Lancet subjournal: Long-distance ischemic adaptation of Ji Xunming's team of Capital Medical University has a significant protective effect on stroke

Stroke is the first fatal and disabling disease
in China.
China adopts the same prevention and control guidelines as European and American countries, but China's prevention and control effect is not satisfactory, and the incidence and recurrence rate still rank first in the world, causing a heavy burden
on society, economy and families.
Stroke in European and American populations is dominated by extracranial atherosclerosis, while Chinese group is dominated by intracranial atherosclerosis (China 46% vs Europe and the United States 9%)
.

Intracranial atherosclerotic stenosis (ICAS) is one of the most common causes of stroke worldwide, and currently recommended treatments are associated with
a high risk of stroke recurrence.

On October 27, 2022, led by the team of Professor Ji Xunming of Capital Medical University, 84 hospitals in China cooperated in Lancet Neurology ( IF=60) published online titled “Chronic remote ischaemic conditioning in patients with symptomatic intracranial atherosclerotic stenosis (the RICA trial): a multicentre, randomised, double-blind sham-controlled trial in China", which found that long-range ischemic adaptation reduced the recurrence rate of stroke by 24% and the incidence of cardiovascular and cerebrovascular diseases by 30%.

This study provides high-level medical evidence
for the adaptation of distant ischemia for symptomatic intracranial atherosclerotic stenosis.

Extracranial atherosclerotic stenosis can be treated with surgery or stents, while clinical studies of intracranial atherosclerotic stenosis surgery or stent have not yielded positive results
.
Despite intensive drug therapy, the risk of stroke recurrence in age is as high as 20%.

To assess the effectiveness of chronic remote ischemia regulation in preventing ischemic events in symptomatic ICAS patients, the study conducted the RICA trial, a multicenter, randomized, double-blind, sham controlled trial
conducted in 84 stroke centers in China.
Patients aged 40-80 years with angiography confirmed 50-99% stenosis of the intracranial aortic arteries leading to ischemic stroke or transient ischemic attack, through computer-generated random coding, through an interactive network system, random (1:1).
Assigned to remote ischemic regulation or pseudo-remote ischemic regulation, once a day for 12 months, after which it is
performed voluntarily.
All investigators and patients were informed of treatment allocation
.
The primary efficacy endpoint was the time to first occurrence of non-fatal or fatal ischemic stroke, and survival was analysed using the Kaplan-Meier method
.

From October 28, 2015 to February 28, 2019 During this day, 3033 eligible patients were enrolled and randomly assigned to the remote ischemic conditioning group (n=1517; experimental group) or pseudodistal ischemic conditioning (n=1516; Control group).

The median follow-up was 3.
5 years (IQR 2.
7 to 4.
4).

The study found that non-fatal or fatal ischemic stroke occurred in 257 cases (16.
9%) in the experimental group and 288 (19.
0%) in the control group
。 There was no difference in the distribution of survival between non-fatal and fatal ischaemic stroke when it first occurred (hazard ratio 0.
87, 95% CI 0.
74 to 1·03; p = 0·12)
。

In addition, 79 (5.
2%) patients died in the trial group and 84 (5.
5%) patients in the control group died from any cause (hazard ratio 0.
93,95% CI 0.
68 - 1.
27; p = 0·65)
。 No serious adverse events
related to the intervention were observed.
This suggests that long-term distant ischemic adaptation can reduce the incidence
of cardiovascular and cerebrovascular diseases in patients with ischemic stroke or TIA due to symptomatic intracranial atherosclerotic stenosis.

Survival curves for primary endpoints (ischemic stroke) and composite endpoints (stroke, TIA, myocardial infarction) (figure from Lancet Neurology).

Taken together, the study showed no difference
in the risk of ischemic stroke between remote ischemic conditioning and pseudo-ischemic conditioning in patients with symptomatic ICAS.
The benefits of remote ischemic regulation may be diluted
by poor adherence.
Future studies of remote ischemic conditioning in this population should address patient adherence challenges and evaluate long-term treatment
.

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