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Strengths and limitations of this study

Strengths

  • This study uses a pragmatic, dual-center, randomized controlled trial design, ensuring a robust methodological approach.

  • The implementation of a perioperative RIC program is designed to encompass the protective windows of RIC, increasing the likelihood of capturing its benefits.

  • The trial employs blinding and a sham RIC group to minimize bias, enhancing the validity of the findings.

Limitations

  • The intervention’s specificity is not completely clear, as the study’s design does not allow for identification of the specific phase of RIC responsible for any observed effects.

  • Conducted across two centers, the findings may have limited generalizability.

Introduction

Cardiovascular disease is the leading cause of mortality in China, with nearly half of the deaths being caused by ischemic heart disease [1]. Consequently, the burden of disease is heavy. Percutaneous coronary intervention (PCI) is an effective treatment method, significantly reducing mortality in myocardial infarction patients and improving prognosis [2, 3]. However, its efficacy in patients with unstable angina (UA) is controversial. Compared to drug therapy, PCI can improve UA symptoms in the short term (3–6 months), but long-term prognosis (12 months and above) shows no difference [4, 5, 6–7]. Moreover, complications associated with PCI further limit its application in patients with UA. Complications due to surgical procedures, such as distal embolization and side branch occlusion (SBO), leading to perioperative myocardial infarction (Type 4a myocardial infarction) and myocardial injury, are most common and correlate with patient prognosis [8, 9–10]. Previous research has shown that the incidence of perioperative myocardial infarction and myocardial injury can reach 20–30% among elective surgery patients with UA [9, 11, 12]. Therefore, co-interventions that can reduce PCI-related complications and possibly facilitate the PCI itself, thus making PCI more broadly applicable in patients with UA, are needed.

Remote ischemic conditioning (RIC) is a candidate co-intervention. It involves a repeated brief interruption of the blood flow of a remote organ or tissue followed by its restoration. In this fashion, it is supposed to stimulate an endogenous physiological response with cardioprotective impact, and thereby improve endothelial as well as cardiac function and reduce the risk of further myocardial injury [13, 14]. RIC is clinically viable and easy-to-implement. There is some previous evidence that RIC may improve angiogenesis [15, 16], stimulate vagus nerve...

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