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Objectives Myocardial injury associated with elective percutaneous coronary intervention (PCI) is a common complication and an adverse prognostic indicator.This study was designed to investigate the effect of remote ischemic preconditioning (RIPC) in the elderly unstable angina pectoris patients with diabetes mellitus (DM) undergoing elective drug-eluting stent (DES) implantation.Methods Eligible patients with DM aged 65 and above were randomized to receive or not RIPC (induced by three cycles of 5-min pneumatic medical tourniquet cuff inflations to 200 mm Hg around the upper arm, followed by 5-min of deflations to allow reperfusion) as an addition to the conventional treatment of coronary artery disease within 2 hours before PCI.A total of 200 eligible patients were finally enrolled after DES implantation, 102 in the RIPC group and 98 in the control group.Results With comparable baseline situation and PCI-related characteristics, RIPC group (n =102) and control group (n =98) showed no significant difference in the level of hs cTnI before PCI (median, 0.01 vs.0.01 ng/mL, p =0.797).At 16 hours after PCI procedure, despite the trend towards decline, the median high sensitive cardiac troponin Ⅰ (hscTnI) level (median 0.29 vs 0.38 ng/mL, P =0.256) and the incidence of myocardial infarction (MI 4a, defined as hscTnI > 0.20 ng/mL, 52.0% vs 63.3%, P =0.106) in the RIPC group was not significantly different from the control group.The median high sensitive C-reactive protein level showed no significant difference between the two groups (6.75 vs 6.80 mg/L, P =0.774).Conclusions RIPC could attenuate the release of myocardial biomarker, but failed to show a significant effect on hscTnI level or MI 4a incidence after PCI procedure in elderly unstable angina peetoris patients with DM undergoing elective DES implantation, which may be associated with the impact of DM on the myocardial protection effect of RIPC.In the future, we still need more large-scale, randomized controlled trials to fully assess the clinical application of RIPC in elective PCI.