SummaryBackgroundRemote ischaemic conditioning with transient ischaemia and reperfusion applied to the arm has been shown to reduce myocardial infarct size in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI). We investigated whether remote ischaemic conditioning could reduce the incidence of cardiac death and hospitalisation for heart failure at 12 months.MethodsWe did an international investigator-initiated, prospective, single-blind, randomised controlled trial (CONDI-2/ERIC-PPCI) at 33 centres across the UK, Denmark, Spain, and Serbia. Patients (age >18 years) with suspected STEMI and who were eligible for PPCI were randomly allocated (1:1, stratified by centre with a permuted block method) to receive standard treatment (including a sham simulated remote ischaemic conditioning intervention at UK sites only) or remote ischaemic conditioning treatment (intermittent ischaemia and reperfusion applied to the arm through four cycles of 5-min inflation and 5-min deflation of an automated cuff device) before PPCI. Investigators responsible for data collection and outcome assessment were masked to treatment allocation. The primary combined endpoint was cardiac death or hospitalisation for heart failure at 12 months in the intention-to-treat population. This trial is registered with ClinicalTrials.gov (NCT02342522) and is completed.FindingsBetween Nov 6, 2013, and March 31, 2018, 5401 patients were randomly allocated to either the control group (n=2701) or the remote ischaemic conditioning group (n=2700). After exclusion of patients upon hospital arrival or loss to follow-up, 2569 patients in the control group and 2546 in the intervention group were included in the intention-to-treat analysis. At 12 months post-PPCI, the Kaplan-Meier-estimated frequencies of cardiac death or hospitalisation for heart failure (the primary endpoint) were 220 (8·6%) patients in the control group and 239 (9·4%) in the remote ischaemic conditioning group (hazard ratio 1·10 [95% CI 0·91–1·32], p=0·32 for intervention versus control). No important unexpected adverse events or side effects of remote ischaemic conditioning were observed.InterpretationRemote ischaemic conditioning does not improve clinical outcomes (cardiac death or hospitalisation for heart failure) at 12 months in patients with STEMI undergoing PPCI.FundingBritish Heart Foundation, University College London Hospitals/University College London Biomedical Research Centre, Danish Innovation Foundation, Novo Nordisk Foundation, TrygFonden.

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BackgroundPre-hospital delays in patients experiencing acute coronary syndromes (ACS) remain unacceptably long.AimsTo examine simultaneously a wide range of clinical, sociodemographic and situational factors associated with total pre-hospital delay and its two components.MethodsPre-hospital delay data were collected from 228 patients with ACS using patient's medical notes and semi-structured interviews. Total pre-hospital delay (symptom onset to hospital admission) was divided into 2 components: decision time (symptom onset to call for medical help), and home-to-hospital delay (call for help to hospital admission).ResultsShorter total pre-hospital delays and decision times were associated with ST segment myocardial infarction (STEMI), recognizing symptoms as cardiac in origin, being married, symptom onset outside the home and the presence of a bystander. Shorter home-to-hospital delays were more likely among younger patients, those experiencing an STEMI, and patients reporting a greater number of symptoms. Initial contact with emergency medical services was related to shorter total delays and decision times.ConclusionsDifferent factors were associated with shorter times in the 2 component phases. Greater understanding of the factors impacting on the component phases may help target interventions more effectively and reduce pre-hospital delays.

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Behavioral and emotional factors are probable triggers of acute coronary syndromes in vulnerable individuals, and the pathophysiological processes elicited by these stimuli are being increasingly understood. The benefits to patients of knowledge to these processes have yet to accrue.

Type-D personality may be associated with prolonged disruption of the hypothalamic-pituitary-adrenal axis function in survivors of acute cardiac events and may contribute to biological responses influencing future cardiac morbidity.