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Blauenfeldt RA, Mortensen JK, Hjort N, Valentin JB, Homburg AM, Modrau B, Sandal BF, Gude MF, Berhndtz AB, Johnsen SP, Hess DC, Simonsen CZ, Andersen G. Effect of Remote Ischemic Conditioning in Ischemic Stroke Subtypes: A Post Hoc Subgroup Analysis From the RESIST Trial. Stroke 2024; 55:874-879. [PMID: 38299363 PMCID: PMC10962424 DOI: 10.1161/strokeaha.123.046144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 01/17/2024] [Accepted: 01/19/2024] [Indexed: 02/02/2024]
Abstract
BACKGROUND Remote ischemic conditioning (RIC) is a simple and noninvasive procedure that has proved to be safe and feasible in numerous smaller clinical trials. Mixed results have been found in recent large randomized controlled trials. This is a post hoc subgroup analysis of the RESIST trial (Remote Ischemic Conditioning in Patients With Acute Stroke), investigating the effect of RIC in different acute ischemic stroke etiologies, and whether an effect was modified by treatment adherence. METHODS Eligible patients were adults (aged ≥18 years), independent in activities of daily living, who had prehospital stroke symptoms with a duration of less than 4 hours. They were randomized to RIC or sham. The RIC treatment protocol consisted of 5 cycles with 5 minutes of cuff inflation alternating with 5 minutes with a deflated cuff. Acceptable treatment adherence was defined as when at least 80% of planned RIC cycles were received. The analysis was performed using the entire range (shift analysis) of the modified Rankin Scale (ordinal logistic regression). RESULTS A total of 698 had acute ischemic stroke, 253 (36%) were women, and the median (interquartile range) age was 73 (63-80) years. Median (interquartile range) overall adherence to RIC/sham was 91% (68%-100%). In patients with a stroke due to cerebral small vessel disease, who were adherent to treatment, RIC was associated with improved functional outcome, and the odds ratio for a shift to a lower score on the modified Rankin Scale was 2.54 (1.03-6.25); P=0.042. The association remained significant after adjusting for potential confounders. No significant associations were found with other stroke etiologies, and the overall test for interaction was not statistically significant (χ2, 4.33, P=0.23). CONCLUSIONS In patients with acute ischemic stroke due to cerebral small vessel disease, who maintained good treatment adherence, RIC was associated with improved functional outcomes at 90 days. These results should only serve as a hypothesis-generating for future trials. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03481777.
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Affiliation(s)
- Rolf Ankerlund Blauenfeldt
- Department of Neurology, Aarhus University Hospital, Denmark (R.A.B., J.K.M., N.H., C.Z.S., G.A.)
- Department of Clinical Medicine, Aarhus University, Denmark (R.A.B., J.K.M., N.H., M.F.G., C.Z.S., G.A.)
| | - Janne Kaergaard Mortensen
- Department of Neurology, Aarhus University Hospital, Denmark (R.A.B., J.K.M., N.H., C.Z.S., G.A.)
- Department of Clinical Medicine, Aarhus University, Denmark (R.A.B., J.K.M., N.H., M.F.G., C.Z.S., G.A.)
| | - Niels Hjort
- Department of Neurology, Aarhus University Hospital, Denmark (R.A.B., J.K.M., N.H., C.Z.S., G.A.)
- Department of Clinical Medicine, Aarhus University, Denmark (R.A.B., J.K.M., N.H., M.F.G., C.Z.S., G.A.)
| | - Jan Brink Valentin
- Department of Clinical Medicine, Danish Center for Health Services Research, Aalborg University, Denmark (J.B.V., S.P.J.)
| | - Anne-Mette Homburg
- Department of Neurology, Research Unit for Neurology, Odense University Hospital, Denmark (A.-M.H.)
| | - Boris Modrau
- Department of Neurology, Aalborg University Hospital, Denmark (B.M.)
| | | | - Martin Faurholdt Gude
- Department of Clinical Medicine, Aarhus University, Denmark (R.A.B., J.K.M., N.H., M.F.G., C.Z.S., G.A.)
- Department of Research and Development, Prehospital Emergency Medical Services, Central Denmark Region, Aarhus, Denmark (M.F.G.)
| | - Anne Brink Berhndtz
- Department of Neurology, Regional Hospital Gødstrup, Denmark (B.F.S., A.B.B.)
| | - Søren Paaske Johnsen
- Department of Clinical Medicine, Danish Center for Health Services Research, Aalborg University, Denmark (J.B.V., S.P.J.)
| | - David C. Hess
- Department of Neurology, Medical College of Georgia, Augusta University, GA (D.C.H.)
| | - Claus Ziegler Simonsen
- Department of Neurology, Aarhus University Hospital, Denmark (R.A.B., J.K.M., N.H., C.Z.S., G.A.)
- Department of Clinical Medicine, Aarhus University, Denmark (R.A.B., J.K.M., N.H., M.F.G., C.Z.S., G.A.)
| | - Grethe Andersen
- Department of Neurology, Aarhus University Hospital, Denmark (R.A.B., J.K.M., N.H., C.Z.S., G.A.)
- Department of Clinical Medicine, Aarhus University, Denmark (R.A.B., J.K.M., N.H., M.F.G., C.Z.S., G.A.)
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Blauenfeldt RA, Hjort N, Valentin JB, Homburg AM, Modrau B, Sandal BF, Gude MF, Hougaard KD, Damgaard D, Poulsen M, Diedrichsen T, Schmitz ML, von Weitzel-Mudersbach P, Christensen AA, Figlewski K, Grove EL, Hreiðarsdóttir MK, Lassesen HM, Wittrock D, Mikkelsen S, Væggemose U, Juelsgaard P, Kirkegaard H, Rostgaard-Knudsen M, Degn N, Vestergaard SB, Damsbo AG, Iversen AB, Mortensen JK, Petersson J, Christensen T, Behrndtz AB, Bøtker HE, Gaist D, Fisher M, Hess DC, Johnsen SP, Simonsen CZ, Andersen G. Remote Ischemic Conditioning for Acute Stroke: The RESIST Randomized Clinical Trial. JAMA 2023; 330:1236-1246. [PMID: 37787796 PMCID: PMC10548297 DOI: 10.1001/jama.2023.16893] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 08/14/2023] [Indexed: 10/04/2023]
Abstract
Importance Despite some promising preclinical and clinical data, it remains uncertain whether remote ischemic conditioning (RIC) with transient cycles of limb ischemia and reperfusion is an effective treatment for acute stroke. Objective To evaluate the effect of RIC when initiated in the prehospital setting and continued in the hospital on functional outcome in patients with acute stroke. Design, Setting, and Participants This was a randomized clinical trial conducted at 4 stroke centers in Denmark that included 1500 patients with prehospital stroke symptoms for less than 4 hours (enrolled March 16, 2018, to November 11, 2022; final follow-up, February 3, 2023). Intervention The intervention was delivered using an inflatable cuff on 1 upper extremity (RIC cuff pressure, ≤200 mm Hg [n = 749] and sham cuff pressure, 20 mm Hg [n = 751]). Each treatment application consisted of 5 cycles of 5 minutes of cuff inflation followed by 5 minutes of cuff deflation. Treatment was started in the ambulance and repeated at least once in the hospital and then twice daily for 7 days among a subset of participants. Main Outcomes and Measures The primary end point was improvement in functional outcome measured as a shift across the modified Rankin Scale (mRS) score (range, 0 [no symptoms] to 6 [death]) at 90 days in the target population with a final diagnosis of ischemic or hemorrhagic stroke. Results Among 1500 patients who were randomized (median age, 71 years; 591 women [41%]), 1433 (96%) completed the trial. Of these, 149 patients (10%) were diagnosed with transient ischemic attack and 382 (27%) with a stroke mimic. In the remaining 902 patients with a target diagnosis of stroke (737 [82%] with ischemic stroke and 165 [18%] with intracerebral hemorrhage), 436 underwent RIC and 466 sham treatment. The median mRS score at 90 days was 2 (IQR, 1-3) in the RIC group and 1 (IQR, 1-3) in the sham group. RIC treatment was not significantly associated with improved functional outcome at 90 days (odds ratio [OR], 0.95; 95% CI, 0.75 to 1.20, P = .67; absolute difference in median mRS score, -1; -1.7 to -0.25). In all randomized patients, there were no significant differences in the number of serious adverse events: 169 patients (23.7%) in the RIC group with 1 or more serious adverse events vs 175 patients (24.3%) in the sham group (OR, 0.97; 95% CI, 0.85 to 1.11; P = .68). Upper extremity pain during treatment and/or skin petechia occurred in 54 (7.2%) in the RIC group and 11 (1.5%) in the sham group. Conclusions and Relevance RIC initiated in the prehospital setting and continued in the hospital did not significantly improve functional outcome at 90 days in patients with acute stroke. Trial Registration ClinicalTrials.gov Identifier: NCT03481777.
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Affiliation(s)
- Rolf Ankerlund Blauenfeldt
- Danish Stroke Center, Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Niels Hjort
- Danish Stroke Center, Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jan Brink Valentin
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Anne-Mette Homburg
- Research Unit for Neurology, Department of Neurology, Odense University Hospital, Odense, Denmark
| | - Boris Modrau
- Department of Neurology, Aalborg University Hospital, Aalborg, Denmark
| | | | - Martin Faurholdt Gude
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Research and Development, Prehospital Emergency Medical Services, Central Denmark Region, Aarhus, Denmark
| | | | - Dorte Damgaard
- Danish Stroke Center, Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Marika Poulsen
- Danish Stroke Center, Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Tove Diedrichsen
- Danish Stroke Center, Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Marie Louise Schmitz
- Danish Stroke Center, Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Paul von Weitzel-Mudersbach
- Danish Stroke Center, Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
- Department of Neurology, Regional Hospital Gødstrup, Gødstrup, Denmark
| | - Alex Alban Christensen
- Research Unit for Neurology, Department of Neurology, Odense University Hospital, Odense, Denmark
| | | | - Erik Lerkevang Grove
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | | | | | - Daniel Wittrock
- Prehospital Research Unit, the Region of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - Søren Mikkelsen
- Prehospital Research Unit, the Region of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - Ulla Væggemose
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Research and Development, Prehospital Emergency Medical Services, Central Denmark Region, Aarhus, Denmark
| | - Palle Juelsgaard
- Department of Research and Development, Prehospital Emergency Medical Services, Central Denmark Region, Aarhus, Denmark
| | - Hans Kirkegaard
- Department of Research and Development, Prehospital Emergency Medical Services, Central Denmark Region, Aarhus, Denmark
- Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark
| | | | - Niels Degn
- Department of Neurology, Aalborg University Hospital, Aalborg, Denmark
| | - Sigrid Breinholt Vestergaard
- Danish Stroke Center, Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Andreas Gammelgaard Damsbo
- Danish Stroke Center, Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Ane Bull Iversen
- Danish Stroke Center, Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Janne Kærgård Mortensen
- Danish Stroke Center, Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jesper Petersson
- Department of Neurology, Lund University, Lund, Sweden
- Department of Health Care Management, Region Skåne, Malmö, Sweden
| | - Thomas Christensen
- Department of Neurology, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Anne Brink Behrndtz
- Danish Stroke Center, Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Hans Erik Bøtker
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Faculty of Health, Aarhus University, Aarhus, Denmark
| | - David Gaist
- Research Unit for Neurology, Department of Neurology, Odense University Hospital, Odense, Denmark
| | - Marc Fisher
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - David Charles Hess
- Department of Neurology, Medical College of Georgia, Augusta University, Augusta
| | - Søren Paaske Johnsen
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Claus Ziegler Simonsen
- Danish Stroke Center, Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Grethe Andersen
- Danish Stroke Center, Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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