Has your hospital implemented remote ischemic conditioning yet? WHAT THE FUCK ARE THEY WAITING FOR?
Why does your board of directors allow such incompetence in themselves and the stroke staff to continue for years at a time?
leg compressions (16 posts to September 2015)
Remote ischemic conditioning (11 posts to July 2018)
leg wraps (7 posts to May 2013)
Leg wraps raise hopes of saved lives after strokes May 2013
Leg compressions may enhance stroke recovery August 2012
The latest here:
Stroke Disability Eased by Remote Ischemic Conditioning in Randomized Trial
Will this alternative to reperfusion therapies hold up in further studies?
Remote ischemic conditioning (RIC) finally showed a functional benefit in stroke when administered for 2 weeks among survivors, according to the RICAMIS trial.
People with acute ischemic stroke randomized to the study's RIC protocol were more likely to enjoy the best functional outcomes at 90 days (modified Rankin Scale [mRS] scores 0-1) compared with controls receiving usual care alone (67.4% vs 62.0%; OR 1.27, 95% CI 1.05-1.54), reported Hui-Sheng Chen, MD, of General Hospital of Northern Theatre Command in Shenyang, China, and colleagues.
In the largest randomized clinical trial of RIC for stroke to date, there was an advantage for RIC recipients who achieved more favorable functional outcomes (mRS 0-2) at 90 days (79.6% vs 75.5%, respectively), they stated in JAMA.
"Although many studies have investigated the effect of RIC on ischemic stroke, previous studies have not provided strong evidence for the neuroprotective effect of RIC, in contrast to the present trial," the authors wrote. "However, these findings require replication in another trial before concluding efficacy for this intervention."
RIC involves intermittent episodes of ischemia and reperfusion in a vascular bed to activate ischemia tolerance in remote tissues and organs. In the trial, the process involved using a pneumatic electronic device with cuffs for each person's arms. Each session lasted 50 minutes -- consisting of 5 cycles of cuff inflation for 5 minutes and deflation for 5 minutes -- and was to be given twice daily for 10-14 days in-hospital.
RIC was associated with a numerical excess in adverse events (6.8% vs 5.6%). These largely comprised redness, swelling, or skin petechiae on the arms. One person experienced dizziness as a result of the protocol.
The therapy conferred no improvements in early neurologic deterioration, stroke-associated pneumonia, change in NIH Stroke Scale score, strokes, and deaths over follow-up.
Nevertheless, RIC may have advantages over current reperfusion therapies for stroke, according to David Hess, MD, of Medical College of Georgia, Augusta University, and colleagues.
"Due to short time windows for thrombolytic therapy administration and the stroke system infrastructure needed for mechanical thrombectomy, these reperfusion therapies are available to only a small proportion of patients who experience stroke. Worldwide, these treatments are used in less than 5% of patients with stroke, and in many low-income nations they are rarely used," Hess' group wrote in an accompanying editorial.
"[RIC] appears to be safe and also may be effective in intracerebral hemorrhage," they noted. "Therefore, this approach could potentially be attractive as an out-of-hospital intervention or in settings where early brain imaging cannot be performed."
RICAMIS was an open-label trial that had 1,893 people with moderate strokes enrolled from 55 hospitals in China. Investigators excluded people who had received IV thrombolysis or other endovascular therapy, or had uncontrolled severe hypertension.
Within 48 hours of symptom onset, the participating cohort was randomized to usual care alone or with RIC.
Between RIC and control groups, baseline characteristics were well balanced. Mean age of the participants was 65 and 34.1% were women.
The RIC cohort started the protocol on average at 25 hours -- likely after the end of the ischemic period in most patients, Hess and colleagues commented. "Accordingly, this was a trial of mostly postconditioning. While cerebroprotection may still be occurring, enhancement of recovery via immune cells or yet undiscovered mechanisms may be more plausible," they said.
Chen's group agreed that RIC works more by recovery than neuroprotection, stating that "the effect of RIC on 90-day outcome may not be attributed to rescue ischemic penumbra as investigated in most previous studies, but to chronic RIC-induced neurorestorative effect such as angioneurogenesis and neuroplasticity of periinfarct area."
Study limitations included the lack of a sham group and reliance on unblinded participants and physicians in the trial. Also, over 5% of randomized people failed to complete their assigned intervention. Finally, information on rehabilitative therapies provided after stroke was lacking.
As such, ongoing studies like RESIST will be needed to confirm RICAMIS' promising results, Hess' group suggested.
"If the results of the RICAMIS study reported by Chen et al are confirmed in other [randomized clinical trials] and in different populations, RIC may be the first cerebroprotective therapy to prove translatable to humans. In that case, RIC could represent a feasible, safe treatment that would not require a large infrastructure and the intervention could be applied in a variety of settings without specialized personnel," they wrote.
![author['full_name']](https://clf1.medpagetoday.com/media/images/author/nicoleLou_188.jpg)
Disclosures
The RICAMIS study was funded by grants from Chinese provincial governments.
Chen and co-authors disclosed no relationships with industry.
Hess disclosed holding a patent with Augusta University and Athersys for stem cells in neurologic diseases, as well as serving on the Athersys scientific advisory board.
Primary Source
JAMA
Secondary Source
JAMA
Source Reference: Hess DC, et al "Remote ischemic conditioning: Feasible and potentially beneficial for ischemic stroke" JAMA 2022; DOI: 10.1001/jama.2022.13365.
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