibition of NF-κB signaling pathway in the myocardium.
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Affiliation(s)
- Chongli Xu
- Nanjing University of Chinese Medicine, Nanjing 210029, People's Republic of China.,Jiangnin Hospital of Nanjing, Nanjing 211100, People's Republic of China
| | - Caihong Liang
- Jiangnin Hospital of Nanjing, Nanjing 211100, People's Republic of China
| | - Weixin Sun
- Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing University of Chinese Medicine, Nanjing 210023, People's Republic of China
| | - Jiandong Chen
- Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing University of Chinese Medicine, Nanjing 210023, People's Republic of China
| | - Xiaohu Chen
- Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing University of Chinese Medicine, Nanjing 210023, People's Republic of China
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20
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Hentia C, Rizzato A, Camporesi E, Yang Z, Muntean DM, Săndesc D, Bosco G. An overview of protective strategies against ischemia/reperfusion injury: The role of hyperbaric oxygen preconditioning. Brain Behav 2018; 8:e00959. [PMID: 29761012 PMCID: PMC5943756 DOI: 10.1002/brb3.959] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 02/12/2018] [Accepted: 02/18/2018] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Ischemia/reperfusion (I/R) injury, such as myocardial infarction, stroke, and peripheral vascular disease, has been recognized as the most frequent causes of devastating disorders and death currently. Protective effect of various preconditioning stimuli, including hyperbaric oxygen (HBO), has been proposed in the management of I/R. METHODS In this study, we searched and reviewed up-to-date published papers to explore the pathophysiology of I/R injury and to understand the mechanisms underlying the protective effect of HBO as conditioning strategy. RESULTS Animal study and clinic observation support the notion that HBO therapy and conditioning provide beneficial effect against the deleterious effects of postischemic reperfusion. Several explanations have been proposed. The first likely mechanism may be that HBO counteracts hypoxia and reduces I/R injury by improving oxygen delivery to an area with diminished blood flow. Secondly, by reducing hypoxia-ischemia, HBO reduces all the pathological events as a consequence of hypoxia, including tissue edema, increased affective area permeability, postischemia derangement of tissue metabolism, and inflammation. Thirdly, HBO may directly affect cell apoptosis, signal transduction, and gene expression in those that are sensitive to oxygen or hypoxia. HBO provides a reservoir of oxygen at cellular level not only carried by blood, but also by diffusion from the interstitial tissue where it reaches high concentration that may last for several hours, improves endothelial function and rheology, and decreases local inflammation and edema. CONCLUSION Evidence suggests the benefits of HBO when used as a preconditioning stimulus in the setting of I/R injury. Translating the beneficial effects of HBO into current practice requires, as for the "conditioning strategies", a thorough consideration of risk factors, comorbidities, and comedications that could interfere with HBO-related protection.
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Affiliation(s)
- Ciprian Hentia
- Master II level in Hyperbaric Medicine Department of Biomedical Sciences University of Padova Padova Italy.,Faculty of Medicine "Victor Babeș" University of Medicine and Pharmacy Timișoara Romania
| | - Alex Rizzato
- Master II level in Hyperbaric Medicine Department of Biomedical Sciences University of Padova Padova Italy
| | | | - Zhongjin Yang
- The Institute for Human Performance SUNY Upstate Medical University Syracuse NY USA
| | - Danina M Muntean
- Faculty of Medicine "Victor Babeș" University of Medicine and Pharmacy Timișoara Romania.,Center for Translational Research and Systems Medicine "Victor Babeș" University of Medicine and Pharmacy Timișoara Romania
| | - Dorel Săndesc
- Faculty of Medicine "Victor Babeș" University of Medicine and Pharmacy Timișoara Romania
| | - Gerardo Bosco
- Master II level in Hyperbaric Medicine Department of Biomedical Sciences University of Padova Padova Italy
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21
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Prunier F, Mirebeau-Prunier D. Lung protection in patients undergoing pulmonary lobectomy: a new perspective for remote ischemic conditioning in surgery? J Thorac Dis 2018; 10:91-93. [PMID: 29600029 DOI: 10.21037/jtd.2017.12.16] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Fabrice Prunier
- Institut MITOVASC, UMR INSERM U1083 and CNRS 6015, CHU Angers, University of Angers, Angers, France
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22
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Pedersen TF, Budtz-Lilly J, Petersen CN, Hyldgaard J, Schmidt JO, Kroijer R, Grønholdt ML, Eldrup N. Randomized clinical trial of remote ischaemic preconditioning versus no preconditioning in the prevention of perioperative myocardial infarction during open surgery for ruptured abdominal aortic aneurysm. BJS Open 2018; 2:112-118. [PMID: 29951634 PMCID: PMC5989967 DOI: 10.1002/bjs5.55] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 01/16/2018] [Indexed: 11/09/2022] Open
Abstract
Background Remote ischaemic preconditioning (RIPC) has been suggested as a means of protecting vital organs from reperfusion injury during major vascular surgery. This study was designed to determine whether RIPC could reduce the incidence of perioperative myocardial infarction (MI) during open surgery for ruptured abdominal aortic aneurysm (AAA). Secondary aims were to see if RIPC could reduce 30-day mortality, multiple organ failure, acute intestinal ischaemia, acute kidney injury and ischaemic stroke. Methods This randomized, non-blinded clinical trial was undertaken at three vascular surgery centres in Denmark. Patients who had open surgery for ruptured AAA were randomized to intervention with RIPC or control in a 1 : 1 ratio. Postoperative complications and deaths were registered, and ECG and blood samples were obtained daily during the hospital stay. Results Of 200 patients randomized, 142 (72 RIPC, 70 controls) were included. There was no difference in rates of perioperative MI between the RIPC and control groups (36 versus 43 per cent respectively), or in rates of organ failure. However, in the per-protocol analysis 30-day mortality was significantly reduced in the RIPC group (odds ratio 0·46, 95 per cent c.i. 0·22 to 0·99; P = 0·048). Conclusion RIPC did not reduce the incidence of perioperative MI in patients undergoing open surgery for ruptured AAA. Registration number: NCT00883363 ( http://www.clinicaltrials.gov).
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Affiliation(s)
- T F Pedersen
- Department of Heart, Lung and Vascular Surgery Aarhus University Hospital Aarhus Denmark
| | - J Budtz-Lilly
- Department of Heart, Lung and Vascular Surgery Aarhus University Hospital Aarhus Denmark
| | - C N Petersen
- Department of Vascular Surgery Aalborg University Hospital Aalborg Denmark
| | - J Hyldgaard
- Department of Heart, Lung and Vascular Surgery Aarhus University Hospital Aarhus Denmark
| | - J-O Schmidt
- Department of Vascular Surgery Kolding Hospital Kolding Denmark
| | - R Kroijer
- Department of Heart, Lung and Vascular Surgery Aarhus University Hospital Aarhus Denmark
| | - M-L Grønholdt
- Department of Vascular Surgery Aalborg University Hospital Aalborg Denmark
| | - N Eldrup
- Department of Heart, Lung and Vascular Surgery Aarhus University Hospital Aarhus Denmark
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23
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Remote Limb Ischemic Conditioning during Cerebral Ischemia Reduces Infarct Size through Enhanced Collateral Circulation in Murine Focal Cerebral Ischemia. J Stroke Cerebrovasc Dis 2018; 27:831-838. [PMID: 29395650 DOI: 10.1016/j.jstrokecerebrovasdis.2017.09.068] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 09/21/2017] [Accepted: 09/24/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Remote ischemic conditioning (RIC) induces protection in focal cerebral ischemia. The conditioning is divided into pre-, per-, and postconditioning. However, the mechanisms of RIC remain unknown. OBJECTIVES This study aimed to determine the most effective subtype of RIC. We also examined involvement of collateral circulation on RIC. METHODS Transient middle cerebral artery occlusion (MCAO) was performed with nylon sutures in adult C57BL/6 mice under the monitoring of cerebral blood flow (CBF). Fifty mice were divided into 5 groups: MCAO control group, delayed pre-RIC group (RIC 24 hours before MCAO), early pre-RIC group (RIC 5 minutes before MCAO), per-RIC group (RIC during MCAO), and post-RIC group (RIC 5 minutes after MCAO). In other middle cerebral artery (MCA) control and per-RIC groups, collateral circulation was visualized with latex compound perfusion. RESULTS After MCAO, CBF was reduced by 80% in all groups. At the end of MCAO, relative increase in CBF in per-RIC group was significantly greater than that in MCA control, whereas the infarct volume in per-RIC group was significantly smaller than that in other groups. The diameter of leptomeningeal anastomosis was larger in the per-RIC group than that in the control group. CONCLUSIONS Among the 4 RIC procedures, only the per-RIC group showed clear brain protection. Enhancement of collateral circulation could play a role in the protective effect of per-RIC.
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24
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Thijssen DHJ, Maxwell J, Green DJ, Cable NT, Jones H. Repeated ischaemic preconditioning: a novel therapeutic intervention and potential underlying mechanisms. Exp Physiol 2018; 101:677-92. [PMID: 26970535 DOI: 10.1113/ep085566] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 03/03/2016] [Indexed: 12/13/2022]
Abstract
What is the topic of this review? This review discusses the effects of repeated exposure of tissue to ischaemic preconditioning on cardiovascular function, the attendant adaptations and their potential clinical relevance. What advances does it highlight? We discuss the effects of episodic exposure to ischaemic preconditioning to prevent and/or attenuate ischaemic injury and summarize evidence pertaining to improvements in cardiovascular function and structure. Discussion is provided regarding the potential mechanisms that contribute to both local and systemic adaptation. Findings suggest that clinical benefits result from both the prevention of ischaemic events and the attenuation of their consequences. Ischaemic preconditioning (IPC) refers to the phenomenon whereby short periods of cyclical tissue ischaemia confer subsequent protection against ischaemia-induced injury. As a consequence, IPC can ameliorate the myocardial damage following infarction and can reduce infarct size. The ability of IPC to confer remote protection makes IPC a potentially feasible cardioprotective strategy. In this review, we discuss the concept that repeated exposure of tissue to IPC may increase the 'dose' of protection and subsequently lead to enhanced protection against ischaemia-induced myocardial injury. This may be relevant for clinical populations, who demonstrate attenuated efficacy of IPC to prevent or attenuate ischaemic injury (and therefore myocardial infarct size). Furthermore, episodic IPC facilitates repeated exposure to local (e.g. shear stress) and systemic stimuli (e.g. hormones, cytokines, blood-borne substances), which may induce improvement in vascular function and health. Such adaptation may contribute to prevention of cardio- and cerebrovascular events. The clinical benefits of repeated IPC may, therefore, result from both the prevention of ischaemic events and the attenuation of their consequences. We provide an overview of the literature pertaining to the impact of repeated IPC on cardiovascular function, related to both local and remote adaptation, as well as potential clinical implications.
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Affiliation(s)
- Dick H J Thijssen
- Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UK.,Radboud Institute for Health Sciences, Department of Physiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Joseph Maxwell
- Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UK
| | - Daniel J Green
- Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UK.,School of Sports Science, Exercise and Health, The University of Western Australia, Crawley, Western Australia, Australia
| | - N Timothy Cable
- Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UK.,School of Sports Science, Exercise and Health, The University of Western Australia, Crawley, Western Australia, Australia.,Department of Sport Science, Aspire Academy, Doha, Qatar
| | - Helen Jones
- Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UK
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25
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The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm. J Vasc Surg 2018; 67:2-77.e2. [DOI: 10.1016/j.jvs.2017.10.044] [Citation(s) in RCA: 1150] [Impact Index Per Article: 191.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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26
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Remote ischemic conditioning preserves cognition and motor coordination in a mouse model of traumatic brain injury. J Trauma Acute Care Surg 2017; 83:1074-1081. [DOI: 10.1097/ta.0000000000001626] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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27
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Blusztein DI, Brooks MJ, Andrews DT. A systematic review and meta-analysis evaluating ischemic conditioning during percutaneous coronary intervention. Future Cardiol 2017; 13:579-592. [PMID: 29076346 DOI: 10.2217/fca-2017-0042] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
AIM A systematic review and meta-analysis, evaluating ischemic conditioning during percutaneous coronary intervention (PCI). METHODS & RESULTS A database search of randomized trials of ischemic conditioning in PCI created three subgroups for meta-analysis: mortality in elective PCI with remote ischemic preconditioning (RIPreC; subgroup 1a, n = 3) - no outcome difference between RIPreC and control (odds ratio: 0.34; 95% CI: 0.08-1.56), myocardial salvage index in ST-elevation myocardial infarction (STEMI) with RIPreC (subgroup 1b, n = 2) - favored RIPreC (mean difference: 0.13; 95% CI: 0.07-0.19), and infarct size in STEMI with local ischemic postconditioning (LIPostC) (subgroup 4b, n = 12) - favored LIPostC (mean difference: -4.13 g.m-2; 95% CI: -7.36 to -0.90 g.m-2). CONCLUSION RIPreC and LIPostC improve myocardial salvage index and myocardial infarct size respectively in PCI for STEMI. No mortality benefit detected with RIPreC in elective PCI.
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Affiliation(s)
- David I Blusztein
- Cardiology Registrar, Department of Cardiology, The Royal Melbourne Hospital, 300 Grattan St, Parkville, Victoria 3050, Australia
| | - Matthew J Brooks
- Cardiologist, Department of Cardiology, The Royal Melbourne Hospital, 300 Grattan St, Parkville, Victoria 3050, Australia
| | - David T Andrews
- Honorary Clinical Associate Professor, Department of Anesthesia, Perioperative & Pain Medicine Unit, The University of Melbourne, Grattan St, Parkville, 3052, Australia.,Visiting Anesthetist, Department of Anesthesia & Pain Management, The Royal Melbourne Hospital, 300 Grattan St, Parkville, Victoria 3050, Australia
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Yuan Y, Cao W, Hong Y, Guo X, Wang Y, Wang Y, Wang X, Hu P. Tilianin pretreatment prevents myocardial ischemia-reperfusion injury via preservation of mitochondrial function in rat heart. PHYTOMEDICINE : INTERNATIONAL JOURNAL OF PHYTOTHERAPY AND PHYTOPHARMACOLOGY 2017; 34:106-114. [PMID: 28899492 DOI: 10.1016/j.phymed.2017.08.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 04/09/2017] [Accepted: 08/06/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND Tilianin has been demonstrated to exert protective effects on the heart against ischemia-reperfusion (I/R) injury, yet whether it is beneficial to the mitochondria during myocardial I/R is unclear. METHODS In this study, we demonstrated that pretreatment with Tilianin dose-dependently raised the levels of ATP of the myocardium, and protected the microstructures and functions of mitochondria in rats. Furthermore, the cytoprotective effect of Tilianin has been confirmed in vivo and in the H9c2 cardiomyoblast cell line with enhancing activities of the mitochondria, controlling the levels of Ca2+ and reactive oxygen species (ROS), and inhibiting the expression of caspase-3 and AIF in cytoplasm. CONCLUSIONS In conclusion, the study suggests that Tilianin may be of clinical value for the protective effects of cardiomyocytes and mitochondria by inhibiting myocardium energy metabolism and apoptosis during myocardial ischemia-reperfusion injury (MIRI).
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Affiliation(s)
- Yong Yuan
- First Affiliated Hospital of the Medical College, Shihezi University, Xin Jiang 832008, China
| | - Wenjiang Cao
- First Affiliated Hospital of the Medical College, Shihezi University, Xin Jiang 832008, China
| | - Ye Hong
- The Xinjiang Production and Construction Corps Hospital of Pharmacy, Urumqi 830002, China
| | - Xinhong Guo
- First Affiliated Hospital of the Medical College, Shihezi University, Xin Jiang 832008, China
| | - Yanfang Wang
- First Affiliated Hospital of the Medical College, Shihezi University, Xin Jiang 832008, China; Pharmacy of College, Shihezi University, Xinjiang 832002, China
| | - Yangyang Wang
- First Affiliated Hospital of the Medical College, Shihezi University, Xin Jiang 832008, China; Pharmacy of College, Shihezi University, Xinjiang 832002, China
| | - Xinchun Wang
- First Affiliated Hospital of the Medical College, Shihezi University, Xin Jiang 832008, China; Pharmacy of College, Shihezi University, Xinjiang 832002, China.
| | - Ping Hu
- College of Pharmaceutical Sciences and Innovative Drug Research Centre, Chongqing University, 55 South Daxuecheng Road, Chongqing 401331, China.
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Effect of Remote Ischemic Preconditioning on Perioperative Cardiac Events in Patients Undergoing Elective Percutaneous Coronary Intervention: A Meta-Analysis of 16 Randomized Trials. Cardiol Res Pract 2017; 2017:6907167. [PMID: 29062582 PMCID: PMC5618784 DOI: 10.1155/2017/6907167] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Revised: 07/25/2017] [Accepted: 08/03/2017] [Indexed: 02/07/2023] Open
Abstract
Background The main objective of this meta-analysis was to investigate whether remote ischemic preconditioning (RIPC) reduces cardiac and renal events in patients undergoing elective cardiovascular interventions. Methods and Results We systematically searched articles published from 2006 to 2016 in PubMed, EMBASE, Web of Science, Cochrane Library, and Google Scholar. Odds ratios (ORs) with 95% confidence intervals (CIs) were used as the effect index for dichotomous variables. The standardized mean differences (SMDs) with 95% CIs were calculated as the pooled continuous effect. Sixteen RCTs of 2435 patients undergoing elective PCI were selected. Compared with control group, RIPC could significantly reduce the incidence of perioperative myocardial infarction (OR = 0.64; 95% CI: 0.48–0.86; P = 0.003) and acute kidney injury (OR = 0.56; 95% CI: 0.322–0.99; P = 0.049). Metaregression analysis showed that the reduction of PMI by RIPC was enhanced for CAD patients with multivessel disease (coef.: −0.05 [−0.09; −0.01], P = 0.022). There were no differences in the changes of cTnI (P = 0.934) and CRP (P = 0.075) in two groups. Conclusion Our meta-analysis of RCTs demonstrated that RIPC can provide cardiac and renal protection for patients undergoing elective PCI, while no beneficial effect on reducing the levels of cTnI and CRP after PCI was reported.
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Alshafey MK, Elrakhawy HM, Rezk ME, Moustafa HM. Role of ascorbic acid in reduction of the incidence of the atrial fibrillation in patients under B-blocker and undergoing coronary artery bypass graft operation in early post-operative period. ACTA ACUST UNITED AC 2017. [DOI: 10.1016/j.jescts.2017.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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31
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McLeod SL, Iansavichene A, Cheskes S. Remote Ischemic Perconditioning to Reduce Reperfusion Injury During Acute ST-Segment-Elevation Myocardial Infarction: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2017; 6:JAHA.117.005522. [PMID: 28515120 PMCID: PMC5524098 DOI: 10.1161/jaha.117.005522] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background Remote ischemic conditioning (RIC) is a noninvasive therapeutic strategy that uses brief cycles of blood pressure cuff inflation and deflation to protect the myocardium against ischemia–reperfusion injury. The objective of this systematic review was to determine the impact of RIC on myocardial salvage index, infarct size, and major adverse cardiovascular events when initiated before catheterization. Methods and Results Electronic searches of Medline, Embase, and Cochrane Central Register of Controlled Trials were conducted and reference lists were hand searched. Randomized controlled trials comparing percutaneous coronary intervention (PCI) with and without RIC for patients with ST‐segment–elevation myocardial infarction were included. Two reviewers independently screened abstracts, assessed quality of the studies, and extracted data. Data were pooled using random‐effects models and reported as mean differences and relative risk with 95% confidence intervals. Eleven articles (9 randomized controlled trials) were included with a total of 1220 patients (RIC+PCI=643, PCI=577). Studies with no events were excluded from meta‐analysis. The myocardial salvage index was higher in the RIC+PCI group compared with the PCI group (mean difference: 0.08; 95% confidence interval, 0.02–0.14). Infarct size was reduced in the RIC+PCI group compared with the PCI group (mean difference: −2.46; 95% confidence interval, −4.66 to −0.26). Major adverse cardiovascular events were lower in the RIC+PCI group (9.5%) compared with the PCI group (17.0%; relative risk: 0.57; 95% confidence interval, 0.40–0.82). Conclusions RIC appears to be a promising adjunctive treatment to PCI for the prevention of reperfusion injury in patients with ST‐segment–elevation myocardial infarction; however, additional high‐quality research is required before a change in practice can be considered.
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Affiliation(s)
- Shelley L McLeod
- Division of Emergency Medicine, Department of Family and Community Medicine, University of Toronto, Ontario, Canada.,Schwartz/Reisman Emergency Medicine Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | | | - Sheldon Cheskes
- Division of Emergency Medicine, Department of Family and Community Medicine, University of Toronto, Ontario, Canada .,Sunnybrook Centre for Prehospital Medicine, Toronto, Ontario, Canada.,Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
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32
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Elbadawi A, Ha LD, Abuzaid AS, Crimi G, Azzouz MS. Meta-Analysis of Randomized Trials on Remote Ischemic Conditioning During Primary Percutaneous Coronary Intervention in Patients With ST-Segment Elevation Myocardial Infarction. Am J Cardiol 2017; 119:832-838. [PMID: 28065491 DOI: 10.1016/j.amjcard.2016.11.036] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2016] [Revised: 11/22/2016] [Accepted: 11/22/2016] [Indexed: 11/25/2022]
Abstract
Ischemia/reperfusion injury adversely affects the final infarct size (IS) after primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI). Few studies have evaluated the role of remote ischemic conditioning (RIC) in reducing ischemia/reperfusion injury. However, the results of these studies were not consistent, and an overview of overall effectiveness of this technique in patients with STEMI is lacking. We conducted this meta-analysis to evaluate the available evidence in literature regarding the application of RIC in patients with STEMI who underwent primary PCI. The authors included randomized trials that studied RIC in patients with STEMI who underwent primary PCI versus no conditioning (standard of care). Final analysis included 8 trials with a total of 1,083 patients. Compared with standard of care alone, RIC was associated with reduced IS assessed by biomarker release (standardized mean difference = -0.23, 95% confidence interval [CI] -0.37 to -0.09; p = 0.001), better rates of ST-segment resolution (54% vs 30%; relative risk [RR] 1.78; 95% CI 1.35 to 2.34; p <0.001), reduced major adverse cardiac and cerebrovascular events (11% vs 20%; RR 0.57; 95% CI 0.39 to 0.83; p = 0.003), and nonsignificant reduction in IS assessed by cardiac imaging (standardized mean difference = -0.15; 95% CI -1.03 to -0.14; p = 0.36). There was no difference in postprocedural Thrombolysis In Myocardial Infarction-III flow between RIC and standard of care groups (86% vs 87%; RR 0.99; 95% CI 0.94 to 1.05; p = 0.81). In conclusion, remote ischemic conditioning may improve cardiovascular outcomes in patients with STEMI who underwent primary PCI evidenced by reduced biomarkers release, major adverse cardiac and cerebrovascular events, and better ST-segment resolution.
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Nair A, Khan S, Omar S, Pei XQ, McNeill K, Chowienczyk P, Webb AJ. Remote ischaemic preconditioning suppresses endogenous plasma nitrite during ischaemia-reperfusion: a randomized controlled crossover pilot study. Br J Clin Pharmacol 2017; 83:1416-1423. [PMID: 28074482 DOI: 10.1111/bcp.13231] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 11/23/2016] [Accepted: 12/18/2016] [Indexed: 01/16/2023] Open
Abstract
AIM The aim of this article is to test the hypothesis that remote ischaemic preconditioning (RIPC) increases circulating endogenous local and systemic plasma (nitrite) during RIPC and ischaemia-reperfusion (IR) as a potential protective mechanism against ischaemia-reperfusion injury (IRI). METHODS Six healthy male volunteers (mean age 29.5 ± 7.6 years) were randomized in a crossover study to initially receive either RIPC (4 × 5 min cycles) to the left arm, or no RIPC (control), both followed by an ischaemia-reperfusion (IR) sequence (20 min cuff inflation to 200 mmHg, 20 min reperfusion) to the right arm. The volunteers returned at least 7 days later for the alternate intervention. The primary outcome was the effect of RIPC vs. control on local and systemic plasma (nitrite). RESULTS RIPC did not significantly change plasma (nitrite) in either the left or the right arm during the RIPC sequence. However, compared to control, RIPC decreased plasma (nitrite) during the subsequent IR sequence by ~26% (from 118 ± 9 to 87 ± 5 nmol l-1 ) locally in the left arm (P = 0.008) overall, with an independent effect of -58.70 nmol l-1 (95% confidence intervals -116.1 to -1.33) at 15 min reperfusion, and by ~24% (from 109 ± 9 to 83 ± 7 nmol l-1 ) systemically in the right arm (P = 0.03). CONCLUSIONS RIPC had no effect on plasma (nitrite) during the RIPC sequence, but instead decreased plasma (nitrite) by ~25% during IR. This would likely counteract the protective mechanisms of RIPC, and contribute to RIPC's lack of efficacy, as observed in recent clinical trials. A combined approach of RIPC with nitrite administration may be required.
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Affiliation(s)
- Ashok Nair
- King's College London British Heart Foundation Centre, Cardiovascular Division, Department of Clinical Pharmacology, St. Thomas' Hospital, London, SE1 7EH, UK.,Biomedical Research Centre, Guy's & St. Thomas' NHS Foundation Trust, London, UK.,Department of Anaesthetics, Guy's & St. Thomas' NHS Foundation Trust, London, UK
| | - Sitara Khan
- King's College London British Heart Foundation Centre, Cardiovascular Division, Department of Clinical Pharmacology, St. Thomas' Hospital, London, SE1 7EH, UK.,Biomedical Research Centre, Guy's & St. Thomas' NHS Foundation Trust, London, UK
| | - Sami Omar
- King's College London British Heart Foundation Centre, Cardiovascular Division, Department of Clinical Pharmacology, St. Thomas' Hospital, London, SE1 7EH, UK.,Biomedical Research Centre, Guy's & St. Thomas' NHS Foundation Trust, London, UK
| | - Xiao-Qing Pei
- King's College London British Heart Foundation Centre, Cardiovascular Division, Department of Clinical Pharmacology, St. Thomas' Hospital, London, SE1 7EH, UK.,Biomedical Research Centre, Guy's & St. Thomas' NHS Foundation Trust, London, UK.,Ultrasound Department, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, People's Republic of China
| | - Karen McNeill
- King's College London British Heart Foundation Centre, Cardiovascular Division, Department of Clinical Pharmacology, St. Thomas' Hospital, London, SE1 7EH, UK.,Biomedical Research Centre, Guy's & St. Thomas' NHS Foundation Trust, London, UK
| | - Phil Chowienczyk
- King's College London British Heart Foundation Centre, Cardiovascular Division, Department of Clinical Pharmacology, St. Thomas' Hospital, London, SE1 7EH, UK.,Biomedical Research Centre, Guy's & St. Thomas' NHS Foundation Trust, London, UK
| | - Andrew James Webb
- King's College London British Heart Foundation Centre, Cardiovascular Division, Department of Clinical Pharmacology, St. Thomas' Hospital, London, SE1 7EH, UK.,Biomedical Research Centre, Guy's & St. Thomas' NHS Foundation Trust, London, UK
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Aggarwal S, Randhawa PK, Singh N, Jaggi AS. Role of ATP-Sensitive Potassium Channels in Remote Ischemic Preconditioning Induced Tissue Protection. J Cardiovasc Pharmacol Ther 2017; 22:467-475. [DOI: 10.1177/1074248416687873] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Remote ischemic preconditioning (RIPC) is an innovative treatment strategy that alleviates ischemia-reperfusion injury, whereby short episodes of regional ischemia and reperfusion delivered to remote organs including hind limb, kidney and intestine, and so on provide protection to the heart. The RIPC is known to reduce infarct size, serum levels of cardiac enzymes, and myocardial dysfunction in various animal species as well as in patients. There have been a large number of studies suggesting that the ATP-sensitive potassium channels (KATP channel) play a significant role as a mediator or end effector in RIPC. The present review discusses the role of KATP channels and possible mechanisms in RIPC-induced cardioprotection.
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Affiliation(s)
- Sapna Aggarwal
- Department of Pharmaceutical Sciences and Drug Research, Punjabi University Patiala, Patiala, India
| | - Puneet Kaur Randhawa
- Department of Pharmaceutical Sciences and Drug Research, Punjabi University Patiala, Patiala, India
| | - Nirmal Singh
- Department of Pharmaceutical Sciences and Drug Research, Punjabi University Patiala, Patiala, India
| | - Amteshwar Singh Jaggi
- Department of Pharmaceutical Sciences and Drug Research, Punjabi University Patiala, Patiala, India
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Therapeutic Effects of Ischemic-Preconditioned Exosomes in Cardiovascular Diseases. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2017; 998:271-281. [PMID: 28936746 DOI: 10.1007/978-981-10-4397-0_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Despite years of researches, cardiovascular disease (CVD) remains the most common cause of death around the world. Lots of studies showed that by pretreating with short nonfatal ischemia in in situ organ or distant organ, one could develop tolerance to the following fatal ischemia. The process is called ischemic preconditioning (IPC). IPC prepare the heart for damage by producing inflammatory signals, miRNA, neuro system stimulation and exosomes. Among them, exosomes have been gaining increasing interest since it is characterized by its capability to carry information and its specific ligand-receptor system. Here we will discuss IPC induced exosomes and its protective effects during ischemic heart disease.
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Park UJ, Kim HT, Cho WH, Park JH, Jung HR, Kim MY. Remote Ischemic Preconditioning Enhances the Expression of Genes Encoding Antioxidant Enzymes and Endoplasmic Reticulum Stress-Related Proteins in Rat Skeletal Muscle. Vasc Specialist Int 2016; 32:141-149. [PMID: 28042553 PMCID: PMC5198760 DOI: 10.5758/vsi.2016.32.4.141] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 09/21/2016] [Accepted: 09/26/2016] [Indexed: 01/16/2023] Open
Abstract
Purpose: Ischemic preconditioning (IPC), including remote IPC (rIPC) and direct IPC (dIPC), is a promising method to decrease ischemia-reperfusion (IR) injury. This study tested the effect of both rIPC and dIPC on the genes for antioxidant enzymes and endoplasmic reticulum (ER) stress-related proteins. Materials and Methods: Twenty rats were randomly divided into the control and study groups. In the control group (n=10), the right hind limb was sham-operated. The left hind limb (IscR) of the control group underwent IR injury without IPC. In the study group (n=10), the right hind limb received IR injury after 3 cycles of rIPC. The IscR received IR injury after 3 cycles of dIPC. Gene expression was analyzed by Quantitative real-time polymerase chain reaction from the anterior tibialis muscle. Results: The expression of the antioxidant enzyme genes including glutathione peroxidase (GPx), superoxide dismutase (SOD) 1 and catalase (CAT) were significantly reduced in IscR compared with sham treatment. In comparison with IscR, rIPC enhanced the expression of GPx, SOD2, and CAT genes. dIPC enhanced the expression of SOD2 and CAT genes. The expression of SOD2 genes was consistently higher in rIPC than in dIPC, but the difference was only significant for SOD2. The expression of genes for ER stress-related proteins tended to be reduced in IscR in comparison with sham treatment. However, the difference was only significant for C/EBP homologous protein (CHOP). In comparison with IscR, rIPC significantly up-regulated activating transcription factor 4 and CHOP, whereas dIPC up-regulated CHOP. Conclusion: Both rIPC and dIPC enhanced expression of genes for antioxidant enzymes and ER stress-related proteins.
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Affiliation(s)
- Ui Jun Park
- Department of Surgery, Keimyung University School of Medicine, Daegu, Ulsan, Korea
| | - Hyoung Tae Kim
- Department of Surgery, Keimyung University School of Medicine, Daegu, Ulsan, Korea
| | - Won Hyun Cho
- Department of Surgery, Keimyung University School of Medicine, Daegu, Ulsan, Korea
| | - Jae Hyoung Park
- Department of Physiology, Keimyung University School of Medicine, Daegu, Ulsan, Korea
| | - Hye Ra Jung
- Department of Pathology, Keimyung University School of Medicine, Daegu, Ulsan, Korea
| | - Min Young Kim
- Department of Nursing, University of Ulsan, Ulsan, Korea
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Alternative Interventions to Prevent Oxidative Damage following Ischemia/Reperfusion. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2016; 2016:7190943. [PMID: 28116037 PMCID: PMC5225393 DOI: 10.1155/2016/7190943] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 09/23/2016] [Accepted: 10/12/2016] [Indexed: 12/25/2022]
Abstract
Ischemia/reperfusion (I/R) lesions are a phenomenon that occurs in multiple pathological states and results in a series of events that end in irreparable damage that severely affects the recovery and health of patients. The principal therapeutic approaches include preconditioning, postconditioning, and remote ischemic preconditioning, which when used separately do not have a great impact on patient mortality or prognosis. Oxidative stress is known to contribute to the damage caused by I/R; however, there are no pharmacological approaches to limit or prevent this. Here, we explain the relationship between I/R and the oxidative stress process and describe some pharmacological options that may target oxidative stress-states.
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Nouraei SM, Baradari AG, Jazayeri A. Does Remote Ischaemic Preconditioning Protect Kidney and Cardiomyocytes After Coronary Revascularization? A Double Blind Controlled Clinical Trial. Med Arch 2016; 70:373-378. [PMID: 27994300 PMCID: PMC5136438 DOI: 10.5455/medarh.2016.70.373-378] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 09/25/2016] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To investigate efficacy of remote ischaemic preconditioning on reducing kidney injury and myocardial damage after coronary artery bypass grafting surgery (CABG). BACKGROUND Ischaemic preconditioning of a remote organ reduces ischaemia-reperfusion injury of kidney and myocardium after CABG. METHOD To reduce myocardial damage and kidney injury by applying Remote Ischaemic Preconditioning we recruited 100 consecutive patients undergoing elective coronary artery bypass grafting surgery. We applied three cycles of lower limb tourniquet, inflated its cuff for 5 minutes in study group or left un-inflated (sham or control group) before the procedure. The primary outcome was serum creatinine, creatinine clearance and troponin-I Levels at time 0, 6, 12, 24 and 48 h. Secondary outcomes were serum C-reactive protein, inotrope score, ventilation time and ICU stay. Data's were analyzed by MedCalc (MedCalc Software bvba, Acacialaan, Belgium). We compared the two group by student t test, chi-square and Mann-Whitney tests. RESULTS The two groups were not statistically different in terms of age, gender, smoking habits, drug use, hypertension, hyperlipidemia and diabetes mellitus. This study showed a higher CRP level in study group comparing with control group (P=0.003), creatinine clearance was slightly higher in study group specially 24 h after procedure but was not statistically significant (p=0.11). Troponin-I level was significantly lower in study group (p=0.001). CONCLUSION This study showed a lower Troponin-I level in study group which suggest a cardio-myocyte protective function of RIPC. It also showed slightly lower Creatinine clearance in control group, gap between two group increases significantly 24 hours after procedure which may suggest a potential kidney protection by RIPC. Serum CRP level was higher in study group. A multi-center randomized controlled trial with a longer time for creatinine clearance measurement may show the potential effectiveness of this non-invasive inexpensive intervention on reducing kidney injury after CABG.
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Affiliation(s)
- Seyed Mahmoud Nouraei
- Thoracic and cardiovascular surgery department, Mazandran University of Medical sciences, Sari, Iran
| | | | - Asieh Jazayeri
- Student Research Committee, Mazandran University of Medical sciences, Sari, Iran
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Al Kasab S, Hess DC, Chimowitz MI. Rationale for ischemic conditioning to prevent stroke in patients with intracranial arterial stenosis. Brain Circ 2016; 2:67-71. [PMID: 30276275 PMCID: PMC6126250 DOI: 10.4103/2394-8108.186260] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 05/12/2016] [Accepted: 05/19/2016] [Indexed: 12/11/2022] Open
Abstract
Intracranial atherosclerotic arterial stenosis (ICAS) is one of the most common causes of stroke worldwide and is associated with particularly a high risk of recurrent stroke. Although aggressive medical management, consisting of dual antiplatelet therapy and intensive control of vascular risk factors, has improved the prognosis of patients with ICAS, subgroups of patients remain at very high risk of stroke. More effective therapies for these high-risk patients are urgently needed. One promising treatment is remote limb ischemic conditioning, which involves producing repetitive, transient ischemia of a limb by inflating a blood pressure cuff with the intention of protecting the brain from subsequent ischemia. In this study, we review the limitations of currently available treatments, discuss the potential mechanisms of action of ischemic conditioning, describe the preclinical and clinical data suggesting a possible role of ischemic conditioning in treating patients with ICAS, and outline the questions that still need to be answered in future studies of ischemic conditioning in subjects with ICAS.
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Affiliation(s)
- Sami Al Kasab
- Department of Neurology, Medical University of South Carolina, Charleston, SC 29425, USA
| | - David C Hess
- Department of Neurology, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Marc I Chimowitz
- Department of Neurology, Medical University of South Carolina, Charleston, SC 29425, USA
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40
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Sardar P, Chatterjee S, Kundu A, Samady H, Owan T, Giri J, Nairooz R, Selzman CH, Heusch G, Gersh BJ, Abbott JD, Mukherjee D, Fang JC. Remote ischemic preconditioning in patients undergoing cardiovascular surgery: Evidence from a meta-analysis of randomized controlled trials. Int J Cardiol 2016; 221:34-41. [PMID: 27400294 DOI: 10.1016/j.ijcard.2016.06.325] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 06/27/2016] [Accepted: 06/29/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND Remote ischemic preconditioning (RIPC) has been associated with reduced risk of myocardial injury in patients undergoing cardiovascular surgery, but uncertainty about clinical outcomes remains, particularly in the light of 2 recent large randomized clinical trials (RCTs) which were neutral. We performed a meta-analysis to evaluate the efficacy of RIPC on clinically relevant outcomes in patients undergoing cardiovascular surgery. METHODS We searched PubMed, Cochrane CENTRAL, EMBASE, EBSCO, Web of Science and CINAHL databases from inception through November 30, 2015. RCTs that compared the effects of RIPC vs. control in patients undergoing cardiac and/or vascular surgery were selected. We calculated summary random-effect odds ratios (ORs) and 95% confidence intervals (CI). RESULTS The analysis included 5652 patients from 27 RCTs. RIPC reduced the risk of myocardial infarction (MI) (OR 0.72, 95% CI, 0.52 to 1.00; p=0.05; number needed to treat (NNT)=42), acute renal failure (OR 0.73, 95% CI, 0.53 to 1.00; p=0.05; NNT=44) as well as the composite of all cause mortality, MI, stroke or acute renal failure (OR 0.60, 95% CI, 0.39 to 0.90; p=0.01; NNT=25). No significant difference between RIPC and the control groups was observed for the outcome of all-cause mortality (OR 1.10, 95% CI, 0.81 to 1.51). Randomization to RIPC group was also associated with significantly shorter hospital stay (weighted mean difference -0.15days; 95% CI -0.27 to -0.03days). CONCLUSIONS RIPC did not decrease overall mortality, but was associated with less MI and acute renal failure and shorter hospitalizations in patients undergoing cardiac or vascular surgery.
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Affiliation(s)
- Partha Sardar
- Division of Cardiovascular Medicine, University of Utah, Salt Lake City, UT, United States.
| | - Saurav Chatterjee
- St Luke's-Roosevelt Hospital of the Mount Sinai Health System, New York, NY, United States
| | - Amartya Kundu
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, United States
| | - Habib Samady
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States
| | - Theophilus Owan
- Division of Cardiovascular Medicine, University of Utah, Salt Lake City, UT, United States
| | - Jay Giri
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Ramez Nairooz
- University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Craig H Selzman
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah, Salt Lake City, UT,United States
| | - Gerd Heusch
- Institute for Pathophysiology, West German Heart and Vascular Center, University of Essen Medical School, Hufelandstr. 55, 45122 Essen, Germany
| | - Bernard J Gersh
- Division of Cardiovascular Diseases, Mayo Clinic and Mayo Clinic College of Medicine, Rochester, MN, United States
| | - J Dawn Abbott
- Division of Cardiology, Brown Medical School, Rhode Island Hospital, Providence, RI, United States
| | | | - James C Fang
- Division of Cardiovascular Medicine, University of Utah, Salt Lake City, UT, United States
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Li B, Lang X, Cao L, Wang Y, Lu Y, Feng S, Yang Y, Chen J, Jiang H. Effect of remote ischemic preconditioning on postoperative acute kidney injury among patients undergoing cardiac and vascular interventions: a meta-analysis. J Nephrol 2016; 30:19-33. [PMID: 27091767 PMCID: PMC5316401 DOI: 10.1007/s40620-016-0301-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Accepted: 03/25/2016] [Indexed: 12/17/2022]
Abstract
It is currently controversial whether remote ischemic preconditioning (RIPC) reduces the incidence of acute kidney injury (AKI) in patients undergoing cardiovascular interventions. The main objective of this meta-analysis was to investigate whether RIPC provides renal protection for patients undergoing cardiac or vascular surgery. We searched the PubMed database (1966-Oct 2015), Embase database (1966-Oct 2015), Google Scholar, Cochrane Library, ClinicalTrials Database and Open Grey. Then we conducted a meta-analysis of the randomized controlled trials that met the inclusion criteria of our study. The interventions included use of an inflatable tourniquet around the limbs or cross-clamping of the iliac arteries before surgery (RIPC groups) and general cardiovascular intervention (control groups). The main outcomes examined included the incidence of AKI; changes in acute kidney injury biomarkers; and use of renal replacement therapy. Other outcomes examined included in-hospital mortality and the lengths of hospital stay and intensive care unit (ICU) stay. Finally, we screened 26 eligible studies containing 6699 patients who underwent cardiac or vascular interventions with RIPC (n = 3343) or without RIPC (n = 3356). The AKI incidence was decreased in the RIPC group as was the length of ICU stay. There were no differences in the changes in AKI biomarkers, use of renal replacement therapy or in-hospital mortality between the two groups. Remote ischemic preconditioning may decrease the occurrence of AKI in cardiovascular surgery patients. Since studies included have a significant heterogeneity, meta-analyses using a stricter inclusion criteria are needed to clarify the renoprotection effect of RIPC.
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Affiliation(s)
- Bingjue Li
- Kidney Disease Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Qinchun Road 79#, Hangzhou, 310003, People's Republic of China.,Kidney Disease Immunology Laboratory, The Third Grade Laboratory, State Administration of Traditional Chinese Medicine of P.R. China, Hangzhou, People's Republic of China.,Key Laboratory of Multiple Organ Transplantation, Ministry of Health, Hangzhou, People's Republic of China.,Key Laboratory of Nephropathy, Zhejiang Province, Hangzhou, Zhejiang, People's Republic of China
| | - Xiabing Lang
- Kidney Disease Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Qinchun Road 79#, Hangzhou, 310003, People's Republic of China.,Kidney Disease Immunology Laboratory, The Third Grade Laboratory, State Administration of Traditional Chinese Medicine of P.R. China, Hangzhou, People's Republic of China.,Key Laboratory of Multiple Organ Transplantation, Ministry of Health, Hangzhou, People's Republic of China.,Key Laboratory of Nephropathy, Zhejiang Province, Hangzhou, Zhejiang, People's Republic of China
| | - Luxi Cao
- Kidney Disease Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Qinchun Road 79#, Hangzhou, 310003, People's Republic of China.,Kidney Disease Immunology Laboratory, The Third Grade Laboratory, State Administration of Traditional Chinese Medicine of P.R. China, Hangzhou, People's Republic of China.,Key Laboratory of Multiple Organ Transplantation, Ministry of Health, Hangzhou, People's Republic of China.,Key Laboratory of Nephropathy, Zhejiang Province, Hangzhou, Zhejiang, People's Republic of China
| | - Yuchen Wang
- Kidney Disease Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Qinchun Road 79#, Hangzhou, 310003, People's Republic of China.,Kidney Disease Immunology Laboratory, The Third Grade Laboratory, State Administration of Traditional Chinese Medicine of P.R. China, Hangzhou, People's Republic of China.,Key Laboratory of Multiple Organ Transplantation, Ministry of Health, Hangzhou, People's Republic of China.,Key Laboratory of Nephropathy, Zhejiang Province, Hangzhou, Zhejiang, People's Republic of China
| | - Yingying Lu
- Kidney Disease Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Qinchun Road 79#, Hangzhou, 310003, People's Republic of China.,Kidney Disease Immunology Laboratory, The Third Grade Laboratory, State Administration of Traditional Chinese Medicine of P.R. China, Hangzhou, People's Republic of China.,Key Laboratory of Multiple Organ Transplantation, Ministry of Health, Hangzhou, People's Republic of China.,Key Laboratory of Nephropathy, Zhejiang Province, Hangzhou, Zhejiang, People's Republic of China
| | - Shi Feng
- Kidney Disease Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Qinchun Road 79#, Hangzhou, 310003, People's Republic of China.,Kidney Disease Immunology Laboratory, The Third Grade Laboratory, State Administration of Traditional Chinese Medicine of P.R. China, Hangzhou, People's Republic of China.,Key Laboratory of Multiple Organ Transplantation, Ministry of Health, Hangzhou, People's Republic of China.,Key Laboratory of Nephropathy, Zhejiang Province, Hangzhou, Zhejiang, People's Republic of China
| | - Yi Yang
- Kidney Disease Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Qinchun Road 79#, Hangzhou, 310003, People's Republic of China.,Kidney Disease Immunology Laboratory, The Third Grade Laboratory, State Administration of Traditional Chinese Medicine of P.R. China, Hangzhou, People's Republic of China.,Key Laboratory of Multiple Organ Transplantation, Ministry of Health, Hangzhou, People's Republic of China.,Key Laboratory of Nephropathy, Zhejiang Province, Hangzhou, Zhejiang, People's Republic of China
| | - Jianghua Chen
- Kidney Disease Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Qinchun Road 79#, Hangzhou, 310003, People's Republic of China.,Kidney Disease Immunology Laboratory, The Third Grade Laboratory, State Administration of Traditional Chinese Medicine of P.R. China, Hangzhou, People's Republic of China.,Key Laboratory of Multiple Organ Transplantation, Ministry of Health, Hangzhou, People's Republic of China.,Key Laboratory of Nephropathy, Zhejiang Province, Hangzhou, Zhejiang, People's Republic of China
| | - Hong Jiang
- Kidney Disease Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Qinchun Road 79#, Hangzhou, 310003, People's Republic of China. .,Kidney Disease Immunology Laboratory, The Third Grade Laboratory, State Administration of Traditional Chinese Medicine of P.R. China, Hangzhou, People's Republic of China. .,Key Laboratory of Multiple Organ Transplantation, Ministry of Health, Hangzhou, People's Republic of China. .,Key Laboratory of Nephropathy, Zhejiang Province, Hangzhou, Zhejiang, People's Republic of China.
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Wang SX, Wang J, Shao JB, Tang WN, Zhong JQ. Plumbagin Mediates Cardioprotection Against Myocardial Ischemia/Reperfusion Injury Through Nrf-2 Signaling. Med Sci Monit 2016; 22:1250-7. [PMID: 27078001 PMCID: PMC4835155 DOI: 10.12659/msm.897618] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Background Plumbagin is a potent antioxidant with anti-inflammatory and anti-carcinogenic action. Myocardial ischemia/reperfusion injury results in organ damage through oxidative stress and inflammatory mechanisms. In this study, we analyzed the potential role of plumbagin against myocardial I/R injury in Wistar rats. Material/Methods Oxidative stress was measured through ROS, lipid peroxide content, and antioxidant enzyme activities. The expression of redox signaling and inflammatory proteins was analyzed through Western blotting. Inflammatory cytokine expressions were determined through ELISA. Results Oxidative stress status was reduced by plumbagin by decreasing ROS and lipid peroxide levels in rats with myocardial I/R (MI/R) injury. Plumbagin regulated redox imbalance induced by I/R injury by modulating the transcription factors NF-κB and Nrf-2. Further, downstream targets of NF-κB (COX-2, iNOS) and Nrf-2 (HO-1, NQO1 and GST) expression were significantly downregulated by plumbagin treatment. Pro-inflammatory cytokine expressions were significantly abrogated by plumbagin treatment. Conclusions This study shows the protective role of plumbagin against myocardial I/R injury by regulating antioxidant and inflammatory mechanisms.
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Affiliation(s)
- Shi-Xun Wang
- Department of Cardiology, Weifang People's Hospital, Weifang, Shandong, China (mainland)
| | - Jian Wang
- Department of Cardiology, Weifang People's Hospital, Weifang, Shandong, China (mainland)
| | - Jing-Bo Shao
- Department of Cardiology, Weifang People's Hospital, Weifang, Shandong, China (mainland)
| | - Wei-Ning Tang
- Department of Cardiology, Weifang People's Hospital, Weifang, Shandong, China (mainland)
| | - Jing-Quan Zhong
- Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health, Department of Cardiology, Qilu Hospital of Shandong University, Jinan, Shandong, China (mainland)
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43
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Heyman SN, Leibowitz D, Mor-Yosef Levi I, Liberman A, Eisenkraft A, Alcalai R, Khamaisi M, Rosenberger C. Adaptive response to hypoxia and remote ischaemia pre-conditioning: a new hypoxia-inducible factors era in clinical medicine. Acta Physiol (Oxf) 2016; 216:395-406. [PMID: 26449466 DOI: 10.1111/apha.12613] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 07/01/2015] [Accepted: 10/02/2015] [Indexed: 01/30/2023]
Abstract
Transient ischaemia leads to tolerance to subsequent protracted ischaemia. This 'ischaemia pre-conditioning' results from the induction of numerous protective genes, involved in cell metabolism, proliferation and survival, in antioxidant capacity, angiogenesis, vascular tone and erythropoiesis. Hypoxia-inducible factors (HIF) play a pivotal role in this transcriptional adaptive response. HIF prolyl hydroxylases (PHDs), serving as oxygen sensors, control HIFα degradation. HIF-mediated ischaemic pre-conditioning can be achieved with the administration of PHD inhibitors, with the attenuation of organ injury under various hypoxic and toxic insults. Clinical trials are currently under way, evaluating PHD inhibitors as inducers of erythropoietin. Once their safety is established, their potential use might be further tested in clinical trials in various forms of acute ischaemic and toxic organ damage. Repeated transient limb ischaemia was also found to attenuate ischaemic injury in remote organs. This 'remote ischaemic pre-conditioning' phenomenon (RIP) has been extensively studied recently in small clinical trials, preceding, or in parallel with an abrupt insult, such as myocardial infarction, cardiac surgery or radiocontrast administration. Initial results are promising, suggesting organ protection. Large-scale multi-centre studies are currently under way, evaluating the protective potential of RIP in cardiac surgery, in the management of myocardial infarction and in organ transplantation. The mechanisms of organ protection provided by RIP are poorly understood, but HIF seemingly play a role as well. Thus, Inhibition of HIF degradation with PHD inhibitors, as well as RIP (in part through HIF), might develop into novel clinical interventions in organ protection in the near future.
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Affiliation(s)
- S. N. Heyman
- Department of Medicine; Hadassah Hebrew University Hospitals; Jerusalem Israel
| | - D. Leibowitz
- Department of Medicine; Hadassah Hebrew University Hospitals; Jerusalem Israel
- Department of Cardiology; Hadassah Hebrew University Hospitals; Jerusalem Israel
| | - I. Mor-Yosef Levi
- Department of Nephrology; Hadassah Hebrew University Hospitals; Jerusalem Israel
| | - A. Liberman
- Department of Neurology; Hadassah Hebrew University Hospitals; Jerusalem Israel
| | - A. Eisenkraft
- The Research Institute for Military Medicine; The Hebrew University Medical School and the Israeli Defense Force Medical Corps; Jerusalem Israel
| | - R. Alcalai
- Department of Medicine; Hadassah Hebrew University Hospitals; Jerusalem Israel
- Department of Cardiology; Hadassah Hebrew University Hospitals; Jerusalem Israel
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Kloner RA. Remote Ischemic Conditioning: Its Benefits and Limitations. J Cardiovasc Pharmacol Ther 2016; 21:219-21. [PMID: 26740183 DOI: 10.1177/1074248415618816] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 11/04/2015] [Indexed: 11/16/2022]
Abstract
This editorial describes benefits and limitations of remote ischemic conditioning. Remote ischemic conditioning was shown to reduce myocardial intact size in at least 4 sizeable clinical trials of acute myocardial infarction. It was not effective in recent studies of cardiac surgery. Reasons for these differences are discussed.
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Affiliation(s)
- Robert A Kloner
- Huntington Medical Research Institutes, Pasadena, CA, USA Cardiovascular Division, Department of Medicine, Keck School of Medicine at University of Southern California, Los Angeles, CA, USA
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46
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Apoptosis-related microRNA changes in the right atrium induced by remote ischemic perconditioning during valve replacement surgery. Sci Rep 2016; 6:18959. [PMID: 26738985 PMCID: PMC4704063 DOI: 10.1038/srep18959] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Accepted: 11/13/2015] [Indexed: 01/05/2023] Open
Abstract
We previously found that remote ischemic perconditioning (RIPerc) was effective in attenuating myocardial injury during cardiac surgery. Given that microRNAs (miRs) act as an important player in ischemic/reperfusion (I/R) injury and apoptosis, this study aimed to investigate whether RIPerc reduces apoptosis in atrial myocardium and which apoptosis-related miRs are involved during valve replacement surgery. Here, we demonstrated that RIPerc inhibited apoptosis in atrial myocardium during cardiac ischemia and that 17 miRs showed at least a 1.5-fold change in expression after ischemia. Of the 17 miRs, 9 miRs, including miR-1, miR-21, miR-24, and miR-195, which are related to apoptosis, exhibited different expression patterns in the RIPerc group compared with the control. Using qRT-PCR and Western blotting, we demonstrated that miR-1 and miR-195 were downregulated and that their common putative target gene Bcl-2 was upregulated in the RIPerc group. However, the differences in miR-21 and miR-24 expression, together with programmed cell death 4 (PDCD4), which is the target gene of miR-21, were not significant. These findings provide some insight into the role of miRs in the cardioprotective effects induced by RIPerc.
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47
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Hess DC, Khan MB, Hoda N, Morgan JC. Remote ischemic conditioning: a treatment for vascular cognitive impairment. Brain Circ 2015; 1:133-139. [PMID: 30221201 DOI: 10.4103/2394-8108.172885] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
There is a strong link between hypoperfusion and white matter (WM) damage in patients with leukoaraiosis and vascular cognitive impairment (VCI). Other than management of vascular risk factors, there is no treatment for WM damage and VCI that delays progression of the disease process to dementia. Observational studies suggest that exercise may prevent or slow down the progression of Alzheimer's disease (AD) and VCI. However, getting patients to exercise is challenging especially with advancing age and disability. Remote ischemic conditioning, an "exercise equivalent", allows exercise to be given with a "device" in the home for long periods of time. Since RIC increases CBF in pre-clinical studies and in humans, RIC may be an ideal therapy to treat VCI and WM disease and perhaps even sporadic AD. By using MRI imaging of WM progression, a sample size in the range of about 100 subjects per group could determine if RIC has activity in WM disease and VCI.
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Affiliation(s)
- David C Hess
- Department of Neurology Medical College of Georgia, Georgia Regent's University, Augusta, GA USA
| | - Mohammad B Khan
- Department of Neurology Medical College of Georgia, Georgia Regent's University, Augusta, GA USA
| | - Nasrul Hoda
- Department of Medical Laboratory, Imaging, and Radiologic Sciences, College of Allied Health Sciences, Georgia Regent's University, Augusta, GA USA
| | - John C Morgan
- Department of Neurology Medical College of Georgia, Georgia Regent's University, Augusta, GA USA
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Walsh M, Whitlock R, Garg AX, Légaré JF, Duncan AE, Zimmerman R, Miller S, Fremes S, Kieser T, Karthikeyan G, Chan M, Ho A, Nasr V, Vincent J, Ali I, Lavi R, Sessler DI, Kramer R, Gardner J, Syed S, VanHelder T, Guyatt G, Rao-Melacini P, Thabane L, Devereaux PJ. Effects of remote ischemic preconditioning in high-risk patients undergoing cardiac surgery (Remote IMPACT): a randomized controlled trial. CMAJ 2015; 188:329-336. [PMID: 26668200 DOI: 10.1503/cmaj.150632] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/26/2015] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Remote ischemic preconditioning is a simple therapy that may reduce cardiac and kidney injury. We undertook a randomized controlled trial to evaluate the effect of this therapy on markers of heart and kidney injury after cardiac surgery. METHODS Patients at high risk of death within 30 days after cardiac surgery were randomly assigned to undergo remote ischemic preconditioning or a sham procedure after induction of anesthesia. The preconditioning therapy was three 5-minute cycles of thigh ischemia, with 5 minutes of reperfusion between cycles. The sham procedure was identical except that ischemia was not induced. The primary outcome was peak creatine kinase-myocardial band (CK-MB) within 24 hours after surgery (expressed as multiples of the upper limit of normal, with log transformation). The secondary outcome was change in creatinine level within 4 days after surgery (expressed as log-transformed micromoles per litre). Patient-important outcomes were assessed up to 6 months after randomization. RESULTS We randomly assigned 128 patients to remote ischemic preconditioning and 130 to the sham therapy. There were no significant differences in postoperative CK-MB (absolute mean difference 0.15, 95% confidence interval [CI] -0.07 to 0.36) or creatinine (absolute mean difference 0.06, 95% CI -0.10 to 0.23). Other outcomes did not differ significantly for remote ischemic preconditioning relative to the sham therapy: for myocardial infarction, relative risk (RR) 1.35 (95% CI 0.85 to 2.17); for acute kidney injury, RR 1.10 (95% CI 0.68 to 1.78); for stroke, RR 1.02 (95% CI 0.34 to 3.07); and for death, RR 1.47 (95% CI 0.65 to 3.31). INTERPRETATION Remote ischemic precnditioning did not reduce myocardial or kidney injury during cardiac surgery. This type of therapy is unlikely to substantially improve patient-important outcomes in cardiac surgery. TRIAL REGISTRATION ClinicalTrials.gov, no. NCT01071265.
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Affiliation(s)
- Michael Walsh
- Population Health Research Institute (Walsh, Whitlock, Vincent, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; McMaster University (Walsh, Whitlock, Syed, VanHelder, Guyatt, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; London Health Sciences Centre (Garg, Lavi), Western University, London, Ont.; Dalhousie University (Légaré), Halifax, NS; Cleveland Clinic (Duncan, Nasr, Sessler), Cleveland, Ohio; Maine Medical Center (Zimmerman, Kramer), Portland, Me.; Wake Forest University (Miller, Gardner), Winston-Salem, NC; Sunnybrook Health Sciences Centre (Fremes), University of Toronto, Toronto, Ont.; University of Calgary (Kieser, Ali), Calgary, Alta.; All India Institute of Medical Sciences (Karthikeyan), New Delhi, India; The Chinese University of Hong Kong (Chan, Ho), Hong Kong SAR, China
| | - Richard Whitlock
- Population Health Research Institute (Walsh, Whitlock, Vincent, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; McMaster University (Walsh, Whitlock, Syed, VanHelder, Guyatt, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; London Health Sciences Centre (Garg, Lavi), Western University, London, Ont.; Dalhousie University (Légaré), Halifax, NS; Cleveland Clinic (Duncan, Nasr, Sessler), Cleveland, Ohio; Maine Medical Center (Zimmerman, Kramer), Portland, Me.; Wake Forest University (Miller, Gardner), Winston-Salem, NC; Sunnybrook Health Sciences Centre (Fremes), University of Toronto, Toronto, Ont.; University of Calgary (Kieser, Ali), Calgary, Alta.; All India Institute of Medical Sciences (Karthikeyan), New Delhi, India; The Chinese University of Hong Kong (Chan, Ho), Hong Kong SAR, China
| | - Amit X Garg
- Population Health Research Institute (Walsh, Whitlock, Vincent, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; McMaster University (Walsh, Whitlock, Syed, VanHelder, Guyatt, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; London Health Sciences Centre (Garg, Lavi), Western University, London, Ont.; Dalhousie University (Légaré), Halifax, NS; Cleveland Clinic (Duncan, Nasr, Sessler), Cleveland, Ohio; Maine Medical Center (Zimmerman, Kramer), Portland, Me.; Wake Forest University (Miller, Gardner), Winston-Salem, NC; Sunnybrook Health Sciences Centre (Fremes), University of Toronto, Toronto, Ont.; University of Calgary (Kieser, Ali), Calgary, Alta.; All India Institute of Medical Sciences (Karthikeyan), New Delhi, India; The Chinese University of Hong Kong (Chan, Ho), Hong Kong SAR, China
| | - Jean-François Légaré
- Population Health Research Institute (Walsh, Whitlock, Vincent, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; McMaster University (Walsh, Whitlock, Syed, VanHelder, Guyatt, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; London Health Sciences Centre (Garg, Lavi), Western University, London, Ont.; Dalhousie University (Légaré), Halifax, NS; Cleveland Clinic (Duncan, Nasr, Sessler), Cleveland, Ohio; Maine Medical Center (Zimmerman, Kramer), Portland, Me.; Wake Forest University (Miller, Gardner), Winston-Salem, NC; Sunnybrook Health Sciences Centre (Fremes), University of Toronto, Toronto, Ont.; University of Calgary (Kieser, Ali), Calgary, Alta.; All India Institute of Medical Sciences (Karthikeyan), New Delhi, India; The Chinese University of Hong Kong (Chan, Ho), Hong Kong SAR, China
| | - Andra E Duncan
- Population Health Research Institute (Walsh, Whitlock, Vincent, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; McMaster University (Walsh, Whitlock, Syed, VanHelder, Guyatt, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; London Health Sciences Centre (Garg, Lavi), Western University, London, Ont.; Dalhousie University (Légaré), Halifax, NS; Cleveland Clinic (Duncan, Nasr, Sessler), Cleveland, Ohio; Maine Medical Center (Zimmerman, Kramer), Portland, Me.; Wake Forest University (Miller, Gardner), Winston-Salem, NC; Sunnybrook Health Sciences Centre (Fremes), University of Toronto, Toronto, Ont.; University of Calgary (Kieser, Ali), Calgary, Alta.; All India Institute of Medical Sciences (Karthikeyan), New Delhi, India; The Chinese University of Hong Kong (Chan, Ho), Hong Kong SAR, China
| | - Robert Zimmerman
- Population Health Research Institute (Walsh, Whitlock, Vincent, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; McMaster University (Walsh, Whitlock, Syed, VanHelder, Guyatt, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; London Health Sciences Centre (Garg, Lavi), Western University, London, Ont.; Dalhousie University (Légaré), Halifax, NS; Cleveland Clinic (Duncan, Nasr, Sessler), Cleveland, Ohio; Maine Medical Center (Zimmerman, Kramer), Portland, Me.; Wake Forest University (Miller, Gardner), Winston-Salem, NC; Sunnybrook Health Sciences Centre (Fremes), University of Toronto, Toronto, Ont.; University of Calgary (Kieser, Ali), Calgary, Alta.; All India Institute of Medical Sciences (Karthikeyan), New Delhi, India; The Chinese University of Hong Kong (Chan, Ho), Hong Kong SAR, China
| | - Scott Miller
- Population Health Research Institute (Walsh, Whitlock, Vincent, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; McMaster University (Walsh, Whitlock, Syed, VanHelder, Guyatt, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; London Health Sciences Centre (Garg, Lavi), Western University, London, Ont.; Dalhousie University (Légaré), Halifax, NS; Cleveland Clinic (Duncan, Nasr, Sessler), Cleveland, Ohio; Maine Medical Center (Zimmerman, Kramer), Portland, Me.; Wake Forest University (Miller, Gardner), Winston-Salem, NC; Sunnybrook Health Sciences Centre (Fremes), University of Toronto, Toronto, Ont.; University of Calgary (Kieser, Ali), Calgary, Alta.; All India Institute of Medical Sciences (Karthikeyan), New Delhi, India; The Chinese University of Hong Kong (Chan, Ho), Hong Kong SAR, China
| | - Stephen Fremes
- Population Health Research Institute (Walsh, Whitlock, Vincent, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; McMaster University (Walsh, Whitlock, Syed, VanHelder, Guyatt, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; London Health Sciences Centre (Garg, Lavi), Western University, London, Ont.; Dalhousie University (Légaré), Halifax, NS; Cleveland Clinic (Duncan, Nasr, Sessler), Cleveland, Ohio; Maine Medical Center (Zimmerman, Kramer), Portland, Me.; Wake Forest University (Miller, Gardner), Winston-Salem, NC; Sunnybrook Health Sciences Centre (Fremes), University of Toronto, Toronto, Ont.; University of Calgary (Kieser, Ali), Calgary, Alta.; All India Institute of Medical Sciences (Karthikeyan), New Delhi, India; The Chinese University of Hong Kong (Chan, Ho), Hong Kong SAR, China
| | - Teresa Kieser
- Population Health Research Institute (Walsh, Whitlock, Vincent, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; McMaster University (Walsh, Whitlock, Syed, VanHelder, Guyatt, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; London Health Sciences Centre (Garg, Lavi), Western University, London, Ont.; Dalhousie University (Légaré), Halifax, NS; Cleveland Clinic (Duncan, Nasr, Sessler), Cleveland, Ohio; Maine Medical Center (Zimmerman, Kramer), Portland, Me.; Wake Forest University (Miller, Gardner), Winston-Salem, NC; Sunnybrook Health Sciences Centre (Fremes), University of Toronto, Toronto, Ont.; University of Calgary (Kieser, Ali), Calgary, Alta.; All India Institute of Medical Sciences (Karthikeyan), New Delhi, India; The Chinese University of Hong Kong (Chan, Ho), Hong Kong SAR, China
| | - Ganesan Karthikeyan
- Population Health Research Institute (Walsh, Whitlock, Vincent, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; McMaster University (Walsh, Whitlock, Syed, VanHelder, Guyatt, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; London Health Sciences Centre (Garg, Lavi), Western University, London, Ont.; Dalhousie University (Légaré), Halifax, NS; Cleveland Clinic (Duncan, Nasr, Sessler), Cleveland, Ohio; Maine Medical Center (Zimmerman, Kramer), Portland, Me.; Wake Forest University (Miller, Gardner), Winston-Salem, NC; Sunnybrook Health Sciences Centre (Fremes), University of Toronto, Toronto, Ont.; University of Calgary (Kieser, Ali), Calgary, Alta.; All India Institute of Medical Sciences (Karthikeyan), New Delhi, India; The Chinese University of Hong Kong (Chan, Ho), Hong Kong SAR, China
| | - Matthew Chan
- Population Health Research Institute (Walsh, Whitlock, Vincent, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; McMaster University (Walsh, Whitlock, Syed, VanHelder, Guyatt, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; London Health Sciences Centre (Garg, Lavi), Western University, London, Ont.; Dalhousie University (Légaré), Halifax, NS; Cleveland Clinic (Duncan, Nasr, Sessler), Cleveland, Ohio; Maine Medical Center (Zimmerman, Kramer), Portland, Me.; Wake Forest University (Miller, Gardner), Winston-Salem, NC; Sunnybrook Health Sciences Centre (Fremes), University of Toronto, Toronto, Ont.; University of Calgary (Kieser, Ali), Calgary, Alta.; All India Institute of Medical Sciences (Karthikeyan), New Delhi, India; The Chinese University of Hong Kong (Chan, Ho), Hong Kong SAR, China
| | - Anthony Ho
- Population Health Research Institute (Walsh, Whitlock, Vincent, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; McMaster University (Walsh, Whitlock, Syed, VanHelder, Guyatt, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; London Health Sciences Centre (Garg, Lavi), Western University, London, Ont.; Dalhousie University (Légaré), Halifax, NS; Cleveland Clinic (Duncan, Nasr, Sessler), Cleveland, Ohio; Maine Medical Center (Zimmerman, Kramer), Portland, Me.; Wake Forest University (Miller, Gardner), Winston-Salem, NC; Sunnybrook Health Sciences Centre (Fremes), University of Toronto, Toronto, Ont.; University of Calgary (Kieser, Ali), Calgary, Alta.; All India Institute of Medical Sciences (Karthikeyan), New Delhi, India; The Chinese University of Hong Kong (Chan, Ho), Hong Kong SAR, China
| | - Vivian Nasr
- Population Health Research Institute (Walsh, Whitlock, Vincent, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; McMaster University (Walsh, Whitlock, Syed, VanHelder, Guyatt, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; London Health Sciences Centre (Garg, Lavi), Western University, London, Ont.; Dalhousie University (Légaré), Halifax, NS; Cleveland Clinic (Duncan, Nasr, Sessler), Cleveland, Ohio; Maine Medical Center (Zimmerman, Kramer), Portland, Me.; Wake Forest University (Miller, Gardner), Winston-Salem, NC; Sunnybrook Health Sciences Centre (Fremes), University of Toronto, Toronto, Ont.; University of Calgary (Kieser, Ali), Calgary, Alta.; All India Institute of Medical Sciences (Karthikeyan), New Delhi, India; The Chinese University of Hong Kong (Chan, Ho), Hong Kong SAR, China
| | - Jessica Vincent
- Population Health Research Institute (Walsh, Whitlock, Vincent, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; McMaster University (Walsh, Whitlock, Syed, VanHelder, Guyatt, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; London Health Sciences Centre (Garg, Lavi), Western University, London, Ont.; Dalhousie University (Légaré), Halifax, NS; Cleveland Clinic (Duncan, Nasr, Sessler), Cleveland, Ohio; Maine Medical Center (Zimmerman, Kramer), Portland, Me.; Wake Forest University (Miller, Gardner), Winston-Salem, NC; Sunnybrook Health Sciences Centre (Fremes), University of Toronto, Toronto, Ont.; University of Calgary (Kieser, Ali), Calgary, Alta.; All India Institute of Medical Sciences (Karthikeyan), New Delhi, India; The Chinese University of Hong Kong (Chan, Ho), Hong Kong SAR, China
| | - Imtiaz Ali
- Population Health Research Institute (Walsh, Whitlock, Vincent, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; McMaster University (Walsh, Whitlock, Syed, VanHelder, Guyatt, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; London Health Sciences Centre (Garg, Lavi), Western University, London, Ont.; Dalhousie University (Légaré), Halifax, NS; Cleveland Clinic (Duncan, Nasr, Sessler), Cleveland, Ohio; Maine Medical Center (Zimmerman, Kramer), Portland, Me.; Wake Forest University (Miller, Gardner), Winston-Salem, NC; Sunnybrook Health Sciences Centre (Fremes), University of Toronto, Toronto, Ont.; University of Calgary (Kieser, Ali), Calgary, Alta.; All India Institute of Medical Sciences (Karthikeyan), New Delhi, India; The Chinese University of Hong Kong (Chan, Ho), Hong Kong SAR, China
| | - Ronit Lavi
- Population Health Research Institute (Walsh, Whitlock, Vincent, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; McMaster University (Walsh, Whitlock, Syed, VanHelder, Guyatt, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; London Health Sciences Centre (Garg, Lavi), Western University, London, Ont.; Dalhousie University (Légaré), Halifax, NS; Cleveland Clinic (Duncan, Nasr, Sessler), Cleveland, Ohio; Maine Medical Center (Zimmerman, Kramer), Portland, Me.; Wake Forest University (Miller, Gardner), Winston-Salem, NC; Sunnybrook Health Sciences Centre (Fremes), University of Toronto, Toronto, Ont.; University of Calgary (Kieser, Ali), Calgary, Alta.; All India Institute of Medical Sciences (Karthikeyan), New Delhi, India; The Chinese University of Hong Kong (Chan, Ho), Hong Kong SAR, China
| | - Daniel I Sessler
- Population Health Research Institute (Walsh, Whitlock, Vincent, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; McMaster University (Walsh, Whitlock, Syed, VanHelder, Guyatt, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; London Health Sciences Centre (Garg, Lavi), Western University, London, Ont.; Dalhousie University (Légaré), Halifax, NS; Cleveland Clinic (Duncan, Nasr, Sessler), Cleveland, Ohio; Maine Medical Center (Zimmerman, Kramer), Portland, Me.; Wake Forest University (Miller, Gardner), Winston-Salem, NC; Sunnybrook Health Sciences Centre (Fremes), University of Toronto, Toronto, Ont.; University of Calgary (Kieser, Ali), Calgary, Alta.; All India Institute of Medical Sciences (Karthikeyan), New Delhi, India; The Chinese University of Hong Kong (Chan, Ho), Hong Kong SAR, China
| | - Robert Kramer
- Population Health Research Institute (Walsh, Whitlock, Vincent, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; McMaster University (Walsh, Whitlock, Syed, VanHelder, Guyatt, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; London Health Sciences Centre (Garg, Lavi), Western University, London, Ont.; Dalhousie University (Légaré), Halifax, NS; Cleveland Clinic (Duncan, Nasr, Sessler), Cleveland, Ohio; Maine Medical Center (Zimmerman, Kramer), Portland, Me.; Wake Forest University (Miller, Gardner), Winston-Salem, NC; Sunnybrook Health Sciences Centre (Fremes), University of Toronto, Toronto, Ont.; University of Calgary (Kieser, Ali), Calgary, Alta.; All India Institute of Medical Sciences (Karthikeyan), New Delhi, India; The Chinese University of Hong Kong (Chan, Ho), Hong Kong SAR, China
| | - Jeff Gardner
- Population Health Research Institute (Walsh, Whitlock, Vincent, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; McMaster University (Walsh, Whitlock, Syed, VanHelder, Guyatt, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; London Health Sciences Centre (Garg, Lavi), Western University, London, Ont.; Dalhousie University (Légaré), Halifax, NS; Cleveland Clinic (Duncan, Nasr, Sessler), Cleveland, Ohio; Maine Medical Center (Zimmerman, Kramer), Portland, Me.; Wake Forest University (Miller, Gardner), Winston-Salem, NC; Sunnybrook Health Sciences Centre (Fremes), University of Toronto, Toronto, Ont.; University of Calgary (Kieser, Ali), Calgary, Alta.; All India Institute of Medical Sciences (Karthikeyan), New Delhi, India; The Chinese University of Hong Kong (Chan, Ho), Hong Kong SAR, China
| | - Summer Syed
- Population Health Research Institute (Walsh, Whitlock, Vincent, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; McMaster University (Walsh, Whitlock, Syed, VanHelder, Guyatt, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; London Health Sciences Centre (Garg, Lavi), Western University, London, Ont.; Dalhousie University (Légaré), Halifax, NS; Cleveland Clinic (Duncan, Nasr, Sessler), Cleveland, Ohio; Maine Medical Center (Zimmerman, Kramer), Portland, Me.; Wake Forest University (Miller, Gardner), Winston-Salem, NC; Sunnybrook Health Sciences Centre (Fremes), University of Toronto, Toronto, Ont.; University of Calgary (Kieser, Ali), Calgary, Alta.; All India Institute of Medical Sciences (Karthikeyan), New Delhi, India; The Chinese University of Hong Kong (Chan, Ho), Hong Kong SAR, China
| | - Tomas VanHelder
- Population Health Research Institute (Walsh, Whitlock, Vincent, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; McMaster University (Walsh, Whitlock, Syed, VanHelder, Guyatt, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; London Health Sciences Centre (Garg, Lavi), Western University, London, Ont.; Dalhousie University (Légaré), Halifax, NS; Cleveland Clinic (Duncan, Nasr, Sessler), Cleveland, Ohio; Maine Medical Center (Zimmerman, Kramer), Portland, Me.; Wake Forest University (Miller, Gardner), Winston-Salem, NC; Sunnybrook Health Sciences Centre (Fremes), University of Toronto, Toronto, Ont.; University of Calgary (Kieser, Ali), Calgary, Alta.; All India Institute of Medical Sciences (Karthikeyan), New Delhi, India; The Chinese University of Hong Kong (Chan, Ho), Hong Kong SAR, China
| | - Gordon Guyatt
- Population Health Research Institute (Walsh, Whitlock, Vincent, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; McMaster University (Walsh, Whitlock, Syed, VanHelder, Guyatt, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; London Health Sciences Centre (Garg, Lavi), Western University, London, Ont.; Dalhousie University (Légaré), Halifax, NS; Cleveland Clinic (Duncan, Nasr, Sessler), Cleveland, Ohio; Maine Medical Center (Zimmerman, Kramer), Portland, Me.; Wake Forest University (Miller, Gardner), Winston-Salem, NC; Sunnybrook Health Sciences Centre (Fremes), University of Toronto, Toronto, Ont.; University of Calgary (Kieser, Ali), Calgary, Alta.; All India Institute of Medical Sciences (Karthikeyan), New Delhi, India; The Chinese University of Hong Kong (Chan, Ho), Hong Kong SAR, China
| | - Purnima Rao-Melacini
- Population Health Research Institute (Walsh, Whitlock, Vincent, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; McMaster University (Walsh, Whitlock, Syed, VanHelder, Guyatt, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; London Health Sciences Centre (Garg, Lavi), Western University, London, Ont.; Dalhousie University (Légaré), Halifax, NS; Cleveland Clinic (Duncan, Nasr, Sessler), Cleveland, Ohio; Maine Medical Center (Zimmerman, Kramer), Portland, Me.; Wake Forest University (Miller, Gardner), Winston-Salem, NC; Sunnybrook Health Sciences Centre (Fremes), University of Toronto, Toronto, Ont.; University of Calgary (Kieser, Ali), Calgary, Alta.; All India Institute of Medical Sciences (Karthikeyan), New Delhi, India; The Chinese University of Hong Kong (Chan, Ho), Hong Kong SAR, China
| | - Lehana Thabane
- Population Health Research Institute (Walsh, Whitlock, Vincent, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; McMaster University (Walsh, Whitlock, Syed, VanHelder, Guyatt, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; London Health Sciences Centre (Garg, Lavi), Western University, London, Ont.; Dalhousie University (Légaré), Halifax, NS; Cleveland Clinic (Duncan, Nasr, Sessler), Cleveland, Ohio; Maine Medical Center (Zimmerman, Kramer), Portland, Me.; Wake Forest University (Miller, Gardner), Winston-Salem, NC; Sunnybrook Health Sciences Centre (Fremes), University of Toronto, Toronto, Ont.; University of Calgary (Kieser, Ali), Calgary, Alta.; All India Institute of Medical Sciences (Karthikeyan), New Delhi, India; The Chinese University of Hong Kong (Chan, Ho), Hong Kong SAR, China
| | - P J Devereaux
- Population Health Research Institute (Walsh, Whitlock, Vincent, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; McMaster University (Walsh, Whitlock, Syed, VanHelder, Guyatt, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; London Health Sciences Centre (Garg, Lavi), Western University, London, Ont.; Dalhousie University (Légaré), Halifax, NS; Cleveland Clinic (Duncan, Nasr, Sessler), Cleveland, Ohio; Maine Medical Center (Zimmerman, Kramer), Portland, Me.; Wake Forest University (Miller, Gardner), Winston-Salem, NC; Sunnybrook Health Sciences Centre (Fremes), University of Toronto, Toronto, Ont.; University of Calgary (Kieser, Ali), Calgary, Alta.; All India Institute of Medical Sciences (Karthikeyan), New Delhi, India; The Chinese University of Hong Kong (Chan, Ho), Hong Kong SAR, China
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