Ischaemic conditioning: are we there yet? | Heart

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Education in Heart

Ischaemic conditioning: are we there yet?

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Re:Ischaemic conditioning: paving the pathway to clinical translation
Heerajnarain Bulluck
Published on: 15 March 2016
Ischaemic conditioning: paving the pathway to clinical translation
Efstathios K. Iliodromitis
Published on: 15 March 2016

Published on: 15 March 2016
Re:Ischaemic conditioning: paving the pathway to clinical translation
- Heerajnarain Bulluck
- Other Contributors:
  Derek J Hausenloy
We thank Iliodromitis and colleagues for their interest in our review article1. Providing a comprehensive account of the extensive literature in this field has been a very challenging task. We are aware of their previous work2 3 on the feasibility of ischaemic postconditioning (IPost) in acute coronary syndrome. Of note, this was a small study of 37 patients and only included a total of 6 patients with non-ST elevation myoc...
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We thank Iliodromitis and colleagues for their interest in our review article1. Providing a comprehensive account of the extensive literature in this field has been a very challenging task. We are aware of their previous work2 3 on the feasibility of ischaemic postconditioning (IPost) in acute coronary syndrome. Of note, this was a small study of 37 patients and only included a total of 6 patients with non-ST elevation myocardial infarction (NSTEMI)2 3. To our knowledge no other study has since investigated the role of IPost in a larger cohort of NSTEMI. Therefore, IPost was not included under NSTEMI in Figure 2 of our review article1 as it has not been investigated in adequately powered studies for us to draw any meaningful conclusions. With regards to the second point raised, we acknowledge that the first study was by the authors' group4 investigating the role of remote ischaemic preconditioning (RIPC) in 40 patients, measuring serum cardiac enzymes as a marker for peri-procedural myocardial injury and they actually demonstrated RIPC-induced myocardial injury. As their study was probably underpowered, the findings should be interpreted with caution. In retrospect, we should have made this clearer in the table of "major" clinical studies in the review article1. The translation of ischaemic conditioning has been challenging and we entirely support the authors' view that all pieces of evidence in this field need to be taken into consideration and critically appraised in order to pave the transition of this intervention from bench to bedside in suitable clinical setting.
1. Bulluck H, Hausenloy DJ. Ischaemic conditioning: are we there yet? Heart 2015;101(13):1067-77. 2. Iliodromitis EK, Paraskevaidis IA, Fountoulaki K, et al. Staccato reperfusion prevents reperfusion injury in patients undergoing coronary angioplasty: a 1-year follow-up pilot study. Atherosclerosis 2009;204(2):497-502. 3. Ikonomidis I, Iliodromitis EK, Tzortzis S, et al. Staccato reperfusion improves myocardial microcirculatory function and long-term left ventricular remodelling: a randomised contrast echocardiography study. Heart 2010;96(23):1898-903. 4. Iliodromitis EK, Kyrzopoulos S, Paraskevaidis IA, et al. Increased C reactive protein and cardiac enzyme levels after coronary stent implantation. Is there protection by remote ischaemic preconditioning? Heart 2006;92(12):1821-6.
Conflict of Interest:
None declared
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Conflict of Interest:
None declared.
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Published on: 15 March 2016
Ischaemic conditioning: paving the pathway to clinical translation
- Efstathios K. Iliodromitis
- Other Contributors:
  Ioannis A. Paraskevaidis, Dimitrios Farmakis
The timely restoration of flow in the culprit coronary artery lesion remains the cornerstone of treatment in patients with evolving myocardial infarction but with the inevitable cost of reperfusion injury. Cardiac ischaemic conditioning (IC) is capable of reducing the extent of final infarct size, but its actual benefit in improving clinical outcomes remains to be established. In their excellent review article published...
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The timely restoration of flow in the culprit coronary artery lesion remains the cornerstone of treatment in patients with evolving myocardial infarction but with the inevitable cost of reperfusion injury. Cardiac ischaemic conditioning (IC) is capable of reducing the extent of final infarct size, but its actual benefit in improving clinical outcomes remains to be established. In their excellent review article published recently in the Journal [1], Bulluck and Hausenloy describe elegantly the expectations emerged from the different forms of IC (pre-, per- and post- conditioning, applied locally or remotely). The authors present the clinical conditions where IC has been tested and they also provide novel thoughts regarding the potential to investigate its use in additional clinical settings. We fully agree that IC can be applied in percutaneous coronary intervention (PCI) during non-ST elevation myocardial infarction (NSTMI), as outlined in Figure 2, but not only in the form of remote ischaemic preconditioning (RIPC). Local ischemic postconditioning (IPost) has also been successfully applied in patients presented with non-totally occlusive coronary artery lesions; we have previously shown that IPost was feasible in patients with unstable angina and NSTMI and effective in reducing circulating biomarkers of oxidative stress, improving microcirculatory function in the short term as well as wall motion score index and left ventricular remodeling in the long term [2,3]. In addition, the authors report that the Hoole's study was the first one that tested the effect of limb remote ischaemic conditioning (RIC) in elective PCI. However, our group published the successful application of the intervention during elective PCI three years earlier, using actually a more potent RIC protocol with cuff inflation in both arms and at more appropriate timing [4]. Taking under consideration any piece of evidence derived by the available IC studies, even with opposing results, may enhance our efforts to recognize and overcome the obstacles that restrain the translation of the benefits demonstrated by proof-of-concept trials into the clinical setting.
References 1. Bulluck H, Hausenloy DJ. Ischaemic conditioning: Are we there yet? Heart 2015;101:1067-77. 2. Iliodromitis EK, Paraskevaidis IA, Fountoulaki K, et al. Staccato reperfusion prevents reperfusion injury in patients undergoing coronary angioplasty: A 1-year follow-up pilot study. Atherosclerosis 2009;204:497 -502. 3. Ikonomidis I, Iliodromitis EK, Tzortzis S, et al. Staccato reperfusion improves myocardial microcirculatory function and long-term left ventricular remodeling: a randomized contrast echocardiography study. Heart 2010;96:1898-1903. 4. Iliodromitis EK, Kyrzopoulos S, Paraskevaidis IA, et al. Increased C reactive protein and cardiac enzyme levels after coronary stent implantation. Is there protection by remote ischaemic preconditioning? Heart 2006;92:1821-26.
Conflict of Interest:
None declared
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Conflict of Interest:
None declared.
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