{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,15]],"date-time":"2026-10-15T12:32:43Z","timestamp":1792067563621,"version":"4.4.0"},"reference-count":93,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"17","funder":[{"name":"Ministero della Salute","award":["GR-2016-02363852"],"award-info":[{"award-number":["GR-2016-02363852"]}]}],"content-domain":{"domain":["www.ahajournals.org"],"crossmark-restriction":true},"short-container-title":["Circulation"],"published-print":{"date-parts":[[2025,10,28]]},"abstract":"<jats:sec>\n                    <jats:title>BACKGROUND:<\/jats:title>\n                    <jats:p>Major noncardiac surgery is associated with high rates of postoperative myocardial injury and other complications. Remote ischemic preconditioning (RIPC) was reported to decrease these complication rates. However, such supportive evidence lacks robustness.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>METHODS:<\/jats:title>\n                    <jats:p>In a multinational, double-blind trial, we randomly assigned adult high-risk patients undergoing noncardiac surgical procedures to receive RIPC or sham RIPC after the induction of general anesthesia and before surgery. RIPC involved three 5-minute ischemic cycles, each followed by 5 minutes of reperfusion, using a blood pressure cuff inflated to 200 mm\u2009Hg. The primary end point was the rate of myocardial injury, defined by an increase in postoperative troponin levels above the highest 99th percentile of reference values. Secondary outcomes included myocardial infarction, stroke, acute kidney injury, need for intensive care unit, length of hospital stay, and 30-day all-cause mortality.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>RESULTS:<\/jats:title>\n                    <jats:p>\n                      We recruited 1213 patients in 25 hospitals and 8 countries. We randomly assigned 599 patients to RIPC and 614 to sham RIPC. The most frequent surgical procedures were abdominal or intrathoracic surgeries (406 patients [33.6%]). RIPC was applied to the upper limb in 1014 patients (84.8%) and to the lower limb in 182 patients (15.2%). Postoperative myocardial injury occurred in 215 of 566 patients (38.0%) in the RIPC group and in 223 of 596 patients (37.4%) in the sham RIPC group (relative risk, 1.02 [95% CI, 0.88\u20131.18;\n                      <jats:italic toggle=\"yes\">P<\/jats:italic>\n                      =0.84). There were no significant differences in the rate of any secondary outcomes. We observed 11 episodes of limb petechiae (10 [1.7%] in the RIPC group versus one [0.2%] in the sham RIPC group) and 34 (6.0%) hospital readmissions in the RIPC group versus 20 (3.5%) in the sham RIPC group.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>CONCLUSIONS:<\/jats:title>\n                    <jats:p>Among adult patients undergoing noncardiac surgery, RIPC did not reduce myocardial injury or other postoperative complications.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>REGISTRATION:<\/jats:title>\n                    <jats:p>\n                      URL:\n                      <jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" ext-link-type=\"uri\" xlink:href=\"https:\/\/www.clinicaltrials.gov\">https:\/\/www.clinicaltrials.gov<\/jats:ext-link>\n                      ; Unique identifier: NCT02427867.\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.1161\/circulationaha.125.075254","type":"journal-article","created":{"date-parts":[[2025,6,13]],"date-time":"2025-06-13T06:00:09Z","timestamp":1749794409000},"page":"1194-1205","update-policy":"https:\/\/doi.org\/10.1161\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":18,"title":["Effect of Remote Ischemic Preconditioning on Myocardial Injury in Noncardiac Surgery: The PRINCE Randomized Clinical Trial"],"prefix":"10.1161","volume":"152","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-1003-4637","authenticated-orcid":true,"given":"Massimiliano","family":"Greco","sequence":"first","affiliation":[{"name":"Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy (M.G., M.C.)."},{"name":"Department of Anesthesiology and Intensive Care, IRCCS Humanitas Research Hospital, Rozzano, Italy (M.G., M.C.)."},{"name":"Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy (M.G., G. Lombardi, M.P., F. Monaco, A.B., S.F., G.G., F.M.O., R. Lembo, S.V., F.D., R. Labanca, M. Marmiere, A.P., L. Beretta, G.M., A.Z., G. Landoni, S.T.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8291-8725","authenticated-orcid":true,"given":"Gaetano","family":"Lombardi","sequence":"additional","affiliation":[{"name":"Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy (M.G., G. Lombardi, M.P., F. Monaco, A.B., S.F., G.G., F.M.O., R. Lembo, S.V., F.D., R. Labanca, M. Marmiere, A.P., L. Beretta, G.M., A.Z., G. Landoni, S.T.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Claudia","family":"Brusasco","sequence":"additional","affiliation":[{"name":"Anaesthesia and Intensive Care, E.O. Ospedali Galliera, Genoa, Italy (C.B., M. Micali)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4101-800X","authenticated-orcid":true,"given":"Marina","family":"Pieri","sequence":"additional","affiliation":[{"name":"Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy (M.G., G. Lombardi, M.P., F. Monaco, A.B., S.F., G.G., F.M.O., R. Lembo, S.V., F.D., R. Labanca, M. Marmiere, A.P., L. Beretta, G.M., A.Z., G. Landoni, S.T.)."},{"name":"School of Medicine, Vita-Salute San Raffaele University, Milan, Italy (M.P., L. Beretta, G.M., A.Z., G. Landoni)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Agostino","family":"Roasio","sequence":"additional","affiliation":[{"name":"Anesthesia and Intensive Care Unit Department, \u201cCardinal Massaia\u201d Hospital, Asti, Italy (A. Roasio, S.B.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5186-1976","authenticated-orcid":true,"given":"Fabrizio","family":"Monaco","sequence":"additional","affiliation":[{"name":"Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy (M.G., G. Lombardi, M.P., F. Monaco, A.B., S.F., G.G., F.M.O., R. Lembo, S.V., F.D., R. Labanca, M. Marmiere, A.P., L. Beretta, G.M., A.Z., G. Landoni, S.T.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9267-3664","authenticated-orcid":true,"given":"Levan","family":"Berikashvili","sequence":"additional","affiliation":[{"name":"V.A. Negovsky Scientific Research Institute of General Reanimatology, Moscow, Russia (L. Berikashvili, K.K., P.R., A.S., V.L.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3131-0565","authenticated-orcid":true,"given":"Alessandro","family":"Belletti","sequence":"additional","affiliation":[{"name":"Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy (M.G., G. Lombardi, M.P., F. Monaco, A.B., S.F., G.G., F.M.O., R. Lembo, S.V., F.D., R. Labanca, M. Marmiere, A.P., L. Beretta, G.M., A.Z., G. Landoni, S.T.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7989-1605","authenticated-orcid":true,"given":"Francesco","family":"Meroi","sequence":"additional","affiliation":[{"name":"Department of Emergency, University Hospital of Udine, Azienda Sanitaria Universitaria Friuli Centrale \u201cSanta Maria della Misericordia,\u201d Udine, Italy (F. Meroi, T.B.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Stefano","family":"Fresilli","sequence":"additional","affiliation":[{"name":"Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy (M.G., G. Lombardi, M.P., F. Monaco, A.B., S.F., G.G., F.M.O., R. Lembo, S.V., F.D., R. Labanca, M. Marmiere, A.P., L. Beretta, G.M., A.Z., G. Landoni, S.T.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Aituar","family":"Kabibulatov","sequence":"additional","affiliation":[{"name":"Astana Medical University, Kazakhstan (A. Kabibulatov, A. Konkayev)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0007-3785-3022","authenticated-orcid":true,"given":"Giuseppe","family":"Giardina","sequence":"additional","affiliation":[{"name":"Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy (M.G., G. Lombardi, M.P., F. Monaco, A.B., S.F., G.G., F.M.O., R. Lembo, S.V., F.D., R. Labanca, M. Marmiere, A.P., L. Beretta, G.M., A.Z., G. Landoni, S.T.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andrea","family":"Russo","sequence":"additional","affiliation":[{"name":"Department of Anesthesia, Pain Medicine and Intensive Care Unit, Fondazione Policlinico Universitario \u201cAgostino Gemelli\u201d IRCCS, Rome, Italy (A. Russo, G.F.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6089-8524","authenticated-orcid":true,"given":"Federico Mattia","family":"Oliva","sequence":"additional","affiliation":[{"name":"Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy (M.G., G. Lombardi, M.P., F. Monaco, A.B., S.F., G.G., F.M.O., R. Lembo, S.V., F.D., R. Labanca, M. Marmiere, A.P., L. Beretta, G.M., A.Z., G. Landoni, S.T.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5581-9169","authenticated-orcid":true,"given":"Sergey","family":"Efremov","sequence":"additional","affiliation":[{"name":"Saint-Petersburg State University Hospital, Russia (S.E., A.C.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rosalba","family":"Lembo","sequence":"additional","affiliation":[{"name":"Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy (M.G., G. Lombardi, M.P., F. Monaco, A.B., S.F., G.G., F.M.O., R. Lembo, S.V., F.D., R. Labanca, M. Marmiere, A.P., L. Beretta, G.M., A.Z., G. 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Negovsky Scientific Research Institute of General Reanimatology, Moscow, Russia (L. Berikashvili, K.K., P.R., A.S., V.L.)."},{"name":"Loginov Moscow Clinical Scientifi\u0441 Center, Moscow, Russia (K.K., V.S.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0004-1766-9752","authenticated-orcid":true,"given":"Rosa","family":"Labanca","sequence":"additional","affiliation":[{"name":"Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy (M.G., G. Lombardi, M.P., F. Monaco, A.B., S.F., G.G., F.M.O., R. Lembo, S.V., F.D., R. Labanca, M. Marmiere, A.P., L. Beretta, G.M., A.Z., G. Landoni, S.T.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0006-7107-7816","authenticated-orcid":true,"given":"Pavel","family":"Ryzhkov","sequence":"additional","affiliation":[{"name":"V.A. Negovsky Scientific Research Institute of General Reanimatology, Moscow, Russia (L. Berikashvili, K.K., P.R., A.S., V.L.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7668-4643","authenticated-orcid":true,"given":"Marilena","family":"Marmiere","sequence":"additional","affiliation":[{"name":"Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy (M.G., G. Lombardi, M.P., F. Monaco, A.B., S.F., G.G., F.M.O., R. Lembo, S.V., F.D., R. Labanca, M. Marmiere, A.P., L. Beretta, G.M., A.Z., G. Landoni, S.T.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0921-7199","authenticated-orcid":true,"given":"Valerii","family":"Subbotin","sequence":"additional","affiliation":[{"name":"Loginov Moscow Clinical Scientifi\u0441 Center, Moscow, Russia (K.K., V.S.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0006-4588-2037","authenticated-orcid":true,"given":"Alessandro","family":"Pruna","sequence":"additional","affiliation":[{"name":"Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy (M.G., G. Lombardi, M.P., F. Monaco, A.B., S.F., G.G., F.M.O., R. Lembo, S.V., F.D., R. Labanca, M. Marmiere, A.P., L. Beretta, G.M., A.Z., G. Landoni, S.T.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nerlep","family":"Rana","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Ospedale Regionale di Lugano, Switzerland (N.R.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Francesca","family":"Livi","sequence":"additional","affiliation":[{"name":"Department of Anesthesia and Critical Care, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy (F.L.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8998-1348","authenticated-orcid":true,"given":"Hugo","family":"Mantilla-Gutierrez","sequence":"additional","affiliation":[{"name":"Fundaci\u00f3n Cardioinfantil-Instituto de Cardiolog\u00eda, Bogot\u00e1, Colombia (H.M.-G.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2562-0199","authenticated-orcid":true,"given":"Fabio","family":"Guarracino","sequence":"additional","affiliation":[{"name":"Department of Cardiothoracic and Vascular Anaesthesia and Intensive Care, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy (F.G.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lorenzo","family":"Schiavoni","sequence":"additional","affiliation":[{"name":"Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy (L.S.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4113-2400","authenticated-orcid":true,"given":"Ivan","family":"\u0160itum","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Reanimatology, Intensive Medicine and Pain Therapy, University Hospital Centre Zagreb, Croatia (I.\u0160.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marco","family":"Micali","sequence":"additional","affiliation":[{"name":"Anaesthesia and Intensive Care, E.O. Ospedali Galliera, Genoa, Italy (C.B., M. Micali)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Stefano","family":"Bosso","sequence":"additional","affiliation":[{"name":"Anesthesia and Intensive Care Unit Department, \u201cCardinal Massaia\u201d Hospital, Asti, Italy (A. Roasio, S.B.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7860-6609","authenticated-orcid":true,"given":"Anastasia","family":"Smirnova","sequence":"additional","affiliation":[{"name":"V.A. Negovsky Scientific Research Institute of General Reanimatology, Moscow, Russia (L. Berikashvili, K.K., P.R., A.S., V.L.)."},{"name":"Oncological Center No. 1 of the S. S. Yudin City Clinical Hospital of the Moscow Department of Health, Moscow, Russia (A.S.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Giuseppe","family":"Fresta","sequence":"additional","affiliation":[{"name":"Department of Anesthesia, Pain Medicine and Intensive Care Unit, Fondazione Policlinico Universitario \u201cAgostino Gemelli\u201d IRCCS, Rome, Italy (A. Russo, G.F.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4290-4206","authenticated-orcid":true,"given":"Andrey","family":"Cherednichenko","sequence":"additional","affiliation":[{"name":"Saint-Petersburg State University Hospital, Russia (S.E., A.C.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Luigi","family":"Beretta","sequence":"additional","affiliation":[{"name":"Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy (M.G., G. Lombardi, M.P., F. Monaco, A.B., S.F., G.G., F.M.O., R. Lembo, S.V., F.D., R. Labanca, M. Marmiere, A.P., L. Beretta, G.M., A.Z., G. Landoni, S.T.)."},{"name":"School of Medicine, Vita-Salute San Raffaele University, Milan, Italy (M.P., L. Beretta, G.M., A.Z., G. Landoni)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3885-9238","authenticated-orcid":true,"given":"Giacomo","family":"Monti","sequence":"additional","affiliation":[{"name":"Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy (M.G., G. Lombardi, M.P., F. Monaco, A.B., S.F., G.G., F.M.O., R. Lembo, S.V., F.D., R. Labanca, M. Marmiere, A.P., L. Beretta, G.M., A.Z., G. Landoni, S.T.)."},{"name":"School of Medicine, Vita-Salute San Raffaele University, Milan, Italy (M.P., L. Beretta, G.M., A.Z., G. Landoni)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lian Kah","family":"Ti","sequence":"additional","affiliation":[{"name":"Department of Anaesthesia, National University Hospital, Singapore (L.K.T.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0873-3586","authenticated-orcid":true,"given":"Pasquale","family":"Sansone","sequence":"additional","affiliation":[{"name":"Department of Women, Child and General and Specialized Surgery, University of Campania \u201cL. Vanvitelli,\u201d Naples, Italy (P.S.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5588-2608","authenticated-orcid":true,"given":"Francesco","family":"Corradi","sequence":"additional","affiliation":[{"name":"Department of Surgical, Medical, Molecular Pathology and Critical Care Medicine, University of Pisa, Italy (F.C.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maurizio","family":"Cecconi","sequence":"additional","affiliation":[{"name":"Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy (M.G., M.C.)."},{"name":"Department of Anesthesiology and Intensive Care, IRCCS Humanitas Research Hospital, Rozzano, Italy (M.G., M.C.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5103-0304","authenticated-orcid":true,"given":"Andrey","family":"Yavorovskiy","sequence":"additional","affiliation":[{"name":"I.M. Sechenov First Moscow State Medical University of the Russian Ministry of Health, Moscow, Russia (A.Y., V.L.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4259-4479","authenticated-orcid":true,"given":"Chong","family":"Lei","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology and Perioperative Medicine, Anesthesia Clinical Research Center, Xijing Hospital, Xi\u2019an, China (L.W., C.L.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Aidos","family":"Konkayev","sequence":"additional","affiliation":[{"name":"Astana Medical University, Kazakhstan (A. Kabibulatov, A. Konkayev)."},{"name":"National Scientific Center of Traumatology and Orthopedia named after academician N. Batpenov, Astana, Kazakhstan (A. Konkayev)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5489-2898","authenticated-orcid":true,"given":"Tiziana","family":"Bove","sequence":"additional","affiliation":[{"name":"Department of Emergency, University Hospital of Udine, Azienda Sanitaria Universitaria Friuli Centrale \u201cSanta Maria della Misericordia,\u201d Udine, Italy (F. Meroi, T.B.)."},{"name":"Department of Medicine, University of Udine, Italy (T.B.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5442-6950","authenticated-orcid":true,"given":"Valery","family":"Likhvantsev","sequence":"additional","affiliation":[{"name":"V.A. Negovsky Scientific Research Institute of General Reanimatology, Moscow, Russia (L. Berikashvili, K.K., P.R., A.S., V.L.)."},{"name":"I.M. 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