Elsevier

American Heart Journal

Volume 168, Issue 4, October 2014, Pages 512-521.e4
American Heart Journal

Clinical Investigation
Acute Ischemic Heart Disease
Cardioprotective role of ischemic postconditioning in acute myocardial infarction: A systematic review and meta-analysis

https://doi.org/10.1016/j.ahj.2014.06.021Get rights and content

Background

Evidence suggests that ischemic postconditioning (IPoC) may reduce the extent of reperfusion injury. We performed a meta-analysis of randomized controlled trials, which compared the role of IPoC during primary percutaneous coronary intervention (PCI) to PCI alone (control group) in ST-segment elevation myocardial infarction.

Methods

Several databases were searched, which yielded 19 studies. The outcomes of interest were measures of myocardial damage (serum cardiac enzymes and infarct size by imaging) and left ventricular function (left ventricular ejection fraction and wall motion score index). Mean difference (MD) and standardized mean difference (SMD) were used to assess the treatment effect. An inverse variance method was used to pool data into a random-effects model.

Results

Ischemic postconditioning demonstrated a decrease in serum cardiac enzymes (SMD −0.48, 95% CI −0.92 to −0.05, I2 = 92%), reduction in infarct size by imaging (SMD −0.30, 95% CI −0.58 to −0.01, I2 = 80%), wall motion score index (MD −0.19, 95% CI −0.29 to −0.09, I2 = 44%), and showed improvement in left ventricular ejection fraction (IPoC 52 ± 0.4, control 49.7 ± 0.4) (MD 2.78, 95% CI 0.66-4.91, I2 = 69%). All included studies were limited by high risk of performance and publication bias.

Conclusions

Ischemic postconditioning during PCI in ST-segment elevation myocardial infarction appears to be superior to PCI alone in reduction of both myocardial injury or damage and improvement in global and regional left ventricular function. The effect seems to be more pronounced when a greater myocardial area is at risk. Given the limitations of the current available evidence, additional data from large randomized controlled trials are warranted.

Section snippets

Data sources and search strategy

The systematic review was carried out in accordance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines.31 The search strategy and subsequent literature search was performed by experienced medical reference librarians (B.F., W.L.). The search strategies were developed in PubMed and translated to match the subject headings and keywords for Embase, Cochrane Central Register of Controlled Trials, ISI Web of Science, and Scopus from last 10 years through

Identification of studies

The literature search identified 506 publications, of which 19 studies were eligible for analysis (Figure 1).8, 9, 10, 11, 12, 13, 14, 16, 17, 18, 19, 23, 24, 25, 27, 28, 29, 30 Articles reporting outcomes from the same study were included once in the analysis.9, 10, 14, 15 There was excellent agreement for the inclusion of the studies, data abstraction, and quality assessment between the reviewers.

Study characteristics

Table summarizes the characteristics of the included studies. A total of 19 studies comprising

Discussion

In our meta-analysis, we found that IPoC showed a beneficial effect in reduction of myocardial injury or damage and improvement of left ventricular function when compared with PCI alone. This cardioprotection was more apparent when the IRA was predominantly LAD as compared with non-LAD. Our results suggest that myocardial salvage is better in the anterior location compared with the inferior location because of a greater myocardial area being at risk. The lack of substantial effect of IPoC in

Conclusions

Ischemic postconditioning during PCI in STEMI appears to be superior to PCI alone in reduction of both myocardial injury or damage and improvement in global and regional left ventricular function. The effect seems to be more pronounced when a greater myocardial area is at risk secondary to LAD involvement. Given the limitations of the current available evidence, additional data from large RCTs are warranted.

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