Effects of late, repetitive remote ischaemic conditioning on myocardial strain in patients with acute myocardial infarction

J Ranjit Arnold, Andrew P Vanezis, Glenn C Rodrigo, Florence Y Lai, Prathap Kanagala, Sheraz Nazir, Jamal N Khan, Leong Ng, Kamal Chitkara, J Gerry Coghlan, Simon Hetherington, Nilesh J Samani, Gerald P McCann, J Ranjit Arnold, Andrew P Vanezis, Glenn C Rodrigo, Florence Y Lai, Prathap Kanagala, Sheraz Nazir, Jamal N Khan, Leong Ng, Kamal Chitkara, J Gerry Coghlan, Simon Hetherington, Nilesh J Samani, Gerald P McCann

Abstract

Late, repetitive or chronic remote ischaemic conditioning (CRIC) is a potential cardioprotective strategy against adverse remodelling following ST-segment elevation myocardial infarction (STEMI). In the randomised Daily Remote Ischaemic Conditioning Following Acute Myocardial Infarction (DREAM) trial, CRIC following primary percutaneous coronary intervention (P-PCI) did not improve global left ventricular (LV) systolic function. A post-hoc analysis was performed to determine whether CRIC improved regional strain. All 73 patients completing the original trial were studied (38 receiving 4 weeks' daily CRIC, 35 controls receiving sham conditioning). Patients underwent cardiovascular magnetic resonance at baseline (5-7 days post-STEMI) and after 4 months, with assessment of LV systolic function, infarct size and strain (longitudinal/circumferential, in infarct-related and remote territories). At both timepoints, there were no significant between-group differences in global indices (LV ejection fraction, infarct size, longitudinal/circumferential strain). However, regional analysis revealed a significant improvement in longitudinal strain in the infarcted segments of the CRIC group (from - 16.2 ± 5.2 at baseline to - 18.7 ± 6.3 at follow up, p = 0.0006) but not in corresponding segments of the control group (from - 15.5 ± 4.0 to - 15.2 ± 4.7, p = 0.81; for change: - 2.5 ± 3.6 versus + 0.3 ± 5.6, respectively, p = 0.027). In remote territories, there was a lower increment in subendocardial circumferential strain in the CRIC group than in controls (- 1.2 ± 4.4 versus - 2.5 ± 4.0, p = 0.038). In summary, CRIC following P-PCI for STEMI is associated with improved longitudinal strain in infarct-related segments, and an attenuated increase in circumferential strain in remote segments. Further work is needed to establish whether these changes may translate into a reduced incidence of adverse remodelling and clinical events. Clinical Trial Registration: https://ichgcp.net/clinical-trials-registry/NCT01664611 .

Keywords: Heart failure; Primary percutaneous coronary intervention; Remodelling; Remote ischaemic conditioning; ST elevation myocardial infarction; Strain.

Conflict of interest statement

The authors declare that they do not have anything to disclose regarding funding or conflict of interest with respect to this manuscript.

© 2022. The Author(s).

Figures

Fig. 1
Fig. 1
CONSORT (Consolidated Standards of Reporting Trials) diagram illustrating recruitment and patient flows in the DREAM trial. LVEF left ventricular ejection fraction
Fig. 2
Fig. 2
Global longitudinal and circumferential strain for control (blue) and treatment (green) groups at baseline and follow up, with absolute change between timepoints. Error bars showing mean standard error
Fig. 3
Fig. 3
Longitudinal strain (transmurally) for control (n = 35) and treatment (n = 38) groups at A baseline (leftmost panel) and B follow up (middle panel), with C absolute change between timepoints (rightmost panel). Blue bars denote remote regions and orange bars denote infarcted regions. Error bars showing mean standard error
Fig. 4
Fig. 4
Circumferential strain (transmurally) for control (n = 35) and treatment (n = 38) at A baseline (leftmost panel) and B follow up (middle panel), with C absolute change between timepoints (rightmost panel). Blue bars denote remote regions and orange bars denote infarcted regions. Error bars showing mean standard error
Fig. 5
Fig. 5
Mean longitudinal strain (upper two panels) and circumferential strain (lower two panels) at each timepoint depicted by myocardial layer  -red denoting epicardial, yellow, mid-myocardial and blue, endocardial. Solid lines denote the treatment group and dashed lines, the control group. P values derived from mixed effects model accounting for differences in strain at baseline. Endo endocardial, Epi epicardial, Mid mid-myocardial

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