| Objective:(1) To assess the short-and long-term effects of postconditioning(Poc)instudies including evolving ST-elevation myocardial infarction(STEMI).(2) To investigate whether remote ischemic perconditioning(RIPer C) performed in patients with ST-segment elevation myocardial infarction(STEMI) before percutaneous coronary intervention(PCI) would reduce ischemic/reperfusion injury.(3) To assess long-term effect of RIPer C for STEMI patients. Methods:(1) Relevant studies were identified through an electronic literature search from the Pub Med, Library of Congress, Embase,Cochrane Central Register of Controlled Trials, and ISI Web of Science. Studies published up to December 2014 were eligible for inclusion. Patients, who were older than 18 years,presenting within 12 hours of the first STEMI and eligible for angioplasty, were included in the study. All analyses were conducted using the statistical software Review Manager(Rev Man) version5.3.(2) STEMI patients were recruited and randomly allocated to two groups:(1) control group(n=66), PCI alone;(2) RIPer C group(n=60), RIPer C combined with PCI, consisting of three cycles of 5min inflation and 5min deflation of the left lowerlimb bloodpressure cuff performed before reperfusion. Serial plasma levels of creatine kinase-MB isoenzyme(CK-MB) during 72 h and cardiac troponin T(c Tn T) during24 h following PCI were measured as surrogate markers of infarct size. ST-segment resolution(STR) was expressed as percentage of change 1h after reperfusion. PET-CT imaging was used to estimate survival myocardium at 7th day after PCI. C-reactive proteins(CRP), Malondialdehyde(MDA), Matrix metalloprotein9(MMP9) and Nitric oxide synthase(NOS) were mearued before and 4 h after referfusion.(3) The incidence of MACCE events and other adverse cardiac events were assessed during 12 months follow-up. Results:(1) 1136 patients were in locational postconditioning cycles at the onset of reperfusion and 1153 patients were in PCI alone group from 25 trials. Compared with the control group, the IPost C group showed no apparent decrease in the level of peak CK after AMI [standard mean difference(SMD) =-0.49; 95 % confidence interval(CI),-1.09 to-0.1; I 2 = 91 %; P = 0.11).There was substantial between-study heterogeneity(Cochran Q test, P < 0.00001, I 2 = 91 %). Subgroup analysis based on the method of PCI(PCI was performed only by direct stenting in some studies, and by other methods including direct stenting, balloon dilatation, and thrombus aspiration in rest of studies)showed that not only the decrease in CK became more significant but the heterogeneity also dropped with direct stenting(SMD =-0.82; 95 % CI,-1.18 to-0.47; I 2 = 64 %; P <0.00001) as compared with other methods(SMD = 0.96; 95 % CI,-0.66 to 2.58; I 2 =96 %; P =0.25). The CK-MB was similar to CK. Reduction of infarct size was showed during7 days after myocardial infarction by imaging in IPost C group(P=0.01), but not in the longterm(P=0.08). Left ventricular ejection fraction(LVEF) and the wall motion score index(WMSI) were improved in both the short term within 7 days and the long term over4 months after receiving IPost C(P<0.05).(2) Compared to control group(PCI alone),peak CK-MB and the area under curve(AUC) of CK-MB were comparable between RIPer C and control groups(281.8 ± 22.33 U/L vs. 368.8 ± 24.96U/L,P = 0.011;6179±437.9 vs.8130± 534.7a.u.,P=0.006). During 24 hours after PCI, peak troponin T(Tn T)was significantly reduced in RIPer C group(5.211 ± 0.47 vs. 6.799 ± 0.321,P=0.007).STR was significantly improved in RIPer C patients than that in control subjects(P<0.05).The incidence of accelerated idioventricular rhythm in RIPer C group was lower than that in control group 1 h after PCI(P<0.05). LVEF and WMSI were also improved in RIPer C group compared with control group(P<0.05). The result of 18F-FDG PET-CT show that survival myocardium increased in RIPer C group compared with control group(P<0.05).4 h after PCI, the levels of serum MDA,CRP in RIPer C group was lower obviously than the control group(P<0.05), and the levels of serum NOS in RIPer C group was higher than the control group(P<0.05).(3) The result of follow-up suggested that incidence of MACCE and other adverse cardiac events in RIPer C group has no significant difference compared with the control group(P>0.05) during 6 months after PCI.However, incidence of target vessel revascularization, angina and heart disease requiring hospital admission was was lower obviously than the control group between 6 and 12 months after PCI.LVEF and WMSI had no significant difference 12 months after PCI. Subgroup analysis based on the lesion numbers showed that LVEF and WMSI were significantly improved in patients with single lesion in RIPer C group compared with control group(P < 0.05).Conclusions:(1) Ischemic postconditioning by brief interruptions of coronary blood flow at the onset of reperfusion after PCI appears to be superior to PCI alone in reducing myocardial injury and improving left ventricular function, especially in patients who have received direct stenting in PCI.(2) RIPer C of the Lower Limb prior to PCI reduced ischemic/reperfusion injury assessed by myocardial injury markers and increased survival myocardium assessed by 18F-FDG PET-CT in STEMI patients. RIPer C Increased the effective perfusion and improved cardiac function, especially in patients whose infarct-related artery were LAD.(3) Remote ischemic conditioning before primary percutaneous coronary intervention seemed to improve long-term clinical outcomes in patients with STEMI. |
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