To Compare the Ischemic Pre-conditioning and Post-conditioning on Reperfusion Injury in Humans.
Condition: Endothelial Dysfunction
MeSH terms: Reperfusion Injury
Study type: Observational

Summary: 
      Reperfusion Injury occurs by the sudden blood flow to the injured and ischemic myocardium
      during restoration of blood flow either by Mechanical revascularization or thrombolysis. A
      phenomenon known as Pre-conditioning has been identified to limit the the extent and severity
      of reperfusion injury but it is very difficult to apply it in patient care setting as timing
      of acute cardiac or neurologic ischemic event is difficult to reliably predict.

      Postconditioning or ischemic postconditioning is well known to attenuate the reperfusion
      injury. There is enough data that shows the benefit of post conditioning in reducing the
      reperfusion injury in animals. However postconditioning in humans has not been investigated.

      We hypothesize that Post conditioning will attenuate the reperfusion injury and will be
      comparable to the effect of preconditioning in humans.
    

Detailed description: 
      Myocardial ischemia is one on the leading causes of mortality and morbidity in the United
      States. The initial injury to the myocardium is due to a state of imbalance when oxygen
      demand exceeds supply. This is most pronounced in the cases of sudden total occlusion of a
      coronary artery that results in myocardial injury and necrosis (AMI). The main stay of the
      therapy in these cases is the restoration of the flow to the ischemic myocardium by means of
      reperfusion therapy such as thrombolysis or mechanical revascularization. Interestingly,
      there is data to suggest that sudden restoration of blood flow to the ischemic myocardium may
      cause another form of myocardial injury ,known as reperfusion injury.

      Although initially controversial, reperfusion injury is now recognized as a distinct entity.
      This refers to the sudden and brisk reperfusion of ischemic myocardium that may induce injury
      that was not originally present-paradoxically exaggerating the end result of an ischemic
      event. Reperfusion injury may increase infarct size, decrease myocardial contractile function
      and induce or exaggerate vascular endothelial dysfunction. The pathophysiology is not well
      understood, but some of the effects of reperfusion injury have been attributed to the
      generation of free oxygen radical and increased oxidative stress possibly related to the
      abnormalities of the nitric oxide synthase (NOS) enzyme and its byproducts. These cellular
      events lead to the endothelial dysfunction, a pivotal event in the development of reperfusion
      injury.

      A concept known as pre-conditioning has been identified as a phenomenon that limits the
      extent and severity of reperfusion injury. Classically, preconditioning refers to the
      occurrence whereby repeated brief episodes of ischemia preceding a prolonged period of
      ischemia results in marked diminution of ischemic injury and injury occurring during
      reperfusion. The mechanism of this ischemic tolerance was thought to be secondary to the
      recruitment of collateral circulation, as it was noted to develop in patients undergoing
      serial balloon inflations during angioplasty. The cellular mechanism involved in ischemic
      preconditioning are not completely understood, but may be related to the attenuation of
      reperfusion injury. These findings are also corroborated by Kharbanda's group in their
      findings made after inducing forearm ischemia in 31 healthy volunteers. In an attempt to test
      the effects of ischemic preconditioning on the attenuation of ischemia-reperfusion injury as
      it pertains to endothelial function and circulating blood cell function, the forearms of
      these volunteers were made ischemic for a 20 minutes period using a pneumatic blood pressure
      cuff to 200 mmHg. This method was then compared to the use of ischemic preconditioning prior
      to the prolonged 20 minutes ischemic episode. Ischemic preconditioning was induced by
      inflating the pneumatic cuff to 200 mmhg for 5 minutes and then deflating the cuff. This was
      repeated for a total of 3 times. Radial artery reactivity testing and blood samples were
      collected from the antecubital vein at timed intervals after cuff deflation in both methods.
      It was noted that ischemic -preconditioning prior to prolonged forearm ischemia prevented
      both endothelial dysfunction and neutrophil activation.

      Unfortunately, although pre-conditioning has been extensively studied and has shown to reduce
      reperfusion injury in both animal and human models, it is difficult to practically apply this
      in a patient-care setting. This is because the timing of acute cardiac or neurologic ischemic
      events is difficult to reliably predict. Accordingly, this has generated great interest in a
      theory known as post-conditioning. Post conditioning or ischemic post-conditioning is a
      concept whereby short, repetitive ischemic episodes applied during early reperfusion of
      ischemic myocardium will attenuate reperfusion injury. It appears that both pre-conditioning
      and post-conditioning target the same pathophysiological mechanism, or share effects on a
      final common pathway involved in the pathogenesis of reperfusion injury. In a recent study,
      the effects of ischemic post-conditioning were compared to ischemic preconditioning in the
      coronary circulation of an animal model. An open chest, left anterior descending coronary
      artery occlusion model was used in 29 dots (10 controls, 9 preconditioning, and 10
      post-conditioning). When compared to controls, both interventions showed protective
      myocardial effects. The strategy of post-conditioning had comparable results to ischemic
      preconditioning regarding reduction in infarct size.

      Endothelial dysfunction is on of the signs of early atherosclerosis, and also a major
      component of ischemia-reperfusion injury. Several factors affect endothelial function, but
      the presence of reactive oxygen species in the vessel wall and the ability of endothelium to
      generated nitric oxide (NO) seem to be the most important determinants of endothelial
      function. Due to abnormalities in NOS, the generation of free oxygen radicals increases, and
      the level of NO decreases during an ischemic episode. This leads to significant alterations
      in the endothelial function. Under ischemic conditions, nitric oxide synthase produces
      superoxide (.O2-) in excess of nitric oxide (NO). Superoxide can react with the surrounding
      nitric oxide to produce a potent oxidizing agent, peroxynitrite (ONOO-). These oxygen
      radicals are thought to contribute to the development of ischemia-reperfusion injury in
      humans. NO has been shown to play a significant role in reducing reperfusion injury in
      humans. The group from our institution demonstrated this where reperfusion injury in the
      forearm of human subjects was attenuated by the administration of tetrahydrobiopterin (BH4),
      a cofactor for NOS that leads to the production of NO (unpublished data, Baballiaros et al.).
      The time course for oxidative marker expression, such as NO, after ischemia-reperfusion
      injury is expected to occur as early as 2.5 to 5 minutes after reperfusion. Several studies
      have examined the time course of NO, nitrosyl hemoglobin, glutathione reduction-oxidation,
      and hydro peroxides. In a study conducted by Mochizuki et al, describing an arterial flow
      mediated dilation model, NO attained a peak value with a first-order time delay and the peak
      level NO concentration was linearly correlated with perfusion rate in each vessel. It must be
      noted, however, that the peak and duration of the levels are somewhat variable and depend on
      perfusion flow and the diameter of the vessel.

      Endothelial function can be non-invasively evaluated using Brachial (or Radial) artery
      reactivity testing (BART) as a measure of flow-mediated dilation (FMD). Since it's beginnings
      in 1989, the study of FMD has now taken on an expanded role in the understanding of
      endothelial physiology. FMD is an endothelial dependent process that reflects relaxation of a
      conduit artery when exposed to shear stress. Increased flow, and thereby increased shear
      stress, through the brachial artery occurs after post occlusive reactive hyperemia. Several
      studies have suggested that the maximal increase in diameter occurs after approximately 60
      seconds after the release of the occlusive cuff or after 45-60 seconds after peak reactive
      hyperemia blood flow. The increase in diameter at this time is prevented by the NO synthase
      inhibitor, N-G monomethyl-L-arginine, indicating that it is an endothelial dependent process
      mediated by NO. Other measures of vasodilator response include time to maximum response,
      duration of the vasodilator response, and the area under the dilation curve .An impairment of
      endothelial function, via FMD assessment by BART, has been shown to correlate with risk
      factors for coronary artery disease (smoking, hyperlipidemia, diabetes mellitus) and adverse
      cardiovascular events.

      Currently, there is data that shows the benefit of post-conditioning in reducing reperfusion
      injury in animal models only. However the use of post-conditioning in humans to reduce
      reperfusion injury has not been well investigated.Given that endothelial dysfunction is a
      significant component of reperfusion injury, we propose to examine the effects of
      post-conditioning on a reperfusion injury by using BART. This study will act as a pilot by
      which we can compare the results of Post-conditioning to preconditioning to reduce the
      reperfusion injury with BART in a human reperfusion injury model. The clinical relevance of
      this study is paramount. If it can be shown that post-conditioning attenuates reperfusion
      injury in humans, as assessed by BART a larger scale trial to assess post-conditioning on
      prevention of ischemia reperfusion injury in humans will be necessary. Furthermore, this
      allows for a possible therapeutic application in the clinical setting, such as potentially
      providing post-conditioning measures to patients undergoing percutaneous coronary
      intervention for abruptly occluded coronary arteries. Attenuation of reperfusion injury may
      further reduce the associated morbidity and mortality of acute coronary ischemic events.
    

Time perspective: Prospective
Keywords: Post conditioning