A systematic review and meta-analysis of the cardioprotective effects of remote ischaemic preconditioning in open cardiac surgery

• Published in: Journal of the Royal Society of Medicine Vol. 105; no. 10; pp. 436 - 445
• Main Authors: Pilcher, Janine M, Young, Paul, Weatherall, Mark, Rahman, Ishtiaq, Bonser, Robert S, Beasley, Richard W
• Format: Journal Article
• Language: English
• Published: London, England SAGE Publications 01.10.2012; Royal Society of Medicine Press
• Subjects: Biological and medical sciences; Cardiac Surgical Procedures - methods; Coronary Artery Bypass - methods; Double-Blind Method; General aspects; Humans; Ischemic Preconditioning - methods; Medical sciences; Myocardial Reperfusion Injury - etiology; Myocardial Reperfusion Injury - prevention & control; Postoperative Complications - prevention & control; Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases; Surgery of the heart; Thoracic Surgery - methods; Troponin - metabolism; Medicine; Ischemia; Cardioprotective agent; Cardiovascular disease; Systematic review; Cardiac surgery; Preconditioning; Metaanalysis
• ISSN: 0141-0768; 1758-1095
• DOI: 10.1258/jrsm.2012.120049

Objective To investigate the cardioprotective efficacy of remote ischaemic preconditioning (RIPC) in cardiac surgery. Design We have performed a systematic search of MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials to identify randomized controlled trials involving RIPC. Setting Randomized controlled trials of RIPC in open cardiac surgery patients. Main outcome measures Meta-analysis was performed with the primary outcome the standardized mean difference between intervention and control groups in 12 hour postoperative troponin concentration. Heterogeneity was examined by fixed effects meta-regression. Results Ten studies with a total of 693 participants were included in the meta-analysis. RIPC reduced troponin levels 12 hours after surgery compared with control. The fixed and random effects differences were 0.35 (95% CI 0.19 to 0.51) and 0.53 (95% CI 0.18-0.88) respectively. However, important heterogeneity was present. Fixed effects meta-regression partially accounted for heterogeneity based on whether studies had full blinding, comprising blinding of patients, surgeons, anaesthetists and investigators. Studies with incomplete or no blinding demonstrated a larger estimate of effect, 0.74 (95% CI 0.47 to 1.00) compared to those with full blinding, 0.13 (95% CI - 0.07 to 0.33). Conclusions Although our analysis suggests RIPC may result in cardiac protection during cardiac surgery, the effect was most marked in studies without full blinding, with a smaller and statistically non-significant effect in fully blinded studies. We propose that further double blind randomized controlled trials investigating the cardioprotective effects of RIPC in cardiac surgery are required to resolve the current clinical uncertainty.