Effect of Remote Ischemic Preconditioning on Myocardial Injury in Noncardiac Surgery: The PRINCE Randomized Clinical Trial
Massimiliano Greco, Gaetano Lombardi, Claudia Brusasco, Marina Pieri, Agostino Roasio, Fabrizio Monaco, Levan Berikashvili, Alessandro Belletti, Francesco Meroi, Stefano Fresilli, Aituar Kabibulatov, Giuseppe Giardina, Andrea Russo, Federico Mattia Oliva, Sergey Efremov, Rosalba Lembo, Lini Wang, Simone Vietri, Elena Momesso, Filippo D’Amico, Kristina Kadantseva, Rosa Labanca, Pavel Ryzhkov, Marilena Marmiere, В. В. Субботин, Alessandro Pruna, Nerlep Rana, Francesca Livi, Hugo Mantilla-Gutierrez, Fabio Guarracino, Lorenzo Schiavoni, Ivan Šitum, Marco Micali, Stefano Bosso, Anastasiya Smirnova, Giuseppe Fresta, Andrey A. Cherednichenko, Luigi Beretta, Giacomo Monti, Lian Kah Ti, Pasquale Sansone, Francesco Corradi, Maurizio Cecconi, Andrey Yavorovskiy, Chong Lei, Aidos Konkayev, Tiziana Bove, В. В. Лихванцев, Alberto Zangrillo, Giovanni Landoni, Rinaldo Bellomo, Remo Daniel Covello, Stefano Turi, Matteo Aldo Bonizzoni, Tiziana Cabrini, Francesca Cavenago, Benedetta Chiodi, Edoardo Cristallo, Jacopo D’Andria Ursoleo, Noemi De Piccoli, Francesco Deni, Sara Fiorito, Rosario Losiggio, Renato Meani, Elena Moizo, Cristina Nakhnoukh, Francesco Giuseppe Nisi, Lisa Notarianni, Anita Nutta, Domenico Pontillo, Erica Ronca, Tommaso Scquizzato, Luisa Zaraca, Özgün Ömer Asiller, Marta Veneziano, Federico Ghignone, Vincenzo Bosco, Giuseppe Neri, Assyia Kadralinova, Nazerke Zhanarystan, Augusta Danella, Lorenzo Foti, Alessandra Besozzi, Laura Pasin, Jelena Lesanovis, Milica Stojicic, Michela Gandini, Marco Gemma, Michele Introna, Carolina Sassorossi, Yamume Tshomba, Renato Ricciardi, Felix Ramon Montes, Pavel Bagdasarov, Daria Yavorovskaya, Federico Piccioni, Andrea Pradella, Roman Mikhey, Yuki Kotani, Sergey Ushakov
Abstract
BACKGROUND: Major noncardiac surgery is associated with high rates of postoperative myocardial injury and other complications. Remote ischemic preconditioning (RIPC) was reported to decrease these complication rates. However, such supportive evidence lacks robustness. METHODS: In a multinational, double-blind trial, we randomly assigned adult high-risk patients undergoing noncardiac surgical procedures to receive RIPC or sham RIPC after the induction of general anesthesia and before surgery. RIPC involved three 5-minute ischemic cycles, each followed by 5 minutes of reperfusion, using a blood pressure cuff inflated to 200 mm Hg. The primary end point was the rate of myocardial injury, defined by an increase in postoperative troponin levels above the highest 99th percentile of reference values. Secondary outcomes included myocardial infarction, stroke, acute kidney injury, need for intensive care unit, length of hospital stay, and 30-day all-cause mortality. RESULTS: We recruited 1213 patients in 25 hospitals and 8 countries. We randomly assigned 599 patients to RIPC and 614 to sham RIPC. The most frequent surgical procedures were abdominal or intrathoracic surgeries (406 patients [33.6%]). RIPC was applied to the upper limb in 1014 patients (84.8%) and to the lower limb in 182 patients (15.2%). Postoperative myocardial injury occurred in 215 of 566 patients (38.0%) in the RIPC group and in 223 of 596 patients (37.4%) in the sham RIPC group (relative risk, 1.02 [95% CI, 0.88–1.18; P =0.84). There were no significant differences in the rate of any secondary outcomes. We observed 11 episodes of limb petechiae (10 [1.7%] in the RIPC group versus one [0.2%] in the sham RIPC group) and 34 (6.0%) hospital readmissions in the RIPC group versus 20 (3.5%) in the sham RIPC group. CONCLUSIONS: Among adult patients undergoing noncardiac surgery, RIPC did not reduce myocardial injury or other postoperative complications. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02427867.