The Effect of Remote Ischemic Preconditioning on Myocardial Injury After Noncardiac Surgery

Myocardial Injury Clinical Trial

Official title:

The Effect of Remote Ischemic Preconditioning on Myocardial Injury After Noncardiac Surgery in Patients at a High Risk of Cardiac Events

Clinical Trial Details — Status: Recruiting

Administrative data

• NCT number: NCT05733208
• Other study ID #: E2022236
• Status: Recruiting
• Phase: N/A
• Start date: May 6, 2023
• Est. completion date: December 31, 2027

Study information

• Verified date: February 2024
• Source: Sixth Affiliated Hospital, Sun Yat-sen University
• Contact: Yang Zhao, MD
• Phone: 0086-13802435520
• Email: zhaoy47[@]mail.sysu.edu.cn
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

This is a multicentre, parallel-group, randomised, sham-controlled, observer blinded trial, assessing the efficacy of remote ischemic preconditioning on preventing myocardial injury after noncardiac surgery.

Description:

This is a multicentre, randomised, sham-controlled, observer blinded trial. Patients at high clinical risk for cardiovascular events and scheduled to undergo major abdominal surgery will be enrolled. A total of 766 patients are randomised (1:1 ratio) to receive RIPC or no RIPC (control) before anaesthesia induction. RIPC will comprise four alternating cycles of cuff inflation for 5 min to 200 mm Hg and deflation for 5 min. In controls, the identical looking cuff will be placed around the arm but not actually inflated for 40 minutes. The primary outcome was myocardial injury after surgery within three days of surgery. The secondary outcomes were peak plasma hs-cTnT and total hs-cTnT release during the first three days after surgery, hs-cTnT above the prognostically important thresholds, length of hospital stay after surgery, and length of stay in the intensive care unit, myocardial infarction, major adverse cardiovascular events, cardiac-related death and all cause death within 30 days, 6 months, 1 year and 2 years after surgery, postoperative morbidity and adverse events within 30 days after surgery.

Recruitment information / eligibility

• Status: Recruiting
• Enrollment: 766
• Est. completion date: December 31, 2027
• Est. primary completion date: December 31, 2025
• Accepts healthy volunteers: No
• Gender: All
• Age group: 45 Years and older

Eligibility

Inclusion criteria

1. Patients at high clinical risk for cardiovascular events;

2. Patients scheduled to undergo major abdominal surgery.

Exclusion criteria

1. Immediate or urgent surgery or surgery where there is insufficient time to perform RIPC.

2. Abdominal vascular surgery, such as surgery for abdominal aortic aneurysm

3. Experience of conditions precluding the use of RIPC in both arms

4. Patients who are being treated with drugs, such as sulphonamide or nicorandil

5. With contraindications for anaesthetic regimes required in this trial.

Related Conditions & MeSH terms

• Ischemia
• Myocardial Injury
• Non-cardiac Surgery
• Remote Ischemic Preconditioning
• Wounds and Injuries

Intervention

Procedure:
• Remote ischemic preconditioning
Remote ischemic preconditioning will consist of four cycles of 5-minute inflation of an blood pressure cuff on the upper arm to 200 mmHg followed by 5-minute deflation. RIPC will be performed twice, one at approximately 24 hours before anaesthesia and the other at approximately 1 hour before anaesthesia.
• Sham-remote ischemic preconditioning
The identical looking cuff will be placed around the upper arm but not actually inflated for 40 minutes. The control device's components and external appearance are identical to that of the RIPC. However, as compared to the RIPC, the blood pressure cuff's line of inflation is disconnected such that the cuff cannot be inflated. Control treatment will be performed twice, one at approximately 24 hours before anaesthesia and the other at approximately 1 hour before anaesthesia.

Locations

Country	Name	City	State
China	The Sixth Affiliated Hospital, Sun Yat-sen University	Guangzhou	Guangdong

Sponsors (1)

Lead Sponsor	Collaborator
Sixth Affiliated Hospital, Sun Yat-sen University

Country where clinical trial is conducted

China, 

References & Publications (18)

Botker HE, Kharbanda R, Schmidt MR, Bottcher M, Kaltoft AK, Terkelsen CJ, Munk K, Andersen NH, Hansen TM, Trautner S, Lassen JF, Christiansen EH, Krusell LR, Kristensen SD, Thuesen L, Nielsen SS, Rehling M, Sorensen HT, Redington AN, Nielsen TT. Remote ischaemic conditioning before hospital admission, as a complement to angioplasty, and effect on myocardial salvage in patients with acute myocardial infarction: a randomised trial. Lancet. 2010 Feb 27;375(9716):727-34. doi: 10.1016/S0140-6736(09)62001-8. — View Citation

Crimi G, Pica S, Raineri C, Bramucci E, De Ferrari GM, Klersy C, Ferlini M, Marinoni B, Repetto A, Romeo M, Rosti V, Massa M, Raisaro A, Leonardi S, Rubartelli P, Oltrona Visconti L, Ferrario M. Remote ischemic post-conditioning of the lower limb during primary percutaneous coronary intervention safely reduces enzymatic infarct size in anterior myocardial infarction: a randomized controlled trial. JACC Cardiovasc Interv. 2013 Oct;6(10):1055-63. doi: 10.1016/j.jcin.2013.05.011. — View Citation

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Gaspar A, Lourenco AP, Pereira MA, Azevedo P, Roncon-Albuquerque R Jr, Marques J, Leite-Moreira AF. Randomized controlled trial of remote ischaemic conditioning in ST-elevation myocardial infarction as adjuvant to primary angioplasty (RIC-STEMI). Basic Res Cardiol. 2018 Mar 7;113(3):14. doi: 10.1007/s00395-018-0672-3. — View Citation

Jiang Q, Xiang B, Wang H, Huang K, Kong H, Hu S. Remote ischaemic preconditioning ameliorates sinus rhythm restoration rate through Cox maze radiofrequency procedure associated with inflammation reaction reduction. Basic Res Cardiol. 2019 Mar 5;114(3):14. doi: 10.1007/s00395-019-0723-4. — View Citation

Kosiuk J, Langenhan K, Stegmann C, Uhe T, Dagres N, Dinov B, Kircher S, Richter S, Sommer P, Bertagnolli L, Bollmann A, Hindricks G. Effect of remote ischemic preconditioning on electrophysiological parameters in nonvalvular paroxysmal atrial fibrillation: The RIPPAF Randomized Clinical Trial. Heart Rhythm. 2020 Jan;17(1):3-9. doi: 10.1016/j.hrthm.2019.07.026. Epub 2019 Jul 26. — View Citation

Lau JK, Pennings GJ, Reddel CJ, Campbell H, Liang HPH, Traini M, Gardiner EE, Yong AS, Chen VM, Kritharides L. Remote ischemic preconditioning inhibits platelet alphaIIb beta3 activation in coronary artery disease patients receiving dual antiplatelet therapy: A randomized trial. J Thromb Haemost. 2020 May;18(5):1221-1232. doi: 10.1111/jth.14763. Epub 2020 Mar 13. — View Citation

Loukogeorgakis SP, Williams R, Panagiotidou AT, Kolvekar SK, Donald A, Cole TJ, Yellon DM, Deanfield JE, MacAllister RJ. Transient limb ischemia induces remote preconditioning and remote postconditioning in humans by a K(ATP)-channel dependent mechanism. Circulation. 2007 Sep 18;116(12):1386-95. doi: 10.1161/CIRCULATIONAHA.106.653782. Epub 2007 Aug 27. — View Citation

Puelacher C, Bollen Pinto B, Mills NL, Duceppe E, Popova E, Duma A, Nagele P, Omland T, Hammerer-Lercher A, Lurati Buse G. Expert consensus on peri-operative myocardial injury screening in noncardiac surgery: A literature review. Eur J Anaesthesiol. 2021 Jun 1;38(6):600-608. doi: 10.1097/EJA.0000000000001486. — View Citation

Reddel CJ, Pennings GJ, Lau JK, Chen VM, Kritharides L. Circulating platelet-derived extracellular vesicles are decreased after remote ischemic preconditioning in patients with coronary disease: A randomized controlled trial. J Thromb Haemost. 2021 Oct;19(10):2605-2611. doi: 10.1111/jth.15441. Epub 2021 Aug 10. — View Citation

Ruetzler K, Smilowitz NR, Berger JS, Devereaux PJ, Maron BA, Newby LK, de Jesus Perez V, Sessler DI, Wijeysundera DN. Diagnosis and Management of Patients With Myocardial Injury After Noncardiac Surgery: A Scientific Statement From the American Heart Association. Circulation. 2021 Nov 9;144(19):e287-e305. doi: 10.1161/CIR.0000000000001024. Epub 2021 Oct 4. — View Citation

Smilowitz NR, Berger JS. Perioperative Management to Reduce Cardiovascular Events. Circulation. 2016 Mar 15;133(11):1125-30. doi: 10.1161/CIRCULATIONAHA.115.017787. No abstract available. — View Citation

Smilowitz NR, Redel-Traub G, Hausvater A, Armanious A, Nicholson J, Puelacher C, Berger JS. Myocardial Injury After Noncardiac Surgery: A Systematic Review and Meta-Analysis. Cardiol Rev. 2019 Nov/Dec;27(6):267-273. doi: 10.1097/CRD.0000000000000254. — View Citation

Thielmann M, Kottenberg E, Kleinbongard P, Wendt D, Gedik N, Pasa S, Price V, Tsagakis K, Neuhauser M, Peters J, Jakob H, Heusch G. Cardioprotective and prognostic effects of remote ischaemic preconditioning in patients undergoing coronary artery bypass surgery: a single-centre randomised, double-blind, controlled trial. Lancet. 2013 Aug 17;382(9892):597-604. doi: 10.1016/S0140-6736(13)61450-6. Erratum In: Lancet. 2013 Sep 14;382(9896):940. — View Citation

Verbree-Willemsen L, Grobben RB, van Waes JA, Peelen LM, Nathoe HM, van Klei WA, Grobbee DE. Causes and prevention of postoperative myocardial injury. Eur J Prev Cardiol. 2019 Jan;26(1):59-67. doi: 10.1177/2047487318798925. Epub 2018 Sep 12. — View Citation

White SK, Frohlich GM, Sado DM, Maestrini V, Fontana M, Treibel TA, Tehrani S, Flett AS, Meier P, Ariti C, Davies JR, Moon JC, Yellon DM, Hausenloy DJ. Remote ischemic conditioning reduces myocardial infarct size and edema in patients with ST-segment elevation myocardial infarction. JACC Cardiovasc Interv. 2015 Jan;8(1 Pt B):178-188. doi: 10.1016/j.jcin.2014.05.015. Epub 2014 Sep 17. — View Citation

Writing Committee for the VISION Study Investigators; Devereaux PJ, Biccard BM, Sigamani A, Xavier D, Chan MTV, Srinathan SK, Walsh M, Abraham V, Pearse R, Wang CY, Sessler DI, Kurz A, Szczeklik W, Berwanger O, Villar JC, Malaga G, Garg AX, Chow CK, Ackland G, Patel A, Borges FK, Belley-Cote EP, Duceppe E, Spence J, Tandon V, Williams C, Sapsford RJ, Polanczyk CA, Tiboni M, Alonso-Coello P, Faruqui A, Heels-Ansdell D, Lamy A, Whitlock R, LeManach Y, Roshanov PS, McGillion M, Kavsak P, McQueen MJ, Thabane L, Rodseth RN, Buse GAL, Bhandari M, Garutti I, Jacka MJ, Schunemann HJ, Cortes OL, Coriat P, Dvirnik N, Botto F, Pettit S, Jaffe AS, Guyatt GH. Association of Postoperative High-Sensitivity Troponin Levels With Myocardial Injury and 30-Day Mortality Among Patients Undergoing Noncardiac Surgery. JAMA. 2017 Apr 25;317(16):1642-1651. doi: 10.1001/jama.2017.4360. — View Citation

Xie J, Zhang X, Xu J, Zhang Z, Klingensmith NJ, Liu S, Pan C, Yang Y, Qiu H. Effect of Remote Ischemic Preconditioning on Outcomes in Adult Cardiac Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Studies. Anesth Analg. 2018 Jul;127(1):30-38. doi: 10.1213/ANE.0000000000002674. — View Citation

* Note: There are 18 references in all — Click here to view all references

Outcome

Type	Measure	Description	Time frame	Safety issue
Other	Acute kidney injury	Acute kidney injury	Within 30 days after surgery
Other	Postoperative pulmonary complications	Postoperative pulmonary complications	Within 30 days after surgery
Primary	Myocardial injury after non-cardiac surgery (MINS)	Number of participants with MINS, diagnosed according to the criteria established by the American Heart Association in 2021	Within the first three days after surgery
Secondary	Participants with the concentration of hs-cTnT reaching/above the prognostically important thresholds	Number of participants with the concentration of hs-cTnT reaching/above the prognostically important thresholds	Within the first three days after surgery
Secondary	Peak concentration of hs-cTnT within the initial 3 days after surgery	Peak concentration of high-sensitivity cTnT	Within the first three days after surgery
Secondary	Total hs-cTnT release within the initial 3 days after surgery (area under the curve)	Total hs-cTnT release	Within the first three days after surgery
Secondary	Length of stay in the intensive care unit	Length of intensive care unit stay	expected 2 days after surgery
Secondary	Length of postoperative stay	Length of hospital stay after surgery	expected 6 days after surgery
Secondary	Myocardial infarction	Number of participants with myocardial infarction	Within 30 days, 6 months, 1 year and 2 years of surgery
Secondary	Major adverse cardiovascular events	Cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke	Within 30 days, 6 months, 1 year and 2 years of surgery
Secondary	Cardiac-related death	Death related by cardiac reason	Within 30 days, 6 months, 1 year and 2 years of surgery
Secondary	All deaths	All-cause death after surgery	Within 30 days, 6 months, 1 year and 2 years of surgery
Secondary	Major postoperative morbidity	Major postoperative morbidity	Within 30 days after surgery
Secondary	Adverse events	Adverse events	Within 30 days after surgery