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F. Roubille, N. Mewton, M. Elbaz, O. Roth, F. Prunier, T.T. Cung, C. Piot, J. Roncalli, G. Rioufol, E. Bonnefoy-Cudraz, J.Y. Wiedemann, A. Furber, L. Jacquemin, S. Willoteaux, W. Abi-Khallil, I. Sanchez, G. Finet, F. Sibellas, S. Ranc, I. Boussaha, P. Croisille, M. Ovize, No post-conditioning in the human heart with thrombolysis in myocardial infarction flow 2–3 on admission, European Heart Journal, Volume 35, Issue 25, 1 July 2014, Pages 1675–1682, https://doi.org/10.1093/eurheartj/ehu054
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Abstract
Proof-of-concept evidence suggests that mechanical ischaemic post-conditioning (PostC) reduces infarct size when applied immediately after culprit coronary artery re-opening in ST-elevation myocardial infarction (STEMI) patients with thrombolysis in myocardial infarction 0–1 (TIMI 0–1) flow grade at admission. Whether PostC might also be protective in patients with a TIMI 2–3 flow grade on admission (corresponding to a delayed application of the post-conditioning algorithm) remains undetermined.
In this multi-centre, randomized, single-blinded, controlled study, STEMI patients with a 2–3 TIMI coronary flow grade at admission underwent direct stenting of the culprit lesion, followed (PostC group) or not (control group) by four cycles of (1 min inflation/1 min deflation) of the angioplasty balloon to trigger post-conditioning. Infarct size was assessed both by cardiac magnetic resonance at Day 5 (primary endpoint) and cardiac enzymes release (secondary endpoint). Ninety-nine patients were prospectively enrolled. Baseline characteristics were comparable between control and PostC groups. Despite comparable size of area at risk (AAR) (38 ± 12 vs. 38 ± 13% of the LV circumference, respectively, P = 0.89) and similar time from onset to intervention (249 ± 148 vs. 263 ± 209 min, respectively, P = 0.93) in the two groups, PostC did not significantly reduce cardiac magnetic resonance infarct size (23 ± 17 and 21 ± 18 g in the treated vs. control group, respectively, P = 0.64). Similar results were found when using creatine kinase and troponin I release, even after adjustment for the size of the AAR.
This study shows that infarct size reduction by mechanical ischaemic PostC is lost when applied to patients with a TIMI 2–3 flow grade at admission. This indicates that the timing of the protective intervention with respect to the onset of reperfusion is a key factor for preventing lethal reperfusion injury in STEMI patients.
NCT01483755.
