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.

Intravenous infusions of enoximone or dobutamine were given, using a double dummy technique, in a randomized, double-blind study, to 18 patients with acute myocardial infarction who had persisting signs of left ventricular failure after treatment with intravenous diuretics. Blood pressure, heart rate and cardiac output, by transcutaneous Doppler aortovelography, were measured and any arrhythmias recorded by Holter monitoring. Eight of the nine enoximone treated patients showed clinical improvement. One patient in the enoximone group failed to respond and subsequently died. Five of the nine dobutamine treated patients showed clinical improvement. The other four patients in the dobutamine group experienced tachyarrhythmias and were withdrawn from the study; one of these patients also deteriorated and died. There were no significant differences in systolic or diastolic blood pressure either within or between the two treatment groups during the study. Enoximone increased cardiac output by 32% (P = 0.003), and dobutamine by 46% (P < 0.001); there was no significant difference between groups. Dobutamine also significantly increased heart rate from a mean of 108 beats.min-1 to 117 beats.min-1 (P < 0.001). There was no difference between the two groups in ventricular ectopic counts, but dobutamine produced significantly more runs of supraventricular and ventricular tachycardia (P = 0.0003). Enoximone was better tolerated with fewer side-effects than dobutamine in doses which produced similar increases in cardiac output. In the setting of an acute myocardial infarction when inotropic therapy is indicated, enoximone is a better choice than dobutamine.

patients are to be tested then surgeons must also be tested. We presume therefore that the Royal College of Surgeons will also support the compulsory testing of the surgeon in order to "secure the safety" of the patient. If surgeons will not accept this they will request HIV serology on their patients in vain, for many microbiologists will refuse to perform the test.

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