The Future of Cardioprotection—Pointing Toward Patients at Elevated Risk as the Target Populations

Translation of the cardioprotective effect by pharmacological and mechanical conditioning therapies into improvement of clinical outcome for the patients has been disappointing. Confounding factors like comorbidity and comedications may explain some of the loss in translation. However, the substantial improvement of outcome in disease states involving ischemia-reperfusion injury, that is, planned cardiac surgery, elective percutaneous coronary intervention, and even primary percutaneous coronary intervention for ST-segment myocardial infarction (STEMI), is the most plausible explanation for the missed demonstration of a clinical benefit. Remote ischemic conditioning has demonstrated consistent cardioprotective effect in experimental and in clinical proof-of-concept studies. As an adjunctive cardioprotective treatment beyond reperfusion, remote ischemic conditioning should address target populations at risk of extensive tissue damage, including patients who experience complications, which may induce profound myocardial ischemia in relation to cardiac surgery or elective percutaneous coronary intervention. Moreover, patients with STEMI and predictable impaired clinical outcome due to delayed hospital admission, high Killip class, cardiogenic shock, and cardiac arrest remain target groups. For high-risk patients, daily remote ischemic conditioning or the corollary of blood flow-restricted exercise may be alternative cardioprotective options during postoperative and post-myocardial infarct rehabilitation.