The present study has investigated the effectiveness of staged-preconditioning, in both remote and target organs. After IP the myocardial release of the biochemical markers including, creatine phosphokinase (CPK), cardiac creatine kinase (CK-MB), cardiac troponin T (cTnT) and lactate dehydrogenase (LDH) were evaluated in patients who underwent CABG, with and without staged-preconditioning. Sixty-one patients entered the study; there were 32 patients in the staged-preconditioning group and 29 patients in the control group. All patients underwent on-pump CABG using cardiopulmonary bypass (CPB) techniques. In the staged-preconditioning group, patients underwent two stages of IP on remote (upper limb) and target organs. Each stage of preconditioning was carried out by 3 cycles of ischemia and then reperfusion. Serum levels of biochemical markers were immediately measured postoperatively at 24, 48 and 72？h. Serum CK-MB, CPK and LDH levels were significantly lower in the staged-preconditioning group than in the control group. The CK-MB release in the staged-preconditioning patients reduced by 51% in comparison with controls over 72？h after CABG. These results suggest that myocardial injury was attenuated by the effect of three rounds of both remote and target organ IP. 1. Introduction New treatment strategies are required to reduce myocardial injury and improve clinical outcomes in patients with coronary heart disease (CHD), the leading cause of death worldwide. The protective effects of ischemic preconditioning (IP) on human heart after cardiac surgeries are well defined [1]. Initially, the positive effect of short periods of ischemia to limit infarct size was referred to IP [2]. It was then established to have beneficial effects on ischemia and reperfusion induced arrhythmia and on myocardial stunning [3, 4]. Furthermore, it has been suggested that IP reduces postoperative inotropic requirements and has a preventive role in postoperative myocardial dysfunction [5, 6]. Ischemic preconditioning can be mechanical or pharmacological. Direct mechanical preconditioning in which the major organ is exposed to brief ischemia prior to prolonged ischemia has the benefit of reducing ischemia-reperfusion injury (IRJ). Remote preconditioning is a brief ischemia of one organ which has been shown to confer protection on distant organs without direct stress to the target organ [7]. Remote ischemic preconditioning (RIPC) can limit myocardial infarction size that has been successfully applied to the protection of other noncardiac organs against ischemia-reperfusion injury
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