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Clinical studies abstracts

2013

Increasing pressure of external counterpulsation augments blood pressure but not cerebral blood flow velocity in ischemic stroke.

Wenhua Lin, Li Xiong, Jinghao Han, Howan Leung, Thomas Leung, Yannie Soo, Xiangyan Chen, Ka Sing Lawrence Wong., Journal of Clinical Neuroscience, 2013, Available online 8 December 2013 abstract
Increasing pressure of external counterpulsation augments blood pressure but not cerebral blood flow velocity in ischemic stroke. External counterpulsation (ECP) is a noninvasive method used to augment cerebral perfusion but the optimal use of ECP in ischemic stroke has not been well documented. We aimed to investigate the effects of ECP treatment pressure on cerebral blood flow and blood pressure (BP). We recruited 38 ischemic stroke patients with large artery occlusive disease and 20 elderly controls. We started ECP treatment pressure at 150 mmHg and gradually increased to 187.5, 225 and 262.5 mmHg. Mean cerebral blood flow velocities (CBFV) of bilateral middle cerebral arteries and continuous beat-to-beat BP were recorded before ECP and during each pressure increment for 3 minutes. Patient CBFV data was analyzed based on whether it was ipsilateral or contralateral to the infarct. Mean... read more

Hemodynamic effect of external counterpulsation is a different measure of impaired cerebral autoregulation from vasoreactivity to breath-holding.

W. Lin, L. Xiong, J. Han, T. Leung, H. Leung, X. Chen, K. S. L. Wong., European Journal of Neurology, 2013, 2013 first published online: 7 DEC 2013 , DOI: 10.1111/ene.12314. abstract
Hemodynamic effect of external counterpulsation is a different measure of impaired cerebral autoregulation from vasoreactivity to breath-holding. Background and purpose: External counterpulsation (ECP) is a novel method to increase cerebral blood flow, which may benefit acute ischaemic stroke patients. Our aim was to identify whether the hemodynamic effect of ECP is associated with cerebral vasoreactivity to breath-holding. Methods: Thirty-seven recent ischaemic stroke patients with large artery steno-occlusive disease were recruited together with 20 healthy controls. All underwent ECP treatment and a breath-holding test combined with transcranial Doppler monitoring on bilateral middle cerebral arteries was performed. The data of the stroke patients were designated as ipsilateral or contralateral based on the side of the infarct, whilst the average of both sides was used in controls. The cerebral augmentation index (CAI) was used to evaluate the augmentation effects of... read more

Enhanced External Counterpulsation inhibits endothelial apoptosis via modulation of BIRC2 and Apaf-1 genes in porcine hypercholesterolemia.

Yan Xiong, Yu-feng Ren, Jia Xu, Da-ya Yang, Xiao-hong He, Jing-yun Luo, Jamal S. Rana, Yan Zhang, Zhen-sheng Zheng, Dong-hong Liu,Gui-fu Wu., International Journal of Cardiology, 2013, Available online 23 November 2013. abstract
Enhanced External Counterpulsation inhibits endothelial apoptosis via modulation of BIRC2 and Apaf-1 genes in porcine hypercholesterolemia. Objectives: Enhanced External Counterpulsation (EECP) could improve endothelium-dependent vasodilatation of carotid artery and restore imbalance of nitric oxide and endothein-1 in patients with coronary artery disease. Our study was designed to test the hypothesis that long-term EECP may protect vascular endothelial cells from apoptosis by modifying apoptosis-related gene expression. Methods: Eighteen male Yorkshire pigs were randomly assigned to three groups: usual diet (Normal), high cholesterol diet (HC) and high cholesterol diet plus EECP (HC + EECP). Vascular endothelial cells were isolated from the aortic endothelium and identified by CD31 staining and DiI-Ac-LDL reaction. Morphological changes were observed by both scanning and transmission electronic microscopes. TUNEL technique was applied to detect the apoptotic index of vascular endothelial cells. Two genes, Apaf-1... read more

Relation between N-terminal pro-brain natriuretic peptide levels and response to enhanced external counterpulsation in chronic angina pectoris.

Sahlén A, Wu E, Rück A, Hagerman I, Förstedt G, Sylvén C, Berglund M, Jernberg T., Coron Artery Dis., 2013, 2013 Nov 8 abstract
Relation between N-terminal pro-brain natriuretic peptide levels and response to enhanced external counterpulsation in chronic angina pectoris. OBJECTIVE: although enhanced external counterpulsation (EECP) provides symptom reduction in many patients with severe angina pectoris, one-quarter of patients fail to respond. Earlier reports have not clearly established whether and how EECP responders may be identified pre-hoc. We hypothesized that clinical and biochemical data may be used to predict EECP response. METHODS: we explored a database of n=53 patients who had undergone clinically indicated EECP during 35 1-h sessions in our unit (65±7 years; 49 male), and sought to clarify which factors are predictive of response. Efficiency of counterpulsation was measured as the diastolic augmentation (DA) ratio, and was recorded both at beginning and end of the EECP treatment course. An increase in 6-min walk (6MW) distance of 5% was... read more

Effect of enhanced external counterpulsation treatment on renal function in cardiac patients.

Prajej Ruangkanchanasetr, Nithi Mahanonda, Ongkarn Raungratanaamporn, Piyanuj Ruckpanich Chagriya Kitiyakara, Amnart Chaiprasert, Surawat Adirekkiat, Dollapas Punpanich, Somlak Vanavanan, Anchalee Chittamma, Thanom Supaporn., BMC Nephrology, 2013, 14:193 doi:10.1186/1471-2369-14-193. abstract
Effect of enhanced external counterpulsation treatment on renal function in cardiac patients. Background: Enhanced external counterpulsation (EECP) enhances coronary perfusion and reduces left ventricular afterload. However, the role of EECP on renal function in cardiac patients is unknown. Our aim was to assess renal function determined by serum cystatin C in cardiac patients before and after EECP treatment. Methods: A prospective observational longitudinal study was conducted in order to evaluate renal function using serum cystatin C (Cys C) and estimated glomerular filtration rate (GFR) after 35 sessions of EECP treatment in 30 patients with chronic stable angina and/or heart failure. The median (IQR) time for follow-up period after starting EECP treatment was 16 (10–24) months. Results: Cys C significantly declined from 1.00 (0.78-1.31) to 0.94 (0.77-1.27) mg/L (p < 0.001) and estimated GFR... read more

Enhanced External Counterpulsation Improves Peripheral Resistance Artery Blood Flow in Patients With Coronary Artery Disease.

Joseph C Avery, Darren T Beck, Darren P Casey, Paloma D Sardina, Randy W. Braith., Applied Physiology, Nutrition, and Metabolism., 2013, Published on the web 11 October 2013. abstract
Enhanced External Counterpulsation Improves Peripheral Resistance Artery Blood Flow in Patients With Coronary Artery Disease. Enhanced external counterpulsation (EECP) increases coronary artery perfusion and improves endothelium-dependent vasodilation in peripheral muscular conduit arteries. It is unknown whether vasodilatory capacity is improved in the peripheral resistance vasculature. Here we provide novel evidence from the first randomized, sham-controlled study that EECP increases peak limb blood flow and improves endothelium-dependent vasodilation in both calf and forearm resistance arteries in patients with coronary artery disease (CAD). ... read more

The effectiveness of enhanced external counterpulsation (EECP) in patients suffering from chronic refractory angina previously treated with transmyocardial laser revascularisation.

Poay Huan Loh, Elizabeth Kennard, Christos V. Bourantas, Raj Chelliah, Paul Atkin, Jocelyn Cook, John G. Cleland, Andrew Michaels, John C.K. Hui for the International EECP Patient Registry (IEPR)., International Journal of Cardiology, 2013, (in press). abstract
The effectiveness of enhanced external counterpulsation (EECP) in patients suffering from chronic refractory angina previously treated with transmyocardial laser revascularisation. Background: Despite treatments, some patients with chronic refractory angina continue to experience disabling symptom. This study investigated the safety and effectiveness of enhanced external counterpulsation (EECP) in treating patients who had had a previous transmyocardial laser revascularization (TMR). Methods: Patients in the International EECP Patient Registry I and II were divided into those who had a prior TMR, those who had a prior percutaneous or surgical revascularization (PCI/CABG) and those who had medical therapy alone (Medical). Their baseline characteristics, treatment outcome and clinical events were compared. Results: Of the 4,306 patients, 91 had a prior TMR, 3,790 had a prior PCI/CABG and 425 were treated with medicat therapy with no previous invasive revascularization procedures. Patients in the TMR were younger... read more

Enhanced external counterpulsation improves cerebral blood flow following cardiopulmonary resuscitation.

Rong Liu, Zi-Jing Liang, Xiao-Xing Liao, Chun-Lin Hu, Li Jiang, Gang Dai, Ying-Qing Li, Hong-Yan Wei, Gui-Fu Wu, Xin Li., American Journal of Emergency Medicine, 2013, 2013 (in press) abstract
Enhanced external counterpulsation improves cerebral blood flow following cardiopulmonary resuscitation. Background:To investigate the therapeutic value of enhanced external counterpulsation (EECP) on recovery of cerebral blood flow following cardiac arrest (CA) and successful resumption of spontaneous circulation (ROSC) by cardiopulmonary resuscitation. Methods: CA models were conducted using beagle dogs induced by alternating current. After successful ROSC by cardiopulmonary resuscitation, 16 dogs were randomly divided into the EECP and control group (n = 8 per group). Dogs underwent dynamic contrast-enhanced and diffusion-weighted magnetic resonance imaging at baseline prior to CA and during the 3 days following ROSC. Mean blood pressure, right common carotid artery blood flow, intracranial microcirculation and blood lactate levels were measured. Neurological outcome was assessed by the neurologic deficit score. Hematoxylin-eosin staining and transmission electron microscopy were performed for... read more

Effect of enhanced external counterpulsation therapy on myeloperoxidase in lowering cardiovascular events of patients with chronic heart failure.

Starry H. Rampengan, Budhi Setianto, Jimmy Posangi, Suzanna Immanuel, Judo Prihartono, Minarma Siagian, Harmani Kalim, Sirowanto Inneke, Murdani Abdullah,8 Sarwono Waspadji., Med J Indones., 2013, 2013;22:152-60. doi: 10.13181/mji.v22.i3.584. abstract
Effect of enhanced external counterpulsation therapy on myeloperoxidase in lowering cardiovascular events of patients with chronic heart failure. Background: Chronic heart failure (CHF) is a slowly progressive disease with high morbidity and mortality; therefore, the management using pharmacological treatments frequently fails to improve outcome. Enhanced external counterpulsation (EECP), a non-invasive treatment, may serve as alternative treatment for heart failure. This study was aimed to evaluate the influence of EECP on myeloperoxidase (MPO) as inflammatory marker as well as cardiac events outcome. Methods: This was an open randomized controlled clinical trial on 66 CHF patients visiting several cardiovascular clinics in Manado between January-December 2012. The subjects were randomly divided into two groups, i.e. the group who receive EECP therapy and those who did not receive EECP therapy with 33 patients in each group. Myeloperoxidase (MPO) as inflammatory marker was... read more

Effect of enhanced external counterpulsation depends on arterial compliance.

Ashkan Eftekhari, Ole May., Acta Cardiol, 2013, 2013;68(1):47-50. abstract
Effect of enhanced external counterpulsation depends on arterial compliance. Enhanced external counterpulsation (EECP) is a non-invasive therapy offered to patients with refractory angina pectoris. Previous studies have demonstrated that its clinical effect depends on the diastolic/systolic augmentation ratio (D/S ratio). We hypothesized that the D/S ratio is associated with arterial stiffness measured as pulse wave velocity (PWV) and brachial pulse pressure (PP). Twenty patients with known refractory angina (17 men, 3 women; mean age 64 years) were included and underwent one hour of EECP treatment (Vasomedical Inc., Westbury, NY, USA). Three sets of cuffs were applied around the lower extremities. Gated by electrocardiography (ECG), air was inflated in diastole at a pressure of 260 mmHg and deflated at the start of systole. The D/S ratio was monitored with finger... read more

The Safety and Efficacy of Enhanced External Counterpulsation as a Treatment for Angina in Patients with Aortic Stenosis.

Debra L Braverman, Len Braitman, Vincent M Fifeuredo., Clin Cardiol, 2013, 2013;36(2):82-87. abstract
The Safety and Efficacy of Enhanced External Counterpulsation as a Treatment for Angina in Patients with Aortic Stenosis. Background: Comorbid aortic stenosis (AS) has been considered a precaution when applying enhanced externalcounterpulsation (EECP) to individuals with angina due to concerns about treatment-related hemodynamic changes. Hypothesis: The aim of this study was to determine whether EECP safety reduces symptoms of myocardial ischemia improves hemodynamics in individuals with AS. Methods: Forty-three patients with AS (average age, 73 years; 86%male) and 43 comparison patients without AS were chosen from a database of 1327 EECP patients. Canadian Cardiovascular Society (CCS) Functional Angina Classification, diastolic augmentation ratio, and blood pressure were measured at baseline and on completion of the course of EECP. Results: Thirty-five of the 43 patients with AS (81%, 95%CI:66.6% to 91.6%) and 38 of the 43 without AS (88%,95% CL:... read more

Clinical study in patients with ocular ischemic diseases treated with enhanced external counterpulsation combined with drugs.

Yang Y, Zhang H, Yan Y, Gui Y., Mol Med Rep., 2013, 2013 Apr 26. doi: 10.3892/mmr.2013.1445. abstract
Clinical study in patients with ocular ischemic diseases treated with enhanced external counterpulsation combined with drugs. The aim of this study was to evaluate the clinical effect in patients with ocular ischemic diseases treated with enhanced external counterpulsation (EECP) combined with drugs. A total of 65 patients with carotid artery stenosis were included in this study. Group A consisted of 31 patients (43 eyes) treated with EECP and medication, and group B consisted of 34 patients (49 eyes) treated with medication alone. The clinical effect was analyzed by comparing the visual acuity, visual fields and optical hemodynamics between the two groups of patients. Ocular ischemic diseases mainly included ischemic optic neuropathy, central (branch) retinal artery occlusion, ophthalmoplegia externa and ocular ischemic syndrome. Significant improvement of visual acuity, visual fields and optical hemodynamics was observed in the... read more

Improvement of angina, quality of life, and working capacity after enhanced external counterpulsation.

Jørgensen MT, May O., Ugeskr Laeger., 2013, 2013 Jan 14;175(3):114-116. abstract
Improvement of angina, quality of life, and working capacity after enhanced external counterpulsation. This case report describes a 43 year-old woman who had had 15 hospital admissions in six years due to chest pain. Repeated coronary angiography showed no significant stenoses, but myocardial scintigraphy revealed reversible ischaemia. In spite of optimal medical treatment, she was in Canadian Cardiovascular Society (CCS) class 3 with a poor quality of life (QoL). After a course of enhanced external counterpulsation the CCS class was reduced to 1, and QoL was significantly improved and remained high for the following three years, resulting in only one hospital admission due to chest pain. The case illustrates that EECP is an efficient therapy for angina pectoris in patients, who are not amenable for invasive procedures. ... read more

Predictors of good functional outcome in counterpulsation-treated recent ischaemic stroke patients.

Wenhua Lin, Jinghao Han, Xiangyan Chen, Li Xiong, Ho Wan Leung, Thomas W Leung, Yannie Soo, Lawrence Ka Sing Wong, BMJ Open, 2013, 2013;3: e002932. doi:10.1136/bmjopen-2013-002932. abstract
Predictors of good functional outcome in counterpulsation-treated recent ischaemic stroke patients. Objectives: External counterpulsation (ECP) is a non-invasive method being investigated for ischemic stroke. We aimed to explore predictors of good functional outcome for ECP-treated ischemic stroke patients who completed a minimum of 10 sessions. Methods: We analyzed our ECP registry of ischemic stroke patients with cerebral large artery stenosis who underwent ECP therapy at the Prince of Wales Hospital from 2004 to 2010. We included 155 patients who completed at least 10 sessions of ECP and had 3-month follow-up data as well as 52 medical controls. Functional outcomes were dichotomized into good outcome (modified Rankin Scale (mRS) 0–2) and bad outcome (mRS 3–6). We compared the differences in two groups in terms of demographics, medical history and parameters of ECP... read more

Early Enhanced External Counter Pulsation Improves Neurological Recovery After the Return of Spontaneous Circulation in a Mongrel Dog Cardiac Arrest Model.

Hu, Chun-Lin, Liu, Rong, Liao, Xiao-Xing, Wei, Hong-Yan, Li, Xin, Zhan, Hong, Jing, Xiao-Li, Xiong, Yan, Huang, Guo-Qing, Wu, Gui-Fu., Critical Care Medicine:, 2013, June 2013 - Volume 41 - Issue 6 - p e62–e73. doi: 10.1097/CCM.0b013e318278b469. abstract
Early Enhanced External Counter Pulsation Improves Neurological Recovery After the Return of Spontaneous Circulation in a Mongrel Dog Cardiac Arrest Model. Objectives: The aim of this study was to investigate whether early enhanced external counter pulsation therapy after cardiopulmonary resuscitation improved neurological outcome in a mongrel dog cardiac arrest model. Subjects: Twenty-four healthy male adult dogs (12-14 kg). Interventions: After minutes of untreated ventricular fibrillation followed by 2 minutes of cardiopulmonary resuscitation, the dogs were randomized to receive 4 hours of enhanced external counter pulsation therapy, to receive 4 hours of hypertension with over 140 mm Hg or to be a control. Measurements: Blood pressure and left ventricular ejection fraction were recorded. Cerebral flow was assessed using magnetic resonance imaging. Arterial blood gases and endothelium-derived vasoactive substances were assessed before cardiac arrest and 4 hours after the return of spontaneous circulation.... read more

Treatment with enhanced external counterpulsation improves cognitive functions in chronic heart failure patients.

Güliz Kozdağ, Pervin İşeri, Gökçen Gökçe, Gökhan Ertaş, Fatih Aygün, Ayşe Kutlu, Kathy Hebert, Dilek Ural., Türk Kardiyol Dern Arş - Arch Turk Soc Cardiol, 2013, 2013;41(5):418-428 doi: 10.5543/tkda.2013.24366. abstract
Treatment with enhanced external counterpulsation improves cognitive functions in chronic heart failure patients. Objectives: Chronic heart failure (CHF) has been associated with an increased risk of poorer cognitive performance in older adults. Reversibility of cognitive impairment after medical treatment has been reported, although the restorative effects of enhanced external counterpulsation (EECP) on cognitive performance have not been studied. We investigated the effect of EECP on cognitive functions in CHF patients. Study design: Thirty-six individuals (mean age: 66±8 years) who were diagnosed with CHF and were New York Heart Association (NYHA) Class II-III and Canadian Cardiovascular Society (CCS) Class II-III participated in this study. Neuropsychological assessment was performed in these patients. Results: Patients in the EECP treatment group showed a statistically significant improvement in spontaneous naming (p=0.011) and forward row score of the attention... read more

Are peripheral arterial changes during enhanced external counterpulsation necessary for and/or evidence of an adequate cardiovascular response?

Daniel Bia and Yanina Zo´ calo, Hypertension Research advance online publication, 2013, 24 January 2013; doi:10.1038/hr.2012.210. abstract
Are peripheral arterial changes during enhanced external counterpulsation necessary for and/or evidence of an adequate cardiovascular response? This is a commentary proposing that a noninvasive evaluation of arterial properties (i.e., arterial stiffness) and functional capabilities (i.e., endothelial function) could have a role in clinical practice in the context of EECP, particularly considering the value/accuracy of the parameters evaluated and that they can be obtained in an easy and quick way with relative low costs for the evaluation of the arterial system before and after EECP would potentially (a) contribute to the understanding of EECP working mechanisms and differences in patient’s capability to respond to the counterpulsation therapy, (b) add information to guide patient’s treatment (i.e., maximize the strategies aimed at modulating arterial load) and (c) aid in patient selection, particularly in those in whom with EECP indication... read more

The collateral circulation of the heart.

Pascal Meier, Stephan H Schirmer, Alexandra J Lansky, Adam Timmis, Bertram Pitt, Christian Seiler, BMC Medicine, 2013, 11:143 doi:10.1186/1741-7015-11-143. abstract
The collateral circulation of the heart. This is a review paper on collateral circulation stating that external counterpulsation is a therapeutic option to increase shear stress on endothelial cells. It has repeatedly been shown to reduce symptoms in patients with angina pectoris but the mechanism of action has remained unknown for years. The first controlled trial in a group of patients with coronary artery disease undergoing a 30-h program of high-pressure ECP (300 mmHg) and in a group undergoing sham ECP at 80 mmHg inflation pressure has demonstrated a relevant improvement of the collateral function (CFI) between baseline and follow-up at 4 weeks. ... read more

Therapeutic effects of Enhanced External Counter Pulsation (EECP) on clinical symptoms, echocardiographic measurements, perfusion scan parameters and exercise tolerance test in coronary artery disease patients with refractory angina

Eslamian F, Aslanabadi N, Mahmoudian B, Shakouri SK, Int J Med Sci Public Health, 2013, Online First: 24 Dec, 2012. doi:10.5455/ijmsph.2013.2.179-187Int J Med Sci Public Health. 2013; 2(2): 179-187. doi: 10.5455/ijmsph.2013.2.179-187 abstract
Therapeutic effects of Enhanced External Counter Pulsation (EECP) on clinical symptoms, echocardiographic measurements, perfusion scan parameters and exercise tolerance test in coronary artery disease patients with refractory angina Background: The purpose of this study was finding relationship between the therapeutic effects of Enhanced External Counterpulsation on treatment resistant angina among the patients, who are unsuitable for invasive interventions. Materials and methods: In an interventional study 50 patients (34 men and 16 women) under EECP therapy were investigated for one year. This machine is composed of three pairs of cuffs which work by attaching cuffs to lower limbs and it is contracted during diastole from distal to proximal and makes pressure to vessels of lower limbs. Treatment effects of EECP on clinical signs were evaluated on the base of Canadian cardiovascular society classification for angina severity, drugs consumption and SF36 quality of life questionnaire. Para clinical assessments including echocardiography,... read more

2012

Enhanced external counterpulsation in patients with refractory angina pectoris: a pilot study with six months follow-up regarding physical capacity and health-related quality of life

Wu E, Mårtensson J, Broström A, Eur J Cardiovasc Nurs, 2012, 2012 Dec 21. [Epub ahead of print] abstract
Enhanced external counterpulsation in patients with refractory angina pectoris: a pilot study with six months follow-up regarding physical capacity and health-related quality of life Background: Refractory angina pectoris (AP) is a persistent, painful condition characterized by angina caused by coronary insufficiency in the presence of coronary artery disease. It has been emphasized that there are possible underlying neuropathophysiological mechanisms for refractory AP but chronic ischemia is still considered to be the main problem. These patients suffer from severe AP and cannot be controlled by a combination of pharmacological therapies, angioplasty or coronary bypass surgery. AP has a negative impact on quality of life and daily life. Enhanced external counterpulsation (EECP) is a therapeutic option for these patients.Aims:The aim of this study was to evaluate EECP after six months regarding physical capacity and health-related quality of life (HRQoL) in patients with refractory AP.Methods:This was a... read more

Anti-inflammatory effects of enhanced external counterpulsation in subjects with abnormal glucose tolerance

Jeffrey S, Martin and Randy W. Braith, Appl. Physiol. Nutr. Metab, 2012, 2012;37:1-5 abstract
Anti-inflammatory effects of enhanced external counterpulsation in subjects with abnormal glucose tolerance Elevated markers of systemic inflammation are associated with impaired glucose and type 2 diabetes mellitus. Enhanced External Counterpulsation (EECP) has been shown to decrease circulating concentrations of pro-inflammatory markers in coronary artery disease patients. Here we provide novel evidence that EECP intervention also has a beneficial effect on circulating markers of systemic inflammation coincident with improvement in glycemic control in subjects with abnormal glucose tolerance. ... read more

Enhanced external counterpulsation creates acute blood flow patterns responsible for improved flow-mediated dilation in humans

Alvaro N Gurovich and Randy W Braith, Hypertension Research advance online publication, 2012, 18 October 2012; doi:10.1038/hr.2012.169 abstract
Enhanced external counterpulsation creates acute blood flow patterns responsible for improved flow-mediated dilation in humans Enhanced external counterpulsation (EECP) is a FDA-approved treatment for patients with coronary artery disease and unstable angina. Although beneficial effects of EECP have been linked to central/cardiac adaptations, recent findings have shown peripheral/vascular effects. Here, we sought to determine EECP-induced blood flow patterns and their association with vascular function. The present study was designed to investigate endothelium-mediated arterial vasodilation changes after one 45-min session of either EECP or Sham EECP in 18 randomly assigned apparently healthy, young men (25±4 years). Brachial (b) and femoral (f) flow-mediated dilation (FMD) were assessed before and within 10 min after completing EECP or Sham. After 20 min of EECP, peak blood flow velocity (V) and brachial and femoral artery diameters (D) were recorded live... read more

Cause or Effect of Arteriogenesis: Compositional Alterations of Microparticles from CAD Patients Undergoing External Counterpulsation Therapy

Al Kaabi A, Traupe T, Stutz M, Buchs N, Heller M, PLoS ONE, 2012, 7(10): e46822. doi:10.1371/journal.pone.0046822 abstract
Cause or Effect of Arteriogenesis: Compositional Alterations of Microparticles from CAD Patients Undergoing External Counterpulsation Therapy Recently, a clinical study on patients with stable coronary artery disease (CAD) showed that external counterpulsation therapy (ECP) at high (300 mmHg) but not at low inflation pressure (80 mmHg) promoted coronary collateral growth, most likely due to shear stress-induced arteriogenesis. The exact molecular mechanisms behind shear stress-induced arteriogenesis are still obscure. This paper characterized plasma levels of circulating microparticles (MPs) from these CAD patients because of their ambivalent nature as a known cardiovascular risk factor and as a promoter of neovascularization in the case of platelet-derived MPs. MPs positive for Annexin V and CD31CD41 were increased statistically significant (p<0.05, vs. baseline) only in patients receiving high inflation pressure ECP as determined by flow cytometry. MPs positive for CD62E, CD146,... read more

External Counterpulsation Augments Blood Pressure and Cerebral Flow Velocities in Ischemic Stroke Patients With Cerebral Intracranial Large Artery Occlusive Disease

Wenhua Lin, Li Xiong, Jinghao Han, Thomas Wai Hong Leung, Yannie Oi Yan Soo, Xiangyan Chen, Ka Sing Lawrence Wong, Stroke, 2012, 2012;43:00-00 abstract
External Counterpulsation Augments Blood Pressure and Cerebral Flow Velocities in Ischemic Stroke Patients With Cerebral Intracranial Large Artery Occlusive Disease Background and Purpose: External counterpulsation (ECP) is a novel noninvasive method used to improve the perfusion of vital organs, which may benefit ischemic stroke patients. We hypothesized that ECP may augment cerebral blood flow of ischemic stroke patients via induced hypertension. Methods: We recruited ischemic stroke patients with cerebral intracranial large artery occlusive disease and healthy elderly controls into this study. Bilateral middle cerebral arteries of subjects were monitored using transcranial Doppler. Flow velocity changes before, during, and after ECP were, respectively, recorded for 3 minutes while continuous beat-to-beat blood pressure data were recorded. Cerebral augmentation index was the increase in percentage of middle cerebral artery mean flow velocity during ECP compared with baseline. Transcranial Doppler data were analyzed based on... read more

Comparison of long term clinical outcomes, event free survival rates of patients undergoing enhanced external counterpulsation for coronary artery disease in the United States and Turkey.

Ozlem Soran, Coskun Ikizler, Atilla Sengui, Bilal Cuglan, Elizabeth Kennard, Sheryl Kelsey, Turk Kardiyol Dem Ars - Arch Turk Soc Cardiol, 2012, 0(4):323-330 abstract
Comparison of long term clinical outcomes, event free survival rates of patients undergoing enhanced external counterpulsation for coronary artery disease in the United States and Turkey. This study assessed the long-term efficacy of Enhanced External Counterpulsation (EECP) in Turkey (TR) patients initially and compared these results with the United States (US) in a real world setting. In this study, 2070 patients were treated and followed in the US and 82 patients were treated and followed in TR. The International EECP Patient Registry Phase I and II was initiated and coordinated at the University of Pittsburgh. The aim of the "registry" was to assess the outcomes of clinical trials in a real world setting. Another unique feature of this study was to enroll patients not only from university hospitals but also from private hospitals, educational hospitals, and treatment centers.TR patients had less diabetes, hypertension, and hyperlipidemia than... read more

Enhanced external counterpulsation: A novel therapy for angina.

Debra L Braverman, Complementary Therapies in Clinical Practice, 2012, 2012;1-7 abstract
Enhanced external counterpulsation: A novel therapy for angina. Improved pharmacological, invasive, and surgical therapies for cardiovascular diseases over the last few decades have led to an increase in life expectancy of individuals with angina. Despite treatment with multiple medications and invasive procedures, these patients remain symptomatic and functionally limited. Enhanced external counterpulsation (EECP) is a safe, noninvasive, well-tolerated, and clinically effective outpatient physical therapy for many patients with refractory angina. Numerous trials demonstrate positive clinical responses to EECP, including reductions in angina and nitrate use, increase in exercise tolerance, and enhanced quality of life. Several mechanisms are thought responsible for the clinical benefits of this therapy. Despite the marked success rates EECP achieves, the treatment remains largely unknown. This review will summarize the current evidence for the use... read more

Vasculoprotective properties of enhanced external counterpulsation for coronary artery disease: Beyond the hemodynamics.

Yang DY, Wu GF, International Journal of Cardiology, 2012, E pub ahead of print, published online 07 May 2012 abstract
Vasculoprotective properties of enhanced external counterpulsation for coronary artery disease: Beyond the hemodynamics. A growing pool of evidence has shown that enhanced external counterpulsation (EECP) is a non-invasive, safe, low-cost, and highly beneficial therapy for patients with coronary artery disease. However, the exact mechanisms of benefit exerted by EECP therapy remain only partially understood. The favorable hemodynamic effects of EECP were previously considered as the primary mechanism of action. Nevertheless, recent advances have shed light on the shear stress-increasing effects of EECP which are vasculoprotective and antiatherosclerotic. EECP-induced endothelial shear stress increase may lead to improvement in endothelial function and morphology, attenuation of oxidative stress and inflammation, and promotion of angiogenesis and vasculogenesis. This review summarizes evidence of the potential mechanisms contributing to the immediate and long-term benefits of EECP, from the perspective... read more

Clinical Effects of Enhanced External Counterpulsation Treatment in Patients with Ischemic Heart Failure.

Kozdağ G, Ertaş G, Aygün F, Emre E, Kırbaş A, Ural D, Soran O., Anadolu Kardiyol Derg, 2012, 2012 Mayıs 1; 12(3): Article in Press abstract
Clinical Effects of Enhanced External Counterpulsation Treatment in Patients with Ischemic Heart Failure. Objective: Enhanced external counterpulsation (EECP) is a noninvasive treatment that is proven safe and effective in patients with coronary artery disease (CAD) and heart failure (HF). The aims of this study are to investigate the clinical effects of EECP therapy in patients with symptomatic CAD and chronic HF, and to find out an answer to the question: Does EECP therapy have any effect on the prognostic markers of HF? Methods: This study was designed as a prospective cohort study. A total of 68 consecutive patients with symptomatic CAD and chronic HF referred to EECP therapy were enrolled in this study between November 2007 and December 2010; 47 patients (39 males and 8 females, 65±7 years) have undergone EECP treatment, and... read more

The Effect of Enhanced External Counterpulsation on C-reactive protein and flow-mediated dilation in porcine model of hypercholesterolaemia.

Yanqiu L, Yan X, Dongshong L, Chufan L, Yan Z, Wu G, Qiang X, Yugang D, Zhensheng Z., Clinical Physiology and Functional Imaging, 2012, 2012; 32 (4): 262–267 abstract
The Effect of Enhanced External Counterpulsation on C-reactive protein and flow-mediated dilation in porcine model of hypercholesterolaemia. Background: Lipid disorder causes vascular endothelial cell damage and contributes to the early development of dyslipidaemia-induced atherosclerosis. In vivo and in vitro, it has been found that increasing shear stress can improve endothelial function. Clinically, enhanced external counterpulsation (EECP) plays important roles in the treatment of coronary artery disease by promoting arterial shear stress. The present study aims to evaluate the effect of EECP on vascular endothelial function in porcine hypercholesterolemic model. Methods: Twenty-six hypercholesterolemic pigs were equally divided into EECP group (HC-EECP group) and control group (HC group). Shear stress of a right forearm superficial artery was measured during EECP in comparison with the basal physiological status in the HC-EECP group. Endothelial-dependent flow-mediated vasodilation (FMD) was applied to assess... read more

Enhanced External Counterpulsation Has No Lasting Effect on Ambulatory Blood Pressure

Ole May, Wael Abdulla Mohammed Khair, Clin Cardiol, 2012, 2012 DOI: 10.1002/cic.22045 abstract
Enhanced External Counterpulsation Has No Lasting Effect on Ambulatory Blood Pressure Background: Enhanced external counterpulsation (EECP) has been reported to reduce blood pressure (BP) using clinic BP readings. The aim of this study was to assess the effect of a course of EECP on BP using ambulatory BP (ABP) measurements. Hypothesis: EECP has a lasting BP lowering effect. Methods: Patients referred for EECP due to refractory angina pectoris were consecutively included in the study. The ABPs were measured for 24 hours using a Spacelabs Ultralite 90217 device at 5 time points during the study period: 2 months before the EECP course, just before the EECP course, just after the EECP course, and at 3 and 12 months after EECP. Antihypertensive medication was held constant during the study period. Changes in BP... read more

The Immediate Hemodynamic Effects of Enhanced External Counterpulsation on the Left Ventricular Function

Eftekhari A, May O., Scandinavian Cardiovascular Journal, 2012, 2012; 46 (2): 81-86 abstract
The Immediate Hemodynamic Effects of Enhanced External Counterpulsation on the Left Ventricular Function Objectives: Enhanced external counterpulsation (EECP) is a non-invasive therapy with long-term anti-anginal effects offered to patients with refractory angina pectoris. The purpose of the present study was to investigate the effect of EECP on myocardial contractility measured as global longitudinal strain (GLS) during EECP treatment. Design: Patients with known refractory angina were enrolled by invitation and underwent 1 h of EECP treatment. Two-dimensional echocardiography and Doppler echocardiography were performed before and during EECP treatment with 15-minute intervals. The peak diastolic/systolic blood pressure ratio (D/S ratio) was monitored with finger plethysmography. GLS was assessed offline with speckle-tracking software (EchoPAC GE Healthcare USA). Results: Twenty patients were included (mean age 65.0 ± 8.2; 85% males). During EECP treatment, the systolic function of... read more

The therapeutic effects of enhanced external counterpulsation on refractory angina in patients, unsuitable for invasive interventions

Aslan Abadi Naser, Salehi Rezvaneyeh, Alizadeh Azin, Eslamityan Fariba, Ahmadzadeh Pournaky Ahmad, Tsban Sadeghi Mohamad Reza, The J of Urmia University of Medical Sciences, 2012, 2012;April-May, 23(1):7-14 abstract
The therapeutic effects of enhanced external counterpulsation on refractory angina in patients, unsuitable for invasive interventions Background & Aims: Enhanced external counterpulsation (EECP) is a non-invasive outpatient treatment used for angina pectoris. In patients with intractable angina who were symptomatic after medical and invasive strategies, several novel techniques are considered including EECP. In patients with refractory angina due to coronary anatomy specific information, CABG or PCI are also up despite anti-ischemic drug therapy are still symptomatic, other treatments including EECP is used. EECP produces an acute hemodynamic effect that is presumed to be similar to that produced by the invasive intra-aortic balloon pump: By applying a series of compressive cuffs sequentially from the calves to the thigh muscles upon diastole and rapidly deflating the cuffs in early systole, an increase in diastolic and decrease in systolic... read more

Pulsatile venous waveform quality in Fontan circulation - clinical implications, venous assists options and the future

Ergin Kocyildirim, Onur Dur, Ozlem Soran, Egemen Tuzun, Matthew W Miller, Greggory J Housler, Peter D Wearden, Theresa W Fossum, Victor O Morell, Kerem Pekkan, Anadolu Kardiyol Derg, 2012, 2012;12(5) abstract
Pulsatile venous waveform quality in Fontan circulation - clinical implications, venous assists options and the future Objective: Functionally univentricular heart (FUH) anomalies are the leading cause of death from all structural birth defects. Total cavopulmonary connection (TCPC) is the last stage of the palliative surgical reconstruction with significant late hemodynamic complications requiring high-risk heart transplantation. Alternative therapeutic options for these critically ill patients are crucial. In Phase I, we investigated the effect of pulsatility of venous flow (VF) waveform on the performance of functional and “failing” Fontan (FF) patients based on conduit power loss. In phase 2, the effect of enhanced external counter pulsation on Fontan circulation flow rates is monitored. Methods: In phase 1, Doppler VFs were acquired from FF patients with ventricle dysfunction. Using computational fluid dynamics (CFD), hemodynamic efficiencies of the FF, functional... read more

The Effects of Enhanced External Counterpulsation on Health-related Quality of Life in Patients with Angina Pectoris

Ziaeirad M, Ziaei GR, Sadeghi N, Motaghi M, Torkan B, Iranian Journal of Nursing and Midwifery Research, 2012, 2012:17(1):1-7 abstract
The Effects of Enhanced External Counterpulsation on Health-related Quality of Life in Patients with Angina Pectoris Background: The complicated concept of quality of life (QOL) has been considered as an important criterion for health outcomes in chronic diseases, such as heart disease, in recent years. The aim of this study was to evaluate the QOL of patients with angina pectoris after treatment with enhanced external counterpulsation (EECP). Methods: This quasi-experimental study was conducted on 64 patients with angina pectoris undergoing EECP who came to Shahid Chamran and Sina Hospitals in Isfahan. Sampling was performed by the convenient method. Data were collected using a questionnaire containing socio-demographic and clinical data. A standard questionnaire called 36-item Short-Form Health Survey was also used. Questionnaires were completed through interviews and phone calls in three stages (before, immediately and three months... read more

2011

Effect of enhanced external counterpulsation treatment on mean platelet volume in patients affected by ischemic chronic heart failure

Gokhan Ertas¸ Guliz Kozdag, Ender Emre, Yas¸ar Akay, Dilek Ural and Kathy Hebert, Blood Coagul Fibrinolysis, 2011, 2011; 22 abstract
Effect of enhanced external counterpulsation treatment on mean platelet volume in patients affected by ischemic chronic heart failure Mean platelet volume (MPV) is increased in chronic heart failure (CHF) and is an independent predictor of mortality in CHF patients. It is not known whether enhanced external counterpulsation (EECP) therapy leads to decrease MPV values or not. The purpose of this study was to examine the effects of EECP on platelet count and MPV values and to assess the influence of MPV on the risk of death and recurrent ischemic events in ischemic CHF patients. A total of 68 ischemic heart failure patients with CHF symptoms and refractory angina pectoris were included in the study, 47 consecutive patients (39 males and eight females) aged 44–82 years. Although follow-up period started after completion of EECP in treated patients, control group... read more

Enhanced External Counterpulsation (EECP) Improves Peripheral Artery Function and Glucose Tolerance in Subjects with Abnormal Glucose Tolerance

Martin JS, Beck DT, Aranda Jr. JM, and Braith, RW, J Appl Physiol, 2011, (December 22, 2011). doi:10.1152/japplphysiol.01336.2011 abstract
Enhanced External Counterpulsation (EECP) Improves Peripheral Artery Function and Glucose Tolerance in Subjects with Abnormal Glucose Tolerance In coronary artery disease patients, enhanced external counterpulsation (EECP) improves peripheral arterial function and nitric oxide (NO) bioavailability, which have been implicated in the pathogenesis of abnormal glucose tolerance (AGT). We sought to evaluate the effects of EECP on outcomes of arterial function, glucose tolerance, and skeletal muscle morphology in subjects with AGT. Methods and Results - Eighteen subjects with AGT were randomly (2:1 ratio) assigned to receive 34 either 7 weeks (35 1-hour sessions) of EECP (n = 12) or 7-weeks of standard care (control; n=6). Peripheral vascular function, biochemical assays, glucose tolerance, and skeletal muscle morphology were evaluated before and after EECP or control. EECP increased normalized brachial artery (27%) and popliteal artery (52%) flow-mediated dilation. Plasma nitrite/nitrate... read more

Effect of enhanced external counterpulsation on C-reactive protein and interlukin-6 in patients with coronary heart disease

WEI Hai-zhu, Hainan, China Hainan Medical J., 2011, 2011; 22(3):56-57 abstract
Effect of enhanced external counterpulsation on C-reactive protein and interlukin-6 in patients with coronary heart disease To investigate the effect of enhanced external counter pulsation (EECP) on reactive protein (CRP) and interlukin-6 (IL-6) in patients with coronary heart disease (CHD) and its mechanism. Methods: The serum level of reactive protein (CRP) and interlukin-6 (IL-6) in 80 cases with CHD and 20 normal controls were tested. Patients were divided into EECP group (40 cases) and medication group (40 cases). The serum concentrations of CRP and IL-6 in each group, before and after treatment were assessed and compared for the correlation analysis. Results: After 6 weeks and 3 courses EECP treatment, compared with the levels before treatment, the serum levels of CRP and IL- 6 in patients with CHD, EECP group were lower significantly (P<0.05). Conclusion: EECP treatment... read more

Reduced peripheral vascular reactivity in refractory angina pectoris: Effect of enhanced external counterpulsation

Susanne M Bondesson, Marie-Louise Edvinsson, Thomas Pettersson, Lars Edvinsson, Journal of Geriatric Cardiology, 2011, 2011; 8: 215−223. doi: 10.3724/SP.J.1263.2011.00215 abstract
Reduced peripheral vascular reactivity in refractory angina pectoris: Effect of enhanced external counterpulsation Objective - To examine if the skin microvascular bed is altered and can be modified by enhanced external counterpulsation (EECP) in patients with chronic refractory angina. Methods - Twenty patients diagnosed with refractory angina were divided into EECP (n = 10) or no EECP (n = 10) groups. The data were compared to matched healthy subjects (n = 20). The cutaneous forearm microvascular blood flow was measured by Laser-Doppler flowmetry. The vascular responsiveness to iontophoretic administration of acetylcholine (ACh), sodium nitroprusside (SNP) and local skin warming were studied. Measurements of Canadian Cardiovascular Society (CCS)-class, blood pressure and plasma samples were registered. Results - EECP patients showed reduced CCS-class compared to no EECP (P < 0.05). Both EECP and no EECP... read more

Microvascular response to metabolic and pressure challenge in the human coronary circulation

Stefano F. de Marchi, Steffen Gloekler, Stefano F. Rimoldi, Patrizia Rölli, Hélène Steck and Christian Seiler, Am J Physiol Heart Circ Physiol, 2011, 2011; 301:H434-H44 abstract
Microvascular response to metabolic and pressure challenge in the human coronary circulation Background - In vivo observations of microcirculatory behavior during autoregulation and adaptation to varying myocardial oxygen demand are scarce in the human coronary system. This study assessed microvascular reactions to controlled metabolic and pressure provocation (bicycle exercise and external counterpulsation (ECP). Method - In 20 healthy subjects, quantitative myocardial contrast echocardiography and arterial applanation tonometry were performed during increasing ECP levels, as well as before and during bicycle exercise. Myocardial blood flow (MBF; ml•min−1•g−1), the relative blood volume (rBV; ml/ml), the coronary vascular resistance index (CVRI; dyn•s•cm−5/g), the pressure-work index (PWI), and the pressure-rate product (mmHg/min) were assessed. Results - MBF remained unchanged during ECP (1.08 ± 0.44 at baseline to 0.92 ± 0.38 at high-level ECP). Bicycle exercise led... read more

Hospital utilization and costs for spinal cord stimulation compared with enhanced external counterpulsation for refractory angina pectoris

Susanne M. Bondesson, Ulf Jakobsson, Lars Edvinsson and Ingalill Rahm Hallberg, Journal of Evaluation in Clinical Practice, 2011, 2011 Epub 31 Oct: ISSN 1365-2753 abstract
Hospital utilization and costs for spinal cord stimulation compared with enhanced external counterpulsation for refractory angina pectoris Aims - The aim of this study was to compare acute hospital utilization and costs for patients with refractory angina pectoris undergoing spinal cord stimulation (SCS) versus enhanced external counterpulsation (EECP). Method - Seventy-three persons were included in this register study. The acute hospital utilization and costs for SCS and EECP were followed over a period from 12 months before treatment to 24 months after treatment using Patient Administrative Support in Skåne for publicly organized care. Results - SCS was significantly more expensive than EECP (p< 0.001). Both SCS and EECP entailed fewer days of hospitalization for coronary artery disease in the 12-month follow-up compared with the 12 months preceding treatment. Patients treated with EECP showed an association between reduced... read more

Enhanced External Counterpulsation Improves Endothelial Function, Inflammatory Markers and Depression

Deepak Hooda, Ravindra Bhardwaj, Wissam Gharib, Bradford E. Warden, Robert Beto, Abnash C. Jain, ACC 60th Annual Scientific Session, Best Fellows-In-Training Poster Awards. J Am Coll Cardiol, 2011, 2011; 57(14) abstract
Enhanced External Counterpulsation Improves Endothelial Function, Inflammatory Markers and Depression Background - Endothelial dysfunction is the earliest and most important factor in the pathogenesis of atherosclerosis. Inflammation has been shown to contribute to endothelial dysfunction. EECP has been shown to improve endothelial function besides symptomatic benefit in patients with refractory angina. In this patient population, depression has an unfavorable impact on mortality. We evaluated the effect of EECP on endothelial function, inflammatory markers of atherosclerosis and depression. Methods - Eight subjects (88%-male) were enrolled in EECP and four matched controls participated in the study. Endothelial dependent brachial artery flow mediated dilatation (FMD) was assessed, inflammatory markers were measured and the psychological effect of EECP was analyzed using Beck’s-Depression-Scale before and after EECP. Results - The EECP group had a significant... read more

Effects of Enhanced External Counterpulsation on Arterial Stiffness and Myocardial Oxygen Demand in Patients With Chronic Angina Pectoris

Darren P. Casey, Darren T. Beck, Wilmer W. Nichols, C. Richard Conti, Calvin Y. Choi, Matheen A. Khuddus, and Randy W. Braith., Am J Cardiol, 2011, 2011;107(10):1466-1472 abstract
Effects of Enhanced External Counterpulsation on Arterial Stiffness and Myocardial Oxygen Demand in Patients With Chronic Angina Pectoris Enhanced external counterpulsation (EECP) is a noninvasive technique for treatment of symptomatic coronary artery disease in patients not amenable to revascularization procedures. However, the mechanisms underlying the benefits of EECP remain unknown. We hypothesized that decreases in arterial stiffness and aortic wave reflection are a therapeutic target for EECP. Patients with coronary artery disease and chronic angina pectoris were randomized (2:1 ratio) to 35 1-hour sessions of EECP (n=28) or sham EECP (n=14). Central and peripheral arterial pulse-wave velocity and aortic wave reflection (augmentation index) were measured using applanation tonometry before, and after 17 and 35 1-hour treatment sessions. Wasted left ventricular pressure energy and aortic systolic tension–time index, markers of left-ventricular myocardial oxygen demand, were derived from the synthesized... read more

Clinical Response of Enhanced External Counter Pulsation (EECP) Among Bangladeshi Ischemic Heart Disease Patients

Kmhs Sirajul Haque, Jabed Iqbal, Mahmudur Rahman Siddiqui, Khondaker Syedus Salehin, University Heart Journal, 2011, 2011 January Vol. 7, No. 1, 19-22 abstract
Clinical Response of Enhanced External Counter Pulsation (EECP) Among Bangladeshi Ischemic Heart Disease Patients EECP is used to stabilize the coronary circulation in patients with severe coronary artery disease when maximal medical therapy and/or invasive procedures have proven inadequate. This prospective observational study was done for a period of 12 months. 40 patients with angina and angiographically proven coronary artery disease, who met the inclusion and exclusion criteria was enrolled in this study. Among 40 enrolled patients 30 (70%) patients completed their treatment. All the patients were in between 42 to 80 years age group. All patients required sublingual nitrate before started EECP treatment. But after completion of treatment, 75% patient required no nitrates. Who completed full course, 100% were improved their angina symptoms from class II, III, IV to class I. Overall 80%... read more

The Effects of Enhanced External Counterpulsation on Cardiac Electrophysiologic Properties of Patients with Ischemic Heart Disease and Refractory Angina at Function Class II-III

Fariborz Akbarzadeh, Yaghoub Salekzamani, Amir Shahram Beigzdeh, Journal of Cardiovascular and Thoracic Research, 2011, 2011; 3 (2): 49- 51 abstract
The Effects of Enhanced External Counterpulsation on Cardiac Electrophysiologic Properties of Patients with Ischemic Heart Disease and Refractory Angina at Function Class II-III Enhanced external counterpulsation (EECP) is a noninvasive circulatory assist device that has been recently emerged as a treatment option for refractory angina or left ventricular (LV) dysfunction. The aims of this study were to examine the effects of EECP on the elecrocardiographic parameters and the heart rate variability indices of patients with the coronary heart disease and function class II-III angina resistant to medication. In a descriptive study, the patients who presented with sever angina at function class II-III were studied. Those meeting the inclusion criteria were invited to participate and provided informed consent. The standard enhanced external counterpulsation treatment (35 one-hour procedures 5-6 times a week) was done. Thirty minute ambulatory electrocardiographic monitoring and electrocardiogram before starting and at... read more

2010

Enhanced External Counter Pulsation (EECP) for Refractory Angina Pectoris (RAP); Results from a first case series

Waqas Ahmed, Naveed Akhter, Ayesha Masood, J Pak Med Assoc, 2010, 2010, Vol. 60, No. 8 :692-694 abstract
Enhanced External Counter Pulsation (EECP) for Refractory Angina Pectoris (RAP); Results from a first case series Enhanced External Counterpulsation (EECP) has emerged as a promising non-invasive modality not only for patients with refractory angina pectoris (RAP) but also for patients with heart failure. To our knowledge, no published data exists in Pakistan about the benefits of EECP. We report on a case series of 16 consecutive patients undergoing EECP. All patients were either deemed not to be candidates for revascularization or had failed revascularization with RAP on optimal medical therapy. Data was collected regarding the coronary anatomy, clinical presentation, Pre and Post EECP Canadian Cardiovascular Society (CCS) class, nitrate use and 6-min walk test. Patients with severe peripheral vascular disease and arrhythmias were excluded. The mean age was 56 ± 11.1 years. Eight patients had 3-vessel... read more

Effects on blood pressure in patients with refractory angina pectoris after enhanced external counterpulsation

Susanne Bondesson , Thomas Pettersson , Ola Ohlsson , Ingalillr Hallberg , Angelica Wackenfors & Larsedvinsson, Blood Pressure, 2010, 2010; 19: 287–294 abstract
Effects on blood pressure in patients with refractory angina pectoris after enhanced external counterpulsation Objective - Enhanced external counterpulsation (EECP) is a non-invasive technique that has been shown to reduce the frequency and severity of angina pectoris. Little is known how EECP affects the blood pressure. Methods - 153 patients with refractory angina were treated with either EECP or retained on their pharmacological treatment (reference group). Systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial blood pressure (MAP) and heart rate were measured pre- and post-treatment and at 12 months follow-up. Results - EECP treatment altered the blood pressure in patients with refractory angina pectoris. A decrease in the blood pressure was more common in the EECP group compared with the reference group. In the reference group, an increase in the blood pressure... read more

Enhanced External Counterpulsation - A Review

Sayami LA, Ullah M, Rahman MT, Rahman Z, Roy D, Majumder AAS, Cardiovascular Journal, 2010, 2010;2(2):236-244 abstract
Enhanced External Counterpulsation - A Review This is a review of current EECP status by a group in Bangladesh summarizing the historical background, principle of operation, and hemodynamics and its effects on endothelial function. Opening of collateral channels in the coronary vascular system after EECP treatment is presumed to be the mechanism to produce sustained benefit lasting several years. EECP is effective in treating refractory angina pectoris as demonstrated by the results of the randomized double blind, sham control multicenter study of EECP (MUST-EECP), and confirmed by the results from the International EECP Patients Registry (IEPR) which enrolled more than 7,500 patients in more than 100 international centers. Because EECP increases right ventricular filling pressure by augmenting venous returns during diastole, its use in patients with... read more

Does External Counterpulsation Augment Mean Cerebral Blood Flow in the Healthy Brain? Effects of External Counterpulsation on Middle Cerebral Artery Flow Velocity and Cerebr

Jungehuelsing GJ, Liman TG, Brunecker P, Ebel A, Endres M, Buschmann I, Pagonas N, Buschmann, Cerebrovascular Diseases, 2010, 2010;30:612-617 abstract
Does External Counterpulsation Augment Mean Cerebral Blood Flow in the Healthy Brain? Effects of External Counterpulsation on Middle Cerebral Artery Flow Velocity and Cerebr Background and Purpose: External counterpulsation (ECP) noninvasively improves myocardial and organ perfusion via diastolic augmentation. The effects on cerebral blood flow velocities (CBFV) and hemodynamics are controversial. In this study, the effect of active ECP treatment on CBF in healthy subjects was continuously measured. Methods: In 9 healthy volunteers (mean age 34.1± 8 11.1 years, 4 females), 20-min active ECP treatment was performed. CBFV in the middle cerebral artery were detected via transcranial Doppler. CBFV were registered continuously before, during and after ECP. The protocol was repeated twice. Results: At onset of ECP, immediate changes in CBFV were observed: peak diastolic blood flow velocities increased from baseline to treatment (63 vs. 76 cm/s; p≤ 0.001) and diastolic blood flow augmentation... read more

Enhanced External Counterpulsation Improves Peripheral Artery Flow-Mediated Dilation in Patients with Chronic Angina. A Randomized Sham-Controlled Study

Braith RW, Conti CR, Nichols WW, Choi CY, Khuddus MA, Beck DT, Casey DP, Circulation, 2010, 2010; 122:1612-1620 abstract
Enhanced External Counterpulsation Improves Peripheral Artery Flow-Mediated Dilation in Patients with Chronic Angina. A Randomized Sham-Controlled Study Background: Mechanisms responsible for anti-ischemic benefits of enhanced external counterpulsation (EECP) remain unknown. This was the first randomized sham-controlled study to investigate the extracardiac effects of EECP on peripheral artery flow-mediated dilation. Methods and Results: Forty-two symptomatic patients with coronary artery disease were randomized (2:1 ratio) to thirty-five1-hour sessions of either EECP (n=28) or sham EECP (n=14). Flow-mediated dilation of the brachial and femoral arteries was performed with the use of ultrasound. Plasma levels of nitrate and nitrite, 6-keto-prostaglandin F1α, endothelin-1, asymmetrical dimethylarginine, tumor necrosis factor-α, monocyte chemoattractant protein-1, soluble vascular cell adhesion molecule, high-sensitivity C-reactive protein, and 8-isoprostane were measured. EECP increased brachial (+51% versus +2%) and femoral (+30% versus +3%) artery flow-mediated dilation, the nitric oxide turnover/production markers... read more

Toxic shock syndrome: A rare complication to enhanced external counterpulsation

PG Jgrgensen, J Lindberg, O May, Can J Cardiol, 2010, 2010;26( l0) ¡e35 l.e3 52 abstract
Toxic shock syndrome: A rare complication to enhanced external counterpulsation A case with a previously unknown complication - toxic shock syndrome (TSS) that occurred twice in an EECP treated patient is described. A 64-year-old rnan with a long history of ischemic heart disease was admitted with a rapid onset of fever, confusion and hypotension. On admission, his blood pressure was 100/65 mrn Hg, but soon dropped to 75/40 mm Hg in spite of fluid replacement. Broad-spectrum antibiotics and vasopressor therapy were started, and the blood pressure normalized. Septic shock was suspected and the patient. On the fourth day of admission, TSS was diagnosed and clindamycin was added to the antibiotic regimen. The symptoms prompting hospitalization started 12 h after the first session in a planned EECP course. After a few... read more

Effect of Enhanced External Counterpulsation on Circulating CD34+ Progenitor Cell Subsets

Kiernan TJ, Boilson BA, Tesmer L, Harbuzariu A, Simari RD, Barsness GW, Int J Cardiol, 2010, 2010, doi 10.1016/j.ijcard.2010.08.020 abstract
Effect of Enhanced External Counterpulsation on Circulating CD34+ Progenitor Cell Subsets Background: Enhanced external counterpulsation (EECP) is associated with improvement in endothelial function, angina and quality of life in patients with symptomatic coronary artery disease, although the mechanisms underlying the observed clinical benefits are not completely clear. The purpose of this study was to examine the effects of EECP on circulating haematopoietic progenitor cells (HPCs) and endothelial progenitor cells (EPCs) in patients with refractory angina. We compared HPC and EPC counts between patients scheduled for EECP and patients with normal angiographic coronary arteries, with and without coronary endothelial dysfunction. We hypothesized that an increase in circulating bone marrow derived progenitor cells in response to EECP may be part of the mechanism of action of EECP. Methods: Thirteen consecutive patients scheduled to... read more

Acute Hemodynamic Effects of Enhanced External Counterpulsation

Reddy BT, Michaels AD, Journal of Geriatric Cardiology, 2010, June 2010 Vol 7, No. 2, 67-73 abstract
Acute Hemodynamic Effects of Enhanced External Counterpulsation This is a review paper on the hemodynamic effects during EECP with comparison to intra-aortic balloon pump (IABP) whenever possible. Early external counterpulsation (ECP) using hydraulic activator with single chamber water filled leg compression bags failed to produce effective systolic unloading, increased oxygen consumption, whereas IABP lower systolic pressure, lower oxygen consumption. The acute hemodynamic effects of the improved design pneumatic-driven sequential inflation EECP have been assessed by various authors both noninvasively by finger plethysmography, thoracic electrical bioimpedance, echocardiography, and radial tonometry as well as invasively by right heart catheterization, radial artery catheterization, intracoronary pressure and Doppler flow, and simultaneous right and left heart catheterization. In patients with uncomplicated acute myocardial infarction, Taguchi et al (see 2000 synopses) demonstrated the... read more

The Four Stages of Development: A Historical Perspective of External Counterpulsation

Hui JCK, Zheng ZS, Journal of Geriatric Cardiology, 2010, June 2010 Vol 7, No. 2, 74-78 abstract
The Four Stages of Development: A Historical Perspective of External Counterpulsation There are four stages of EECP development. Phase 1 Physiological concepts and innovation idea: EECP starts with two ideas: Kantrowitz and Kantrowitz first described the principle of diastolic augmentation (DA) to increase coronary blood flow in 1953 and Sarnoff and colleagues described that myocardial workload is proportional to the pressure generated by the left ventricular and its contraction time. Then in 1957 Birtwell proposed to design a device that can synthesize the two concepts. Phase 2 Technical development, from concept to design: in 1963 Soroff and coworkers described an actuator with a chamber to receive arterial blood via a cannulation of the descending aorta to withdraw a volume of blood during systole and returning the blood during diastole. Then in... read more

EECP in the Treatment of Endothelial Dysfunction: Preventing Progression of Cardiovascular Disease

Hui JCK, Lawson WE, Barsness GW, Journal of Geriatric Cardiology, 2010, June 2010 Vol 7, No. 2, 79-87 abstract
EECP in the Treatment of Endothelial Dysfunction: Preventing Progression of Cardiovascular Disease The link between risk factors leading eventually cardiovascular disease including heart failure is endothelial dysfunction. EECP increases velocity of blood flow and shear stress acting on the endothelial cells, stimulating release of endothelial nitric oxide synthase (eNOs), increases release of vasodilator nitric oxide (NO) and suppresses vasoconstrictor endothelin E-1, thereby improving flow mediated vasodilatation, a measure of endothelial function. EECP also lowers arterial stiffness, systolic and pulse pressure leading to reduction of cardiac workload and myocardial oxygen demand. It has been documented EECP also stimulates endothelium to release vascular endothelial growth factor (VEGF), and together with the mechanical pressure gradient generated during EECP, promotes coronary collateral flow index, coronary fractional flow reserve and reduces microcirculatory resistance. EECP also decreases circulating... read more

Role of External Counterpulsation in the Treatment of Ischemic Stroke

Han JH, Leung WH, Wong KS, Journal of Geriatric Cardiology, 2010, June 2010 Vol 7, No. 2, 88-92 abstract
Role of External Counterpulsation in the Treatment of Ischemic Stroke There is accumulating evidence that ECP therapy may improve cerebral blood flow (CBF). A study showed that the mean carotid flow velocity integral increased by 22% during ECP, with an average peak carotid diastolic flow velocity of 56 cm/sec, which is 75% as high as the systolic wave. There were two randomized controlled studies demonstrated ECP improved the average CBF from 45.7±6.0 ml/100 g/min to 55.6±6.0 ml/100 g/min in the ECP treated group, whereas no significant change was found in the control group; and a second study with 29 (72.5%) patients in the ECP group versus 22(55%) patients in the control group had a favorable clinical outcome. Studies also have shown a significant decrease in hematocrit, fibrinogen level and plasma... read more

Enhanced External Counter Pulsation for Refractory Angina Pectoris; Results from a first case series

Ahmed, W, Akhter N, Masood, A, Journal of Pakistan Medical Association, 2010, 2010: 60:8; 692-694 abstract
Enhanced External Counter Pulsation for Refractory Angina Pectoris; Results from a first case series Enhanced External Counterpulsation (EECP) has emerged as a promising non-invasive modality not only for patients with refractory angina pectoris (RAP) but also for patients with heart failure. To our knowledge, no published data exists in Pakistan about the benefits of EECP. We report on a case series of 16 consecutive patients undergoing EECP. All patients were either deemed not to be candidates for revascularization or had failed revascularization with RAP on optimal medical therapy. Data was collected regarding the coronary anatomy, clinical presentation, Pre and Post EECP Canadian Cardiovascular Society (CCS) class, nitrate use and 6-min walk test. Patients with severe peripheral vascular disease and arrhythmias were excluded. The mean age was 56 ± 11.1 years. Eight patients had 3-vessel... read more

Impact of Enhanced External Counterpulsation on Canadian Cardiovascular Society Angina Class in Patients with Chronic Stable Angina: A Meta-analysis

Shah SA, Shapiro RJ, Mehta R, Snyder JA, Pharmacotherapy, 2010, 2010: 30: 7; 639-645 abstract
Impact of Enhanced External Counterpulsation on Canadian Cardiovascular Society Angina Class in Patients with Chronic Stable Angina: A Meta-analysis Objective: To evaluate the true magnitude of benefit from enhanced external counterpulsation (EECP) by determining the effect of EECP on Canadian Cardiovascular Society (CCS) angina class in patients with chronic stable angina. Design: Meta-analysis of 13 prospective studies that evaluated patients with stable angina and reported adequate data on CCS angina class. Patients: A total of 949 adult patients with stable angina who underwent EECP treatment. Measurements and Main Results: A systematic literature search of studies published between 1950 and February 2009 was performed. Studies were included for meta-analysis if they were reported in the English language, included human subjects, had a prospective study design, and reported adequate data on CCS angina class. The EECP treatment consisted of 35 sessions-1... read more

Enhanced External Counterpulsation (EECP) Therapy: Current Evidence For Clinical Practice And Who Will Benefit?

Prasad GN, Ramasamy S, M.Thomas JM, Nayar PG, Sankar MN, Sivakadaksham N, Cherian KM, Indian Heart J., 2010, 2010; 62:296-30 abstract
Enhanced External Counterpulsation (EECP) Therapy: Current Evidence For Clinical Practice And Who Will Benefit? This is a review paper by a group of Indian EECP physicians documenting the mechanism of action and clinical outcome in patients with refractory angina and heart failure. Specifically this review provides a list of patients who will benefit from EECP: patients whom PTCA or CABG is not contemplated, patients with ischemic or idiopathic cardiomyopathy and patients with cardiac syndrome X (microvascular angina). This review also outlines some interesting papers published in India which reconfirm the improvement in myocardial perfusion and improvement in LV ejection fraction in the Indian population. These effects were seen in both patients with refractory angina and ischemic Cardiomyopathy. The data from the Indian patient EECP registry which tracks both the subjective and objective improvements shown... read more

Prinzmetal’s Variant Angina is Effectively Treated with Enhanced External Counterpulsation

Tarpgaard Jorgensen M, Gerdes C, May O., Acta Cardiology, 2010, 2010;65(2):265-267 abstract
Prinzmetal’s Variant Angina is Effectively Treated with Enhanced External Counterpulsation This is a case report of a 57-year-old woman admitted to the local hospital due to chest pain in 2001. Coronary angiography (CA) showed proximal subocclusion of the first diagonal branch (D1), significant stenosis in the LAD. Percutaneous coronary intervention (PCI) without stent was performed on D1 and a bare metal stent on the LAD. In the following two years, patient was admitted frequently due to chest pain in spite of normal perfusion, biochemical markers and optimal medications including beta-blockers, Ca antagonists, nitrates, ACE-inhibitors and statins. Several CA were performed showing no occlusion. It was concluded that patent suffered from Prinzmetal’s angina and beta-blockers were withdrawn. Despite optimal medical therapy, the patient was admitted numerous times with chest pain and... read more

Enhanced External Counterpulsation: Mechanisms of Action and Clinical Applications

Kitsou V, Xanthos T, Roberts R, Karlis G, Padadimitriou L, Acta Cardiology, 2010, 2010;65(2):239-247 abstract
Enhanced External Counterpulsation: Mechanisms of Action and Clinical Applications Symptomatic coronary artery disease (CAD) and heart failure (HF), either of ischemic or nonischemic etiology¡ are common medical problems. Despite optimal medical treatment and improved revascularization techniques, a significant number of patients are not successfully managed. Among the non-pharmacological, alternative, non-invasive treatments suggested for these patients, enhanced external counterpulsation (EECP) is considered the most effective one. EECP administered in an outpatient setting, consists of three pneumatic cuffs applied to each of the patient's legs that are sequentially inflated and deflated synchronized with the cardiac cycle. Numerous clinical trials have shown that EECP is safe and effective in patients with ischemic heart disease, with or without left ventricular dysfunction, improving their quality of life, EECP appears to be beneficial as an... read more

Enhanced External Counterpulsation Attenuates Atherosclerosis Progression Through Modulation of Proinflammatory Signal Pathway

Zhang Y, He X, Liu D, Wu G, Chen X, Ma H, Du Z, Dong Y, Jin Y, He W, Wang K, Lawson WE, Hui JCK, and Zheng Z, Arterioscler Thromb Vasc Biol, 2010, 2010;30;773-780; originally published online Feb 11,2010 abstract
Enhanced External Counterpulsation Attenuates Atherosclerosis Progression Through Modulation of Proinflammatory Signal Pathway Objective: Shear stress may be the most crucial local factor affecting atherogenesis. The present study investigated the effect of exposure to increased shear stress promoted by enhanced external counterpulsation (EECP) on the progression of atherosclerosis and the underlying inflammation-related molecular mechanisms in a porcine model of hypercholesterolemia. Methods and Results: Hypercholesterolemic pigs were subjected to a 7-week EECP intervention while being fed a high-cholesterol diet. EECP resulted in a 34.38% increase of mean wall shear stress and a significantly lower pulsatility index in the brachial artery. The animals receiving EECP showed a marked reduction in atherosclerotic lesion size in the coronary artery and abdominal aorta compared with the hypercholesterolemic control group, associated with a decrease in macrophage accumulation. The expression... read more

Enhanced External Counterpulsation and Traction Therapy Ameliorates Rotational Vertebral Artery Flow Insufficiency Resulting from Cervical Spondylosis

Wang X, Guo F, Wang H, Xie J, Wang S, Zhao Y, Li X, Spine, 2010, 2010: 35(15):1415-1422 abstract
Enhanced External Counterpulsation and Traction Therapy Ameliorates Rotational Vertebral Artery Flow Insufficiency Resulting from Cervical Spondylosis Study Design: Clinical trial of patients with rotational vertebrobasilar insufficiency (VBI) resulting from cervical spondylosis. Objective: To investigate the effectiveness of enhanced external counterpulsation (EECP) and traction therapy for these patients. Summary of Background Data: EECP would reduce arterial stiffness and vascular resistance, and increase regional blood flow of vertebral arteries, thus may ameliorate symptoms in these patients. Methods: One hundred sixty-three patients who were clinically suspected rotational VBI caused by cervical spondylosis were enrolled in this study. They were randomly allocated into 3 groups: EECP + traction, EECP, and traction group. All patients and 50 healthy volunteers received transcranial color Doppler examination of the vertebral artery and basilar artery in both a neutral cervical spine position and a rotational... read more

Enhanced external counterpulsation is a regenerative therapy

Coty W. Jewell, Philip D. Houck, Linley E. Watson, David E. Dostal, Gregory J. Dehmer, Frontier in Bioscience, 2010, 2010, E2, 111-121 abstract
Enhanced external counterpulsation is a regenerative therapy Enhanced external counterpulsation (EECP) is used for the treatment of severe angina and heart failure in patients who are not candidates for revascularization. The clinical benefits of EECP extend well beyond the time period of any hemodynamic effects, but the cause of this prolonged effect is not understood. The prolonged clinical benefits suggest EECP could be a regenerative therapy. This study was performed to determine whether EECP increased circulating hematopoietic progenitor cells (HPCs) or endothelial progenitor cells (EPCs) and thus be a possible regenerative therapy. The proposed mechanism of the increase in regenerative circulating stem cells is the enhanced shear forces induced on the endothelial boundary by the flow reversal produced by the sequential inflation of the pneumatic cuffs during... read more

2009

Effect of Enhanced External Counterpulsation on Plasma Level of Nitric Oxide and Vascular Endothelial Growth Factor

Pourmoghadas M, Nourmohamamadi H, Tabesh F, Haghjoo S, Tabesh E, ARYA Atherosclerosis Journal, 2009, 2009, 5(2):59-63 abstract
Effect of Enhanced External Counterpulsation on Plasma Level of Nitric Oxide and Vascular Endothelial Growth Factor BACKGROUND: Endothelial dysfunction contributes to the manifestation of stable and unstable coronary syndromes in patients with established coronary artery disease (CAD). Enhanced external counterpulsation (EECP) is a noninvasive therapeutic modality for patients with CAD, non responsive to medical and/or surgical treatment. The aim of this research was to determine the long-term effect of EECP on endothelial function via releasing angiogenic factors, NO (nitric oxide) and VEGF (vascular endothelial growth factor), in patients with CAD. METHODS: The study was performed on 19 consecutive patients with ischemic coronary artery disease. All subjects were treated with EECP 1-h per day, 5 days a week, over 7 weeks (totally 35 h). Serum level of VEGF and nitrite (stable NO metabolite) concentration was measured before... read more

Coronary Collateral Growth by External Counterpulsation: A Randomized Controlled Trial

Steffen Gloekler, Pascal Meier, Stefano F de Marchi, Tobias Rutz, Tobias Traupe, Stefano F Rimoldi, Kerstin Wustmann, Helene Steck, Stephane Cook, Rolf Vogel, Mario Togni, Christian Seiler, Heart, 2009, 2010; 96: 202-207 originally published online November 5, 2009 abstract
Coronary Collateral Growth by External Counterpulsation: A Randomized Controlled Trial Background: The efficacy of external counterpulsation (ECP) on coronary collateral growth has not been investigated in a randomized controlled study. Objective: To test the hypothesis that ECP augments collateral function during a 1 min coronary balloon occlusion. Patients and methods: Twenty patients with chronic stable coronary artery disease were studied. Before and after 30 h of randomly allocated ECP (20 90 min sessions over 4 weeks at 300 mm Hg inflation pressure) or sham ECP (same setting at 80 mm Hg inflation pressure), the invasive collateral flow index (CFI, no unit) was obtained in 34 vessels without coronary intervention. CFI was determined by the ratio of mean distal coronary occlusive pressure to mean aortic pressure with central venous pressure subtracted... read more

The efficacy and safety of enhanced external counterpulsation in patients with peripheral arterial disease

Bhavik V Thakkar, Alan T Hirsch1, Daniel Satran, BradleyA Bart, Gregory Barsness, Peter A McCullough, Elizabeth DKennard, Sheryl F Kelsey and Timothy D Henry., Vascular Medicine, 2009, 2009, Oct 19, 1-6. DOI: 110.1177/1358863X09106549 http://vmj.sagepub.com abstract
The efficacy and safety of enhanced external counterpulsation in patients with peripheral arterial disease Peripheral arterial disease (PAD) is common in patients with severe coronary artery disease (CAD) and is considered a relative contraindication to external enhanced counterpulsation (EECP), but there are no data that define the efficacy and safety of EECP in patients with PAD. The International EECP Patient Registry (IEPR) was used to compare initial post therapy and 2-year follow-up clinical outcomes and adverse event rates in patients with and without PAD. From January 2002 to October 2004, 2126 patients were enrolled in the IEPR, of whom 493 (23%) had a history of PAD. Immediately following EECP, the reduction in angina (≥ 1 Canadian Cardiovascular Society class) was similar in patients with and without PAD (76.6% vs 79.0%, p = 0.27) as... read more

Enhanced External Counterpulsation: An Innovative Physical Therapy for Refractory Angina

Debra L. Braverman, American Academy of Physical Medicine and Rehabilitation, 2009, 2009,1, 268-276. DOI: 10.1016/j.pmrj.2008.12.002 abstract
Enhanced External Counterpulsation: An Innovative Physical Therapy for Refractory Angina The prevalence of refractory angina in the United States is 600,000 to 1.8 million. Improved pharmacological, invasive, and surgical therapies for cardiovascular diseases during the last few decades have led to an increase in life expectancy of such individuals. Despite treatment with multiple medications and invasive procedures, these patients remain symptomatic and functionally limited. Enhanced external counterpulsation (EECP) is a safe, noninvasive, well tolerated, and clinically effective outpatient physical therapy for many patients with refractory angina. Numerous trials demonstrate positive clinical responses among at least 80% of patients undergoing EECP, including reductions in angina and nitrate use, increases in exercise tolerance, and enhanced quality of life. Several mechanisms, including the promotion of collateral blood flow, improvement in endothelial function, reduction... read more

Improvement of fractional flow reserve and collateral flow by treatment with external counterpulsation

E E Buschmann, W Utz, N Pagonas, J Schulz-Menger, A Busjahn, J Monti,W Maerz, F le Noble, LThierfelder, R Dietz, V Klauss, M Gross and I R Buschmann , On behalf of the Arteriogenesis Network (Art. Net)., Eur J Clin Invest, 2009, (Art.Net.-2 Trial). 2009. DOI: 10.1111/j.1365-2362.2009.02192.x abstract
Improvement of fractional flow reserve and collateral flow by treatment with external counterpulsation Background Arteriogenesis (collateral artery growth) is nature’s most efficient rescue mechanism to overcome the fatal consequences of arterial occlusion or stenosis. The goal of this trial was to investigate the effect of external counterpulsation (ECP) on coronary collateral artery growth. Materials and methods A total of 23 patients (age 61 ± 2.5 years) with stable coronary artery disease and at least one hemodynamic significant stenosis eligible for percutaneous coronary intervention were prospectively recruited into the two study groups in a 2 : 1 manner (ECP : control). One group (ECP group, n = 16) underwent 35 1-h sessions of ECP in 7 weeks. In the control group (n = 7), the natural course of collateral circulation over 7 weeks was... read more

Assessment of the effect of external counterpulsation on myocardial adaptive arteriogenesis by invasive functional measurements — design of the arteriogenesis network trial 2

Nikolaos Pagonas, Wolfgang Utz, Jeanette Schulz-Menger, Andreas Busjahn, Jan Monti, Ludwig Thierfelder, Rainer Dietz, Volker Klauss, Michael Gross, Ivo R. Buschmann, Eva-Elina Buschmann, International J of Cardiology, on behalf of the Arteriogenesis Network (Art.Net)., 2009, 2009:12087; No of Pages 6 abstract
Assessment of the effect of external counterpulsation on myocardial adaptive arteriogenesis by invasive functional measurements — design of the arteriogenesis network trial 2 Background Stimulation of collateral artery growth is a promising therapeutic option for patients with coronary artery disease. External counterpulsation is a non-invasive technique suggested to promote the growth of myocardial collateral arteries via increase of shear stress. The Art.Net.2 Trial tests invasively and functionally for the first time the hypothesis whether a treatment course with external counterpulsation (over 7 weeks) can induce the growth of myocardial collateral arteries. Methods This study is designed as a prospective, controlled, proof-of-concept study. Inclusion criteria are (1) age 40 to 80 years, (2) stable coronary disease, (3) a residual significant stenosis of at least one epicardial artery and (4) a positive ischemic stress-test for the region of interest. As primary endpoint serves the pressure-derived... read more

Evaluation of left ventricular systolic and diastolic regional function after enhanced external counterpulsation therapy using strain rate imaging

Maryam Esmaeilzadeh1, Arsalan Khaledifar, Majid Maleki, Anita Sadeghpour1, Niloufar Samiei, Hassan Moladoust, Feridoun Noohi, Zahra Ojaghi Haghighi, and Ahmad Mohebbi, European Journal of Echocardiography, 2009, (2009) 10, 120–126. doi:10.1093/ejechocard/jen183 abstract
Evaluation of left ventricular systolic and diastolic regional function after enhanced external counterpulsation therapy using strain rate imaging Aims Enhanced external counter pulsation (EECP) is a non-invasive and non-pharmacological therapy for patients with symptomatic coronary artery disease (CAD). There are, however, insufficient data to support the effectiveness of EECP in improving the myocardial mechanical properties of patients with refractory stable angina. We aimed to assess the effects of EECP on myocardial mechanical properties and cardiac functions in CAD patients not eligible for surgical or percutaneous revascularization procedures. Methods and results Twenty patients in New York Heart Association (NYHA) functional Class III and IV angina were evaluated. The mean age of the patients was 63±9 years, and 65% were male. A comprehensive echocardiographic study including an evaluation of the tissue Doppler-based parameters of systolic and diastolic functions was performed... read more

Enhanced external counterpulsation promotes growth cytokines-mediated myocardial angiogenesis in a porcine model of hypercholesterolemia

Luo Jing-yun, Wu Gui-fu, Xiong Yan, Chen Guo-wei, Xie Qiang, Yang Da-ya, He Xiao-hong, Zhang Yan, Liu Dong-hong, Wang Kui-jian, Ma Hong, Zheng Zhen-sheng and Du Zhi-min, Chin Med J, 2009, 2009;122(10):1188-1194 abstract
Enhanced external counterpulsation promotes growth cytokines-mediated myocardial angiogenesis in a porcine model of hypercholesterolemia Background Enhanced external counterpulsation (EECP) improves ischemia in patients with refractory angina pectoris, but the mechanism remains unclear. To explore the mechanisms of EECP action, we detected progenitor cells presenting any of the following markers CD34+, CD29+, and CD106+. Methods Growth cytokines-mediated progenitor cell mobilization and associated angiogenesis potential were assessed in a porcine model of hypercholesterolemia. Twenty-four male domestic swines were randomly assigned to 4 groups: normal diet (control, n=6), hypercholesterolemic diet (CHOL, n=6), hypercholesterolemic diet with administration of recombinant human granulocyte colony-stimulating factor (rhG-CSF) (rhG-CSF, n=6), and hypercholesterolemic diet with EECP treatment (EECP, n=6). EECP was applied 2 hours every other day for a total of 36 hours. Serum levels of vascular endothelial growth factor (VEGF) and granulocyte... read more

EECP : A non-invasive therapy for refractory angina

Beaini Y, Morley C, The Practitioner, 2009, 2009;253(1715):27-31 abstract
EECP : A non-invasive therapy for refractory angina Intervention is increasing both in the management of acute coronary syndromes and chronic stable angina and so too is the need for repeated intervention, where the complexity and procedural risk may be increased as well as the psychological and traumatic burden to patients of increasing age and morbidity. Enhanced external counter pulsation (EECP) is an alternative means of managing coronary disease. This therapy provides augmentation of diastolic flow, through sequential inflation and after-load reduction by simultaneous deflation, from a series of three cuffs applied to calves, lower thigh, upper thigh and buttocks. Currently, EECP is used predominantly in patients with severe angina, who are at high risk and are not suitable for revascularization. It provides a therapeutic and supportive approach... read more

Effect of Enhanced External Counterpulsation on Clinical Symptoms, Quality of Life, 6-Minute Walking Distance, and Echocardiographic Measurements of Left Ventricular Systolic and Diastolic Function After 35 Days of Treatment and at 1-Year Follow Up in 47

Kumar A, Aronow WS, Vadnerkar A, Sidhu P, Mittal S, Kasliwal RR, Trehan N, American Journal of Therapeutics, 2009, 2009 Mar/Apr;16(2):116-118 abstract
Effect of Enhanced External Counterpulsation on Clinical Symptoms, Quality of Life, 6-Minute Walking Distance, and Echocardiographic Measurements of Left Ventricular Systolic and Diastolic Function After 35 Days of Treatment and at 1-Year Follow Up in 47 In a prospective study, enhanced external counterpulsation (EECP) was performed for 1 hour each day for 35 days in 47 patients, mean age 61 ± 8 years, with prior coronary revascularization who had chronic refractory angina pectoris despite antianginal drugs and who were not candidates for further coronary revascularization. Compared with baseline values, EECP significantly improved anginal symptoms, dyspnea on exertion, and quality of life after 35 days of treatment (p< 0.001) and at 1-year follow up (p<0.001). Compared with the baseline value of 653 ± 249 feet, EECP significantly improved the 6-minute walking distance to 1025 ± 234 feet after 35 days of treatment (p<0.001) and to 1040 ± 221 feet at 1-year follow up (p<0.001). However, EECP did... read more

Invasive Left Ventricular Energetics During Enhanced External Counterpulsation

Michaels AD, Tacy T, Teitel D, Shapiro M, Grossman W, American Journal of Therapeutics, 2009, 2009;16:239-246 abstract
Invasive Left Ventricular Energetics During Enhanced External Counterpulsation Enhanced external counterpulsation (EECP) is a noninvasive technique that provides beneficial effects for patients with chronic, symptomatic angina pectoris. However, the direct left ventricular effects of EECP have not been studied invasively. We examined invasive right atrial pressure and left ventricular hemodynamics during EECP. Ten patients referred for diagnostic evaluation underwent left heart catheterization from the radial artery. At baseline and during EECP, left ventricular pressure and volume were measured using a micromanometer pressure-conductance catheter, along with recording of right atrial and central aortic pressures. Hemodynamics was recorded at different lower extremity cuff configuration and cuff inflation pressures. As cuff inflation pressure increased, EECP resulted in a dose-dependent increase in right atrial and aortic diastolic pressure (P < 0.0001). The... read more

Treatment Options for Refractory Angina Pectoris: Enhanced External Counterpulsation Therapy

Ozlem Soran, Current Treatment Options Cardiovascular Medicine, 2009, 2009 Feb;11(1):54-60 abstract
Treatment Options for Refractory Angina Pectoris: Enhanced External Counterpulsation Therapy Refractory angina pectoris, defined as angina refractory to maximal medical therapy and standard coronary revascularization procedures, remains a significant health problem in the United States and the world. Despite a panoply of recent therapeutic advances, patients with refractory angina pectoris are not adequately treated; therefore, scientists have been investigating new technologies to help these patients. The technique of counterpulsation, studied for almost half a century, is considered a safe, highly beneficial, low-cost, noninvasive treatment for these angina patients and now also for those with heart failure. Recent evidence suggests that enhanced external counterpulsation (EECP) therapy may improve symptoms and decrease long-term morbidity via several mechanisms, including improvement in endothelial function, promotion of collateralization, enhancement of ventricular function, improvement in oxygen... read more

2008

Enhanced External Counter pulsation in Treatment of Refractory Angina Pectoris: Two Year Outcome and Baseline Factors Associated with Treatment Failure

Erdling A, Bondesson S, Petterson T, Edvinsson L, BMC Cardiovasc Disord, 2008, 2008 Dec 18;8(1):39. [Epub ahead of print] abstract
Enhanced External Counter pulsation in Treatment of Refractory Angina Pectoris: Two Year Outcome and Baseline Factors Associated with Treatment Failure BACKGROUND: Enhanced external counter pulsation (EECP) is a non-invasive treatment option for patients with refractory angina pectoris ineligible to further traditional treatment. The aim of this study was to evaluate the effect of EECP on patients at a Scandinavian medical center and to investigate if outcome can be predicted by analyzing baseline factors. METHODS: 86 consecutive patients (70 male, 16 female) were treated with EECP and followed for two years post treatment. Canadian cardiovascular society (CCS) class was analyzed, and medication and adverse clinical events were researched prior to EECP, at the end of the treatment, and at six, 12 and 24 months thereafter. Patients responding to therapy by improving at least one CCS class were compared with those who... read more

Enhanced External Counterpulsation Improves Systolic Blood Pressure in Patients with Refractory Angina

Campbell AR, Satran D, Zenovich AG, Campbell KM, Espel JC, Arndt TL, Poulose AK, Boisjolie CR, Juusola K, Bart BA, Henry TD, American Heart Journal, 2008, 2008 Dec;156(6):1217-22. Epub 2008 Oct 5 abstract
Enhanced External Counterpulsation Improves Systolic Blood Pressure in Patients with Refractory Angina Background Enhanced external counterpulsation (EECP) is a noninvasive treatment of patients with refractory angina. The immediate hemodynamic effects of EECP are similar to intra-aortic balloon pump counterpulsation, but EECP effects on standard blood pressure measurements during and after treatment are unknown. Methods We evaluated systolic blood pressure (SBP) and diastolic blood pressure (DBP) for 108 consecutive patients undergoing EECP. Baseline SBP, DBP, and heart rate were compared for each patient before and after each EECP session, at the end of the course of EECP, and 6 weeks after the final EECP session. Results One hundred eight patients (mean age 66.4 ± 11.2 years, 81% male) completed 36.5 ± 5.1 EECP sessions per patient. Overall, based on 3,586 individual readings, EECP... read more

Comparison of Patients Undergoing Enhanced External Counterpulsation and Spinal Cord Stimulation for Refractory Angina Pectoris

Bondesson S, Pettersson T, Erdling A, Hallberg IR, Wackenfors A, Edvinsson L, Coronary Artery Disease, 2008, 2008 Dec;19(8):627-634 abstract
Comparison of Patients Undergoing Enhanced External Counterpulsation and Spinal Cord Stimulation for Refractory Angina Pectoris Introduction As more patients survive coronary events, the prevalence of patients with refractory angina pectoris is increasing. The aim was to evaluate the effects of enhanced external counterpulsation (EECP) and spinal cord stimulation (SCS) and compare with optimal medically treated patients with refractory angina. Methods 153 patients with refractory angina were treated with either EECP, SCS, or were retained on their pharmacological treatment (control). Glyceryl trinitrate usage and Canadian Cardiovascular Society classification were registered at baseline, 6 and 12 months after therapy. Results Both EECP and SCS reduced the angina as compared with controls (p< 0.001). Patients treated with EECP showed a more effective reduction as compared with SCS patients (p< 0.05). Both treatments resulted in significantly decreased glyceryl trinitrate... read more

Passive Tobacco Exposure May Impair Symptomatic Improvement in Patients with Chronic Angina Undergoing Enhanced External Counterpulsation

Efstratiadis S, Kennard ED, Kelsey SF, Michaels AD International EECP Patient Registry-2 Investigators, BMC Cardiovascular Disorders, 2008, 2008 Sep:8(23) abstract
Passive Tobacco Exposure May Impair Symptomatic Improvement in Patients with Chronic Angina Undergoing Enhanced External Counterpulsation Background The adverse effects of tobacco abuse on cardiovascular outcomes are well-known. However, the impact of passive smoke exposure on angina status and therapeutic response is less well-established. We examined the impact of second-hand smoke (SHS) exposure on symptomatic improvement in patients with chronic ischemic coronary disease undergoing enhanced external counterpulsation (EECP). Methods This observational study included 1,026 non-smokers (108 exposed and 918 not-exposed to SHS) from the Second International EECP Patient Registry. We also assessed angina response in 363 current smokers. Patient demographics, symptomatic improvement and quality of life assessment were determined by self-report prior and after EECP treatment. Results Non-smoking SHS subjects had a lower prevalence of prior revascularization (85% vs 90%), and had an increased prevalence of... read more

Long-term Effect of Enhanced External Counterpulsation on Endothelial Function in the Patients with Intractable Angina

Hashemi M, Hoseinbalam M, Khazaei M, Heart Lung Circulation, 2008, 2008 Aug 13. [Epub ahead of print] abstract
Long-term Effect of Enhanced External Counterpulsation on Endothelial Function in the Patients with Intractable Angina Background Enhanced external counterpulsation (EECP) is a noninvasive, pneumatic technique that provides favourable effects in patients with coronary artery disease. The objective of this study was to describe the long-term effect of EECP on endothelial function in patients with ischaemic cardiomyopathy. Method The study was performed in 15 patients with ischaemic cardiomyopathy. All subjects were treated with EECP 1-h per day, 5 days a week, over 7 weeks (totally 35 h). Endothelium-dependent and -independent relaxation was assessed by flow-mediated dilation (FMD) and nitroglycerine-mediated dilatation (NMD). In each patient, FMD and NMD measurements were performed before, at midcourse (day 17th) and after completion of EECP course (day 35th). In addition, FMD index was assessed 1 month after completion of EECP therapy.... read more

Enhanced External Counterpulsation in the Treatment of Chronic Refractory Angina: A Long-term Follow-up Outcome from the International Enhanced External Counterpulsation Patient Registry

Loh PH, Cleland JG, Louis AA, Kennard ED, Cook JF, Caplin JL, Barsness GW, Lawson WE, Soran OZ, Michaels AD, Clinical Cardiology, 2008, 2008 Apr 10;31(4):159-164 abstract
Enhanced External Counterpulsation in the Treatment of Chronic Refractory Angina: A Long-term Follow-up Outcome from the International Enhanced External Counterpulsation Patient Registry BACKGROUND The management of patients who suffer from medically refractory angina and are unsuitable for conventional revascularization therapy is often unsatisfactory. Enhanced external counterpulsation (EECP) is a noninvasive treatment that is safe and effective immediately after a course of treatment. However, the duration of benefit is less certain. HYPOTHESIS To evaluate the 3-year outcome of EECP treatment. METHODS One thousand four hundred and twenty seven patients from 36 centers registered in the International EECP Patient Registry (IEPR)-Phase 1 was prospectively followed for a median of 37 months. Two hundred and twenty patients (15.4%) died, while 1,061 patients (74.4%) completed their follow-up. RESULTS The mean age was 66+/-11 years and 72% were men. Seventy-six percent had multivessel coronary disease for 11+/-8... read more

Enhanced External Counterpulsation and Future Directions: Step Beyond Medical Management for Patients with Angina and Heart Failure

Manchanda A, Soran O, Journal of the American College of Cardiology, 2008, 2007 Oct 16;50(16):1523-1531. Epub 2007 Oct 1 abstract
Enhanced External Counterpulsation and Future Directions: Step Beyond Medical Management for Patients with Angina and Heart Failure Between 25,000 and 75,000 new cases of angina refractory to maximal medical therapy and standard coronary revascularization procedures are diagnosed each year. In addition, heart failure also places an enormous burden on the U.S. health care system, with an estimated economic impact ranging from $20 billion to more than $50 billion per year. The technique of counterpulsation, studied for almost one-half century now, is considered a safe, highly beneficial, low-cost, noninvasive treatment for these angina patients, and now for heart failure patients as well. Recent evidence suggests that enhanced external counterpulsation (EECP) therapy may improve symptoms and decrease long-term morbidity via more than 1 mechanism, including improvement in endothelial function, promotion of collateralization, enhancement of ventricular function, improvement in oxygen... read more

The Semantic Extension and Storage of EECP Hemodynamic Waveforms Based on DICOM Standard

Xie S, Yu D, Wei X, Wang K, Medical Biological Engineering and Computing, 2008, 2008 Apr;46(4):391-397. Epub 2008 Feb 12 abstract
The Semantic Extension and Storage of EECP Hemodynamic Waveforms Based on DICOM Standard Digital imaging and communications in medicine (DICOM) Standard has a detailed description on the Information Object Definition (IOD) of all kinds of medical images and waveforms. With the development and application of DICOM, all medical imaging and waveform devices will support the standard. This article describes the method and implementation on how to encapsulate the EECP Hemodynamic Waveforms data acquired from EECP device, integrating patient information, EECP physiological parameters, and diagnosis and treat information into DICOM Hemodynamic Waveform file. We define Private Data Elements to encode and represent EECP parameters which haven't been registered as Standard Data Elements. This is the semantic extension of DICOM applied in EECP. The paper introduces following parts in detail: the structure of DICOM waveform... read more

The Effects of External Counter Pulsation Therapy on Circulating Endothelial Progenitor Cells in Patients with Angina Pectoris

Barsheshet A, Hod H, Shechter M, Sharabani-Yosef O, Rosenthal E, Barbash IM, Matetzky S, Tal R, Bentancur AG, Sela BA, Nagler A, Leor J, Cardiology, 2008, 2008;110(3):160-166. Epub 2007 Dec 4 abstract
The Effects of External Counter Pulsation Therapy on Circulating Endothelial Progenitor Cells in Patients with Angina Pectoris OBJECTIVES External counter pulsation therapy (ECPT) offers symptomatic relief and improves ischemia in patients with refractory angina pectoris. We aimed to determine the effects of ECPT on circulating endothelial progenitor cells (EPCs). METHODS We prospectively studied 25 patients with angina pectoris treated with ECPT (n = 15) or receiving standard care (n = 10). The number of EPCs positive for CD34 and kinase insert domain receptor (KDR) was determined by flow cytometry and the number of colony-forming units (CFUs) was assessed in a 7-day culture, before ECPT and after 9 weeks. RESULTS ECPT improved anginal score from a median of 3.0 to 2.0 (p < 0.001). Concomitantly, ECPT increased EPC number from a median of 10.2 to 17.8/10(5) mononuclear cells... read more

Effect of Enhanced External Counterpulsation on Inflammatory Cytokines and Adhesion Molecules in Patients with Angina Pectoris and Angiographic Coronary Artery Disease

Casey DP, Conti CR, Nichols WW, Choi CY, Khuddus MA, Braith RW, American Journal of Cardiology, 2008, 2008 Feb 1;101(3):300-302. Epub 2007 Dec 11 abstract
Effect of Enhanced External Counterpulsation on Inflammatory Cytokines and Adhesion Molecules in Patients with Angina Pectoris and Angiographic Coronary Artery Disease Cardiovascular disease is associated with chronic low-level inflammation, as evidenced by elevated circulating proinflammatory cytokines. Experimental evidence suggests that inflammation can be suppressed under conditions of high shear stress. This study was conducted to examine the effects of enhanced external counterpulsation (EECP), a noninvasive therapy that increases endothelial shear stress, on circulating levels of inflammatory biomarkers and adhesion molecules in patients with angina pectoris. Twenty-one patients were randomly assigned to either 35 1-hour treatments at cuff pressures of 300 mm Hg (EECP; n=12) or 75 mm Hg (sham; n=9). Plasma tumor necrosis factor-alpha, monocyte chemoattractant protein-1, and soluble vascular cell adhesion molecule-1 were measured before and after 35 1-hour sessions of treatment or sham. Patients in the EECP group demonstrated... read more

2007

Effects of Enhanced External Counterpulsation (EECP) on Myocardial Perfusion

Arora RR, Bergmann S, American Journal of Therapeutics, 2007, 2007 Nov-Dec;14(6):519-523 abstract
Effects of Enhanced External Counterpulsation (EECP) on Myocardial Perfusion PURPOSE To evaluate whether enhanced external counterpulsation (EECP) exerts an effect on myocardial perfusion. METHODS Eleven patients with angina were studied before and after 35 sessions of EECP treatment. Myocardial perfusion was quantified with positron emission tomography and intravenous 13N-ammonia at rest and after dipyridamole, by means of a two-compartment mathematical model. CONCLUSION The results suggest that EECP has no effect on myocardial perfusion. However, because of the small number of patients in this study and highly variable clinical responses, additional studies are required to corroborate this finding. The beneficial effects of EECP appear to be mediated by other mechanisms. ... read more

Echocardiographic Characteristics Including Tissue Doppler Imaging After Enhanced External Counterpulsation Therapy

Estahbanaty G, Samiei N, Maleki M, Noohi F, Mohebi A, Ojaghi Z, Esmaeilzadeh M, Sadeghpour A, Soran O, The American Heart Hospital Journal, 2007, 2007 Fall;5(4):241-246 abstract
Echocardiographic Characteristics Including Tissue Doppler Imaging After Enhanced External Counterpulsation Therapy This study assessed the effects of a course of enhanced external counterpulsation (EECP) therapy on systolic and diastolic cardiac function using echocardiography to measure left ventricular ejection fraction (LVEF), end-systolic volume (ESV), end-diastolic volume (EDV), systolic wave (Sm), early diastolic wave (Ea), Vp, E/Ea, E/Vp, and diastolic function grade in 25 patients before and after 35 hours of EECP. EECP reduced ESV and EDV and increased ejection fraction significantly in patients with baseline LVEF ≤50% (p=0.018, 0.013, 0.002), baseline E/Ea ≥14 (P=.032, .038, .007), baseline grade II or III diastolic dysfunction (decreased compliance) (P=.014, .032, .027), baseline Ea <7 cm/s (P=.015, .024, .001), and baseline Sm <7 cm/s (P=.017, .016, .006), but not in patients with baseline LVEF >50%, baseline... read more

An Analysis of the Efficacy and Safety of Enhanced External Counterpulsation at West Virginia University Hospitals

Sajja V, Dod H, Beto R, Jain AC, Hobbs GR, Finkel MS, The West Virginia Medical Journal, 2007, 2007 May-Jun;103(3):10-12 abstract
An Analysis of the Efficacy and Safety of Enhanced External Counterpulsation at West Virginia University Hospitals A retrospective analysis was conducted of 79 consecutive patients who underwent enhanced external counterpulsation (EECP) at West Virginia University Hospitals during the period of November 1998 to September 2005 to determine its efficacy and safety in treating angina. A chart review and/or phone survey was performed to analyze pertinent clinical data (sublingual nitroglycerin use and angina class) pre and post EECP. A total of 60 (76%) patients who were referred for EECP successfully finished the 35 treatments. Seventy-five percent of the patient population improved at least one angina class after a full course of treatment. Therapy was discontinued due to adverse effects in 12 (15%) patients. Statistically significant improvements in angina class and reduction in anti-angina medications were observed in... read more

Residual High-Grade Angina After Enhanced External Counterpulsation Therapy

McCullough PA, Henry TD, Kennard ED, Kelsey SF, Michaels AD; IEPR Investigators, Cardiovascular Revascularization Medicine: Including Molecular Interventions, 2007, 2007 Jul-Sep;8(3):161-165 abstract
Residual High-Grade Angina After Enhanced External Counterpulsation Therapy OBJECTIVE We evaluated the degree of residual angina on the outcomes of enhanced external counterpulsation (EECP) therapy for chronic stable angina. BACKGROUND Angina refractory to medical therapy is common in the pool of patients who are not completely revascularized by angioplasty or bypass surgery. METHODS We examined 902 patients enrolled from 1998 to 2001 in the Second International Enhanced External Counterpulsation Patient Registry. Baseline and outcome variables were stratified by the last recorded Canadian Cardiovascular Society class. RESULTS Residual Class 3 (12.1%) or 4 (2.3%) angina was uncommon among patients with severe coronary artery disease after treatment with EECP. Prevalence of diabetes, hypertension, dyslipidemia, and heart failure was similar among the anginal post-EECP anginal classes. Multivessel coronary disease was more... read more

Effects of Enhanced External Counterpulsation on Carotid Circulation in Patients with Coronary Artery Disease

Levenson J, Simon A, Megnien JL, Chironi G, Gariepy J, Pernollet MG, Craiem D, Iliou MC, Cardiology, 2007, 2007;108(2):104-110. Epub 2006 Sep 29 abstract
Effects of Enhanced External Counterpulsation on Carotid Circulation in Patients with Coronary Artery Disease Background Enhanced external counterpulsation (EECP) is a noninvasive method previously shown to improve measures of myocardial ischemia in patients with coronary artery disease. However, the concomitant effects of EECP on large and small arterial properties have been poorly examined. In a randomized controlled study, we investigated whether arterial stiffness and resistance of the carotid circulation are altered by EECP. Methods Thirty patients with angiographically demonstrated coronary artery disease were randomized into two groups to receive either ‘sham’ or ‘active’ EECP therapy for 35 1-hour sessions. The β stiffness index was calculated by the ln(Ps/Pd)/DD equation where Ps and Pd = systolic and diastolic blood pressure, and DD = the ratio between carotid pulse and diastolic diameter, measured by ultrasound sequential... read more

Enhanced External Counterpulsation Inhibits Intimal Hyperplasia by Modifying Shear Stress Responsive Gene Expression in Hypercholesterolemic Pigs

Zhang Y, He X, Chen X, Ma H, Liu D, Luo J, Du Z, Jin Y, Xiong Y, He J, Fang D, Wang K, Lawson WE, Hui JCK, Zheng Z, Wu G, Circulation, 2007, 2007 Jul 31;116(5):526-534. Epub 2007 Jul 9 abstract
Enhanced External Counterpulsation Inhibits Intimal Hyperplasia by Modifying Shear Stress Responsive Gene Expression in Hypercholesterolemic Pigs BACKGROUND Enhanced external counterpulsation (EECP) is a circulation assist device that may improve endothelial dysfunction by increasing shear stress. Chronic exposure of vascular endothelial cells and vascular smooth muscle cells to relatively high physiological shear stress has antiproliferative and vasoprotective effects. The present study hypothesizes that EECP inhibits intimal hyperplasia and atherogenesis by modifying shear stress-responsive gene expression. METHODS AND RESULTS Thirty- five male pigs were randomly assigned to 3 groups: high-cholesterol diet (n=11), high-cholesterol diet plus EECP (n=17), and usual diet (control; n=7). The coronary arteries and aortas were collected for histopathological study and immunohistochemical and Western blot analysis. The peak diastolic arterial wall shear stress during EECP increased significantly compared with before EECP (49.62+/-10.71 versus 23.92+/-7.28 dyne/cm2; p<0.001).... read more

Effects of Enhanced External Counterpulsation on Anginal Symptoms and Improvements in Objective Measures of Myocardial Ischemia

Yavari M, Montazeri HR, Cardiovascular Journal of South Africa, 2007, 2007 May-Jun;18(3):154-156 abstract
Effects of Enhanced External Counterpulsation on Anginal Symptoms and Improvements in Objective Measures of Myocardial Ischemia BACKGROUND Enhanced external counterpulsation (EECP) is a novel, potentially beneficial adjunct therapy used for angina pectoris. We assessed the efficacy of this method in relieving angina and improving objective measures of myocardial ischaemia. METHODS All patients (67) who referred for EECP to Shahid Chamran Hospital, Isfahan, Iran from 2002 to 2005 were included. Demographic data, coronary artery disease (CAD) risk factors and baseline angiographic data were collected. Anginal symptoms, Canadian Cardiovascular Society (CCS) functional class, echocardiographic parameters (ejection fraction, left ventricular end-diastolic and end-systolic diameters) and exercise test duration before and after the treatment was compared. RESULTS Seventy-seven per cent of patients who had undergone EECP had a positive clinical response. Exercise test duration and CCS functional class improved after... read more

The Effects of Enhanced External Counterpulsation on Time- and Frequency-Domain Measures of Heart Rate Variability

Michaels AD, Bart BA, Pinto T, Lafferty J, Fung G, Kennard ED, Journal of Electrocardiology, 2007, 2007 Nov-Dec;40(6):515-521. Epub 2007 May 29 abstract
The Effects of Enhanced External Counterpulsation on Time- and Frequency-Domain Measures of Heart Rate Variability BACKGROUND AND PURPOSE We hypothesized that symptom improvement from enhanced external counterpulsation (EECP) is related to improved heart rate variability (HRV). METHODS This prospective, multicenter study enrolled 27 patients with angina who underwent 48-hour ambulatory electrocardiogram monitoring at baseline, immediately after 35 hours of EECP, and at 1 month. Primary end points included change in time-domain (SD of normal-to-normal intervals) and frequency-domain HRV. RESULTS Twenty-four patients completed the full course of EECP therapy and 3 ambulatory electrocardiograms. There were no significant changes in time-domain HRV measures after EECP. Patients younger than 65 years and those with heart failure had improved SD of normal-to-normal interval after EECP (p=0.02). Although frequency-domain HRV measures did not change in the overall cohort, patients with... read more

Impact of Enhanced External Counterpulsation on Peripheral Circulation

Werner D, Michalk F, Hinz B, Werner U, Voigt JU, Daniel WG, Angiology, 2007, 2007 Apr-May;58(2):185-190 abstract
Impact of Enhanced External Counterpulsation on Peripheral Circulation Enhanced external counterpulsation (EECP) is a noninvasive counterpulsation technique that reduces angina and improves exercise capacity in patients with coronary artery disease. Diastolic coronary perfusion is augmented by pneumatic compression of 3 sets of cuffs wrapped around the lower extremities. Although central hemodynamic changes are well investigated, almost no data exist about the changes of peripheral circulation during EECP. In this study, 12 patients with angina and angiographic evidence of coronary artery disease were treated for 1 hour with EECP. In these patients, peripheral artery disease was excluded by duplex sonography. The patients rested 1 hour before EECP in supine position, and they remained in that position for 1 hour after the procedure. Changes of flow volumes and flow pattern... read more

Effect of Enhanced External Counterpulsation on Medically Refractory Angina Patients with Erectile Dysfunction

Lawson WE, Hui JCK, Kennard ED, Soran O, McCullough PA, Kelsey SF; for the IEPR Investigators, International Journal of Clinical Practice, 2007, 2007 May;61(5):757-762 abstract
Effect of Enhanced External Counterpulsation on Medically Refractory Angina Patients with Erectile Dysfunction Patients with refractory angina often suffer from erectile dysfunction. Enhanced external counterpulsation (EECP) decreases symptoms of angina, and increases nitric oxide release. This study evaluated the effect of EECP on sexual function in men with severe angina. The International Index of Erectile Function (IIEF) was used to assess erectile function of severe angina patients enroled in the International EECP Patient Registry. Their symptom status, medication use, adverse clinical events and quality of life were also recorded before and after completing a course of EECP. A cohort of 120 men (mean age 65.0+/-9.7) was enroled. The men had severe coronary disease with 69% having a prior myocardial infarction, 90% prior coronary artery bypass graft or percutaneous coronary intervention, 49% with three... read more

Portable Enhanced External Counterpulsation for Acute Coronary Syndrome and Cardiogenic Shock: A Pilot Study

Cohen J, Grossman W, Michaels AD, Clinical Cardiology, 2007, 2007 May;30(5):223-228 abstract
Portable Enhanced External Counterpulsation for Acute Coronary Syndrome and Cardiogenic Shock: A Pilot Study Background Enhanced external counterpulsation (EECP) currently is used as an outpatient therapy for patients with refractory chronic angina. Hypothesis We sought to determine the safety and feasibility of a portable EECP unit to treat patients with acute coronary syndrome and/or cardiogenic shock in the coronary care unit (CCU). Methods Ten patients with acute coronary syndrome and/or cardiogenic shock who were not considered candidates for invasive intra-aortic balloon counterpulsation (IABP) by the treating cardiologist were prospectively enrolled in this single-center study. Each patient received 2-4 one-hour EECP treatments performed at the bedside in the CCU. Anticoagulation or recent femoral access was not an exclusion criterion. Results The mean age was 58 ± 19 years (range 28-81), and half were women. Patients... read more

Enhanced External Counterpulsation in Patients with Coronary Artery Disease-Associated Erectile Dysfunction. Part I: Effects of Risk Factors

El-Sakka A, Morsy A, Fagih B, Journal of Sexual Medicine, 2007, 2007 May;4(3):771-779. Epub 2007 Apr 13 abstract
Enhanced External Counterpulsation in Patients with Coronary Artery Disease-Associated Erectile Dysfunction. Part I: Effects of Risk Factors Introduction Recently it has been demonstrated that enhanced external counterpulsation (EECP) could improve erectile dysfunction (ED) in patients with refractory ischemic heart disease (IHD). Aim To assess the effect of risk factors on the efficacy and the satisfaction rate of EECP in patients with coronary artery disease (CAD)-associated ED. Main Outcome Measures To assess the effect of risk factors on EECP efficacy and satisfaction rate, we compared the pre- and post-EECP responses to erectile function domain, Q3, and Q4 in patients with and without risk factors. Overall satisfaction and global efficacy question (GEQ) were also assessed. Methods A total of 44 male consecutive patients with intractable angina caused by coronary insufficiency which cannot be controlled by conventional therapy were enrolled... read more

Enhanced External Counterpulsation in Patients with Coronary Artery Disease-Associated Erectile Dysfunction. Part II: Impact of Disease Duration and Treatment Courses

Ahmed I. El-Sakka, Ayman M. Morsy, and Bassam I. Fagih, Journal of Sexual Medicine, 2007, 2007;4:1448–1453 abstract
Enhanced External Counterpulsation in Patients with Coronary Artery Disease-Associated Erectile Dysfunction. Part II: Impact of Disease Duration and Treatment Courses Introduction Enhanced external counterpulsation (EECP) is a noninvasive outpatient treatment used for patients with intractable angina refractory to aggressive surgical and medical treatment. Recent results have demonstrated a positive impact of EECP on patients with ischemic heart disease (IHD)-associated erectile dysfunction (ED). Aim To assess the effect of IHD duration and number of EECP courses on efficacy and satisfaction rate of EECP on patients with IHD-associated ED. Main Outcome Measures We compared pre- and post-EECP responses to erectile function (EF) domain, Q3 and Q4 of the International Index of Erectile Function score in patients who received one or two courses of EECP and those who had <5 or ≥ 5-years duration of IHD. Methods As mentioned in part I a... read more

Impact of External Counterpulsation Treatment on Emergency Department Visits and Hospitalizations in Refractory Angina Patients with Left Ventricular Dysfunction

Soran O, Kennard ED, Bart BA, Kelsey SF, Congestive Heart Failure, 2007, 2007 Jan-Feb;13(1):36-40 abstract
Impact of External Counterpulsation Treatment on Emergency Department Visits and Hospitalizations in Refractory Angina Patients with Left Ventricular Dysfunction Patients with refractory angina and left ventricular (LV) dysfunction exert an enormous burden on health care resources primarily because of the number of recurrent emergency department (ED) visits and hospitalizations. Enhanced external counterpulsation (EECP) therapy has emerged as a treatment option for patients with angina and LV dysfunction and has been shown to improve clinical outcomes and LV function. Improvements in symptoms and laboratory assessments in these patients, however, do not necessarily correlate with a reduction in ED visits and hospitalizations. This is the first study to assess the impact of EECP therapy on ED visits and hospitalization rates at 6-month follow-up. This prospective cohort study included 450 patients with LV dysfunction (ejection fraction <or=40%) treated with EECP therapy for... read more

2006

Prospective Evaluation of EECP in Congestive Heart Failure (PEECH) Investigators. Enhanced External Counterpulsation Improves Exercise Duration and Peak Oxygen Consumption in Older Patients With Heart Failure: A Subgroup Analysis of the PEECH Trial

Abbottsmith CW, Chung ES, Varricchione T, de Lame PA, Silver MA, Francis GS, Feldman AM, Congestive Heart Failure, 2006, 2006 Nov-Dec;12(6):307-311 abstract
Prospective Evaluation of EECP in Congestive Heart Failure (PEECH) Investigators. Enhanced External Counterpulsation Improves Exercise Duration and Peak Oxygen Consumption in Older Patients With Heart Failure: A Subgroup Analysis of the PEECH Trial The Prospective Evaluation of Enhanced External Counterpulsation in Congestive Heart Failure (PEECH) trial demonstrated that enhanced external counterpulsation (EECP) therapy increased exercise duration and improved functional status and quality of life without affecting peak oxygen consumption. The authors present data from a prespecified subgroup of elderly patients (65 years or older) enrolled in the PEECH trial. The 2 co-primary end points were the percentage of subjects with a >60-second increase in exercise duration and the percentage of subjects with a >1.25-mL/kg/min increase in peak volume of oxygen consumption. At 6-month follow-up, the exercise responder rate was significantly higher in EECP patients compared with controls (P=.008). Further, in contrast to the overall PEECH study, the EECP group demonstrated a significantly higher... read more

Effectiveness of Repeat Enhanced External Counterpulsation for Refractory Angina in Patients Failing to Complete an Initial Course of Therapy.

Lawson WE, Barsness G, Michaels AD, Soran O, Kennard ED, Kelsey SF, Hui JCK, Cardiology, 2006, Nov 1;108(3):170-175, Epub ahead of print abstract
Effectiveness of Repeat Enhanced External Counterpulsation for Refractory Angina in Patients Failing to Complete an Initial Course of Therapy. Aims: This study examined the causes and results of retreatment of patients who failed to complete an initial 35-hour Enhanced External Counterpulsation (EECP) course. Methods and Results Data of 2,311 successive angina patients from the International EECP Patient Registry were analyzed, 86.5% completed their EECP course (Complete cohort). Of the 13.5% patients failing to complete the initial course (Incomplete cohort), 28.3% had repeat EECP within 1 year vs. 10.1% of the Complete group. The predictors of failure to complete the initial course of EECP were: female gender, heart failure, use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and use of nitroglycerin. For the Complete group, 83.4% had a reduction of at least one Canadian Cardiovascular Society (CCS) class after... read more

Practical Approach to the Selection of Patients for and Application of EECP

Michaels AD, McCullough PA, Soran OZ, Lawson WE, Barsness GW, Henry TD, Linnemeier G, Ochoa A, Kelsey SF, Kennard ED. Primer, Nature Clinical Practice Cardiovascular Medicine, 2006, 2006 Nov;3(11):623-632 abstract
Practical Approach to the Selection of Patients for and Application of EECP Over the past decade, the frequency of use of enhanced external counterpulsation (EECP) has increased in patients with angina, irrespective of medical therapy and coronary revascularization status. Many patients referred for EECP have one or more comorbidities that could affect this treatment's efficacy, safety, or both. By use of data from more than 8,000 patients enrolled in the International EECP Patient Registry, we provide practical guidelines for the selection and treatment of patients. We have focused on considerations for patients who have one or more of the following characteristics: age older than 75 years, diabetes, obesity, heart failure, and peripheral vascular disease. We have also reviewed outcomes and treatment recommendations for individuals with poor diastolic augmentation during treatment, for those... read more

Enhanced External Counterpulsation for the Treatment of Angina Pectoris. Progress in Cardiovascular Diseases

Cohn PF, Progress in Cardiovascular Diseases, 2006, 2006 Sep-Oct;49(2):88-97 abstract
Enhanced External Counterpulsation for the Treatment of Angina Pectoris. Progress in Cardiovascular Diseases The treatment of refractory chronic angina pectoris presents an increasing problem for all physicians caring for patients with coronary artery disease because of the large number of individuals who have either failed multiple revascularization procedures or are not appropriate candidates for such procedures. The aim of this study was to review the safety, efficacy, and clinical applicability of a noninvasive technique (external counterpulsation) for the treatment of angina pectoris. A MEDLINE search for all English language abstracts, meeting presentations, journal articles, and reviews from 1960 through December 2005 was conducted. Of the 194 citations in the literature, 60 appeared before 1983 when the enhanced version of the technique (the one that is presently used) was first reported. Criteria for further... read more

Effects of Enhanced External Counterpulsation on Carotid Circulation in Patients with Coronary Artery Disease

Levenson J, Simon A, Megnien JL, Chironi G, Gariepy J, Pernollet MG, Craiem D, Iliou MC, Cardiology, 2006, 2006 Sep 29;108(2):104-110 [Epub ahead of print]. abstract
Effects of Enhanced External Counterpulsation on Carotid Circulation in Patients with Coronary Artery Disease BACKGROUND Enhanced external counterpulsation (EECP) is a noninvasive method previously shown to improve measures of myocardial ischemia in patients with coronary artery disease. However, the concomitant effects of EECP on large and small arterial properties have been poorly examined. In a randomized controlled study, we investigated whether arterial stiffness and resistance of the carotid circulation are altered by EECP. METHODS Thirty patients with angiographically demonstrated coronary artery disease were randomized into two groups to receive either 'sham' or active EECP therapy for 35 1-hour sessions. The beta stiffness index was calculated by the ln(Ps/Pd)/DD equation where Ps and Pd = systolic and diastolic blood pressure, and DD = the ratio between carotid pulse and diastolic diameter, measured by ultrasound sequential... read more

Enhanced External Counterpulsation Improves Exercise Tolerance in Patients With Chronic Heart Failure

Feldman AM, Silver MA, Francis GS, Abbottsmith CW, Fleishman BL, Soran O, de Lame PA, Varricchione T for the PEECH Investigators, Journal of the American College of Cardiology, 2006, 2006 Sep 9;48(6):1199-1206. Epub 2006 Aug 25 abstract
Enhanced External Counterpulsation Improves Exercise Tolerance in Patients With Chronic Heart Failure OBJECTIVES The PEECH (Prospective Evaluation of Enhanced External Counterpulsation in Congestive Heart Failure) study assessed the benefits of enhanced external counterpulsation (EECP) in the treatment of patients with mild-to-moderate heart failure (HF). BACKGROUND Enhanced external counterpulsation reduced angina symptoms and extended time to exercise-induced ischemia in patients with coronary artery disease, angina, and normal left ventricular function. A small pilot study and registry analysis suggested benefits in patients with HF. METHODS We randomized 187 subjects with mild-to-moderate symptoms of HF to either EECP and protocol-defined pharmacologic therapy (PT) or PT alone. Two co-primary end points were pre-defined: the percentage of subjects with a 60 s or more increase in exercise duration and the percentage of subjects with at least 1.25... read more

Enhanced External Counterpulsation Treatment Improves Arterial Wall Properties and Wave Reflection Characteristics in Patients With Refractory Angina

Nichols WW, Estrada JC, Braith RW, Owens K, Conti CR, Journal of the American College of Cardiology, 2006, 2006 Sep 19;48(6):1209-1215. Epub 2006 Aug 25 abstract
Enhanced External Counterpulsation Treatment Improves Arterial Wall Properties and Wave Reflection Characteristics in Patients With Refractory Angina OBJECTIVES To determine if arterial properties and wave reflection characteristics are favorably altered after enhanced external counterpulsation (EECP) treatment in patients with refractory angina. BACKGROUND Early return of reflected waves from the lower body, resulting from increased arterial stiffness, augments central aortic pressure and increases left ventricular (LV) afterload and myocardial oxygen demand. EECP acutely enhances coronary perfusion (supply)and reduces LV afterload (demand). However, the mechanisms responsible for the sustained beneficial effects of EECP treatment are unclear. METHODS Radial artery pressure waveforms were recorded by applanation tonometry and central aortic pressure waveforms generated using a mathematical transfer function in 20 patients with stable refractory angina. Data were collected before and after 34 1-h EECP sessions. Augmentation index (AIa) and timing... read more

Effect of Enhanced External Counterpulsation on Resting Oxygen Uptake in Patients Having Previous Coronary Revascularization and in Healthy Volunteers

Ochoa AB, Dejong A, Grayson D, Franklin B, McCullough P, American Journal Cardiology, 2006, 2006 Sep 1;98(5):613-615. Epub 2006 Jun 30 abstract
Effect of Enhanced External Counterpulsation on Resting Oxygen Uptake in Patients Having Previous Coronary Revascularization and in Healthy Volunteers This study analyzed the acute effects of enhanced external counterpulsation (EECP) on oxygen uptake (VO2) at rest in adults with symptomatic coronary artery disease (CAD) compared with healthy volunteers. EECP therapy increases exercise tolerance in patients with refractory angina pectoris. This may be attributed, at least in part, to a training effect, but measurement of VO2 during an EECP treatment session has not been previously reported. We measured VO2 continuously in 20 adults during a single treatment session of EECP, including 10 subjects with previous coronary revascularization who were referred for EECP therapy for refractory angina, and 10 healthy, sedentary volunteers. VO2 was measured for 10 minutes before EECP, during a 30-minute EECP treatment session, and for 10 minutes after... read more

Cyclic GMP Release by Acute Enhanced External Counterpulsation

Levenson J, Pernollet MG, Iliou MC, Devynck MA, Simon A, American Journal Hypertension, 2006, 2006 Aug;19(8):867-872 abstract
Cyclic GMP Release by Acute Enhanced External Counterpulsation BACKGROUND Enhanced external counterpulsation (EECP) is a noninvasive, pneumatic technique that provides favorable effects in patients with coronary artery disease and heart failure. The mechanisms by which EECP exerts its beneficial effects remain poorly understood. Cyclic GMP (cGMP) regulates vascular smooth muscle tone that may improve arterial function. We investigated the effect of a single session of EECP on plasma and platelet cGMP in asymptomatic subjects with cardiovascular risk factors (HCVR) and in patients with coronary artery disease (CAD). METHODS Fifty-five subjects were included (25 HCVR and 30 CAD) and randomized into two groups to receive either sham (control) or active EECP during 1 h. Plasma and platelet cGMP were measured immediately before and after EECP by radioimmunoassay. RESULTS One... read more

Treatment Options for Refractory Angina in Patients Who Are Not Candidates for Revascularization

Conti CR, Current Cardiology Reports, 2006, 2006 Jul;8(4):272-276 abstract
Treatment Options for Refractory Angina in Patients Who Are Not Candidates for Revascularization Patients with refractory angina are those for whom medical therapy has failed to eradicate the angina completely and who have persistent symptoms that are stable but limit their activities of daily living. Approach to management must include the elimination of the secondary causes of this condition and maximum medical therapy, and if angina persists, the consideration of other strategies. Controversy exists regarding the value of transmural myocardial laser revascularization. Enhanced external counterpulsation is clinically effective in approximately 70% of patients. Spinal cord stimulation is not being used clinically in the United States. In the United States, it is still an investigational procedure that is currently being evaluated prospectively in a randomized trial. Ranolazine, an inhibitor of sodium-dependent calcium overload, may... read more

Effect of External Counterpulsation on Plasma Nitric Oxide and Endothelin-1 Levels

Akhtar M, Wu GF, Du ZM, Zheng ZS, Michaels AD, American Journal Cardiology, 2006, 2006 Jul 1;98(1):28-30. Epub 2006 May 3 abstract
Effect of External Counterpulsation on Plasma Nitric Oxide and Endothelin-1 Levels Enhanced external counterpulsation (EECP) significantly augments diastolic blood flow and has been postulated to improve endothelial function by increased shear stress. We examined the effects of EECP on plasma nitric oxide and endothelin-1 (ET-1) levels. Plasma nitrate and nitrite (NOx) and ET-1 levels were measured serially in 13 patients with coronary artery disease who received 1-hour daily treatments of EECP over 6 weeks. During the course of EECP therapy, plasma NOx progressively increased and plasma ET-1 progressively decreased. After 36 hours of EECP, there was a 62 ±17% increase in plasma NOx compared with baseline (43.6 ± 4.3 vs 27.1±2.6 micromol/L, p <0.0001) and a 36 ± 8% decrease in plasma ET-1 (76.7 ± 9.5 vs 119.5 ± 8.5 pg/L,... read more

One Year Follow-up of Patients with Refractory Angina Pectoris Treated with Enhanced External Counterpulsation

Pettersson T, Bondesson S, Cojocaru D, Ohlsson O, Wackenfors A, Edvinsson L, BMC Cardiovascular Disorder, 2006, 2006 Jun 15;6:28 abstract
One Year Follow-up of Patients with Refractory Angina Pectoris Treated with Enhanced External Counterpulsation Background: Enhanced external counterpulsation (EECP) is a non-invasive technique that has been shown to be effective in reducing both angina and myocardial ischemia in patients not responding to medical therapy and without revascularization alternatives. The aim of the present study was to assess the long-term outcome of EECP treatment at a Scandinavian centre, in relieving angina in patients with chronic refractory angina pectoris. Methods: 55 patients were treated with EECP. Canadian cardiovascular society (CCS) class, antianginal medication and adverse clinical events were collected prior to EECP, at the end of the treatment, and at six and 12 months after EECP treatment. Clinical signs and symptoms were recorded. Results: EECP treatment significantly improved the CCS class in 79 ± 6% of... read more

Enhanced External Counterpulsation Reduces Lung/Heart Ratio at Stress in Patients with Coronary Artery Disease

Lee CM, Wu YW, Jui HY, Chen MF, Lee YT, Soran O, Cardiology, 2006, 2006 May 9;106(4):237-240 [Epub ahead of print] abstract
Enhanced External Counterpulsation Reduces Lung/Heart Ratio at Stress in Patients with Coronary Artery Disease Enhanced external counterpulsation (EECP) is a recently approved treatment modality for patients with angina and heart failure. However, the efficacy of EECP on left ventricular (LV) function has not been well established. The study was aimed to determine whether EECP leads to an improvement in objective parameters of LV function. Patients with coronary artery disease (n = 10) who showed evidence of stress-induced myocardial ischemia despite conventional medical or surgical therapies were enrolled and received EECP therapy for a total of 35 h. The therapeutic effects of EECP were examined by thallium-201 single-photon emission computed tomography (201Tl-SPECT). Compared with baseline, the lung/heart ratio at stress decreased significantly from 0.40 +/- 0.08 to 0.35 +/- 0.08 (p = 0.001) at 1... read more

Enhanced External Counterpulsation for Treatment of Refractory Angina Pectoris

Novo G, Bagger JP, Carta R, Koutroulis G, Hall R, Nihoyannopoulos P, Journal of Cardiovascular Medicine, 2006, 2006 May;7(5):335-339 abstract
Enhanced External Counterpulsation for Treatment of Refractory Angina Pectoris OBJECTIVE Enhanced external counterpulsation (EECP) is a noninvasive, well-tolerated treatment, effective for managing patients with refractory angina pectoris. The aim of this study was to evaluate the efficacy of EECP to relieve symptoms, to decrease myocardial ischaemia and to improve cardiac performance in patients with intractable angina, refractory to surgical and medical treatment. METHODS Twenty-five patients (24 men and one woman, mean age 65 years) with persistent ischaemia notwithstanding optimal medical therapy or after interventional or surgical procedure received EECP sessions for 35 h. Each patient underwent dobutamine stress echocardiography before and after treatment. We evaluated modifications in either cardiac systolic or diastolic function, and in wall motion score index. RESULTS Eighty-four percent of patients showed an increase in at... read more

Mechanisms and Evidence for the Role of Enhanced External Counterpulsation in Heart Failure Management

Silver MA, Current Heart Failure Reports, 2006, 2006 Apr;3(1):25-32 abstract
Mechanisms and Evidence for the Role of Enhanced External Counterpulsation in Heart Failure Management Balloon counterpulsation has gained widespread acceptance as a therapy for cardiogenic shock. However, over the past four decades a parallel method of noninvasive counterpulsation, enhanced external counterpulsation (EECP), has been defined and developed. Mechanisms of benefit for this technology continue to emerge and include enhanced coronary and other key target organ perfusion beds. Other mechanisms include angiogenesis and enhanced cellular metabolism. Beyond putative mechanisms there is ample evidence for improved and sustained outcomes in patients with and without left ventricular dysfunction. This evidence comes from long-term registry reports and randomized clinical trials. With respect to heart failure (HF), there is registry, pilot trial, and randomized clinical trial evidence of safety and efficacy. This paper summarizes some of the mechanisms and... read more

The Immediate and Long-term Outcome of Enhanced External Counterpulsation in Treatment of Chronic Stable Refractory Angina

Loh PH, Louis AA, Wundram J, Rigby AS, Cook J, Hurren S, Nikolay NP, Caplin J, Cleland JG, Journal of Internal Medicine, 2006, 2006 Mar;259(3):276-284 abstract
The Immediate and Long-term Outcome of Enhanced External Counterpulsation in Treatment of Chronic Stable Refractory Angina BACKGROUND Treatment of angina recalcitrant to conventional pharmacological therapy and revascularization remains problematic. Safe, effective and affordable treatments with high patient acceptability are desirable. Enhanced external counterpulsation (EECP) may fulfill these criteria better than many other proposed interventions. OBJECTIVE To examine the immediate and long-term effect of EECP in treatment of chronic stable refractory angina. DESIGN Prospective observational study of consecutive patients treated with EECP and follow-up for 1 year. MAIN OUTCOME MEASURES Canadian Cardiovascular Society (CCS) angina grading, weekly angina frequency and glyceryl trinitrate (GTN) use. RESULTS Sixty-one patients were treated with EECP and 58 completed a course of treatment. Further analysis is confined to those who completed EECP. About 52% of patients suffered from CCS III and IV... read more

Two-Year Outcomes in Patients with Mild Refractory Angina Treated with Enhanced External Counterpulsation

Lawson WE, Hui JCK, Kennard ED, Kelsey SF, Michaels AD, Soran O, Clinical Cardiology, 2006, 2006 Feb;29(2):69-73 abstract
Two-Year Outcomes in Patients with Mild Refractory Angina Treated with Enhanced External Counterpulsation BACKGROUND In the International Enhanced External Counterpulsation Patient Registry (IEPR), approximately 85% of the patients treated are in Canadian Cardiovascular Society (CCS) class III-IV with no option for further invasive coronary revascularization procedures. HYPOTHESIS This study sought to determine whether it is clinically important to establish whether the observed durable reduction in disabling severe angina with enhanced external counterpulsation (EECP) treatment can be extended to those with less severe CCS class II angina, who also have no option for further revascularization. METHODS This study evaluated the immediate response, durability and clinical events over a 2-year period after EECP treatment in 112 patients with Canadian Cardiovascular Society (CCS) class II angina versus 1346 patients with class III-IV angina using data from... read more

Two-Year Clinical Outcomes After Enhanced External Counterpulsation (EECP) Therapy in Patients with Refractory Angina Pectoris and Left Ventricular Dysfunction (Report from The International EECP Patient Registry)

Soran O, Kennard ED, Kfoury AG, Kelsey SF; IEPR Investigators, American Journal of Cardiology, 2006, 2006 Jan 1;97(1):17-20. Epub 2005 Nov 2 abstract
Two-Year Clinical Outcomes After Enhanced External Counterpulsation (EECP) Therapy in Patients with Refractory Angina Pectoris and Left Ventricular Dysfunction (Report from The International EECP Patient Registry) Enhanced external counterpulsation (EECP) is a noninvasive circulatory assist device that has recently emerged as a treatment option for refractory angina in left ventricular (LV) dysfunction. This 2-year cohort study describes the long-term follow-up of patients who had severe LV dysfunction that was treated with EECP for angina pectoris and reports clinical outcomes, event-free survival rates, and the incidence of repeat EECP. This study included 363 patients who had refractory angina and LV ejection fraction < or =35%. Most patients reported quality of life as poor. After completion of treatment, there was a significant decrease in severity of angina class (p < 0.001), and 72% improved from severe angina to no angina or mild angina. Fifty-two percent of patients discontinued... read more

Impact of Body Mass Index on Outcomes of Enhanced External Counterpulsation Therapy

McCullough PA, Silver MA, Kennard ED, Kelsey SF, Michaels AD; IEPR Investigators, American Heart Journal, 2006, 2006 Jan;151(1):139 e9-e13 abstract
Impact of Body Mass Index on Outcomes of Enhanced External Counterpulsation Therapy OBJECTIVES We evaluated the association of baseline body mass index (BMI) on the outcomes of enhanced external counterpulsation (EECP) therapy for chronic stable angina. BACKGROUND We are in the midst of a pandemic of obesity, which is complicating the care of patients with coronary artery disease (CAD). METHODS We examined 2730 patients enrolled from 2002 to 2004 in the IEPR-2. Baseline and outcome variables were stratified by the entry BMI in kilograms per meter squared. RESULTS Obesity (BMI > 30 kg/m2) was common (40.6%) among patients with severe CAD referred for EECP. Within the total cohort, 2.6% was underweight (BMI < or = 20 kg/m2) and 4.5% was morbidly obese (BMI > 40 kg/m2). Prevalence of diabetes, hypertension, dyslipidemia, and... read more

2005

Angiogenic Effects of Long-term Enhanced External Counterpulsation in a Dog Model of Myocardial Infarction

Wu G, Du Z, Hu C, Zheng Z, Zhan C, Ma H, Fang D, Ahmed KT, Laham RJ, Hui JCK, Lawson WE, American Journal of Physiology – Heart and Circulatory Physiology, 2005, 2006 Jan;290(1):H248-54. Epub 2005 Aug 19 abstract
Angiogenic Effects of Long-term Enhanced External Counterpulsation in a Dog Model of Myocardial Infarction Enhanced external counterpulsation (EECP) is an effective noninvasive treatment of coronary artery disease. Its mechanism of action remains unknown. An acute coronary occlusion dog model was created to explore the angiogenic effect of EECP. After coronary occlusion, 12 dogs were randomly assigned to either EECP (n = 6) or control (n = 6). Immunohistochemical studies of alpha-actin and von Willebrand factor (vWF) were used to detect newly developed microvessels. Systemic and local vascular endothelial growth factor (VEGF) were identified by ELISA and reverse transcriptase PCR analysis. There was a significant increase in the density of microvessels per squared millimeter in the infarcted regions of the EECP group compared with the control group (vWF, 15.2 +/- 6.3 vs. 4.9 ± 2.1,... read more

The Effects of Enhanced External Counterpulsation on Myocardial Perfusion in Patients with Stable Angina: A Multicenter Radionuclide Study

Michaels ADF, Raisinghani A, Soran O, de Lame PA, Lemaire ML, Kligfield P, Watson DD, Conti CR, Beller G, American Heart Journal, 2005, 2005 Nov;150(5):1066-1073 abstract
The Effects of Enhanced External Counterpulsation on Myocardial Perfusion in Patients with Stable Angina: A Multicenter Radionuclide Study BACKGROUND Enhanced external counterpulsation (EECP) reduces angina and extends time to exercise-induced ischemia in patients with symptomatic coronary disease. One- and two-center studies and a retrospective case series reported that EECP improves myocardial perfusion in stable angina pectoris. We sought to critically evaluate and quantify the effect of EECP on myocardial perfusion. METHODS In 6 US university hospitals, EECP was performed for 35 hours in patients with class II to IV angina who had exercise-induced myocardial ischemia. Symptom-limited quantitative gated technetium Tc 99m sestamibi single photon emission computed tomography exercise perfusion imaging was performed at baseline and 1 month post-EECP. Sestamibi was injected at the same heart rate in both stress tests. Single photon emission computed tomography images were read... read more

Enhanced External Counterpulsation Improves Endothelium-Dependent Vasorelaxation in the Carotid Arteries of Hypercholesterolemic Pigs

Tao J, Tu C, Yang Z, Zhang Y, Chung XL, Ma H, Zhen ZS, International Journal of Cardiology, 2005, 2005 Nov 23; [Epub ahead of print] abstract
Enhanced External Counterpulsation Improves Endothelium-Dependent Vasorelaxation in the Carotid Arteries of Hypercholesterolemic Pigs BACKGROUND Enhanced external counterpulsation (EECP) has been demonstrated to be an effective method for the treatment of atherosclerotic vascular disease. However, the exact mechanism underlying the beneficial effects of EECP is not completely clear. We hypothesized that EECP leads to improvement in endothelial function, contributing to its clinical benefits. METHODS Fifteen male domestic pigs were initially divided into 2 dietary groups: one consumed a normal feeding (NF) of pig chow (n=5), and one consumed a high-fat (HF) pig chow (n=10). After 8 weeks on the NF or HF diet, 5 HF pigs received EECP treatment (HF+EECP) 1 h daily for 6 weeks and the remaining 5 HF pigs continued to be fed by high cholesterol diet. At the end of... read more

Effects of Enhanced Counterpulsation on Vascular Cell Release of Coagulation Factors

Arora R, Chen HJ, Rabbani L, Heart & Lung: The Journal of Acute Critical Care, 2005, 2005 Jul-Aug;34(4):252-256 abstract
Effects of Enhanced Counterpulsation on Vascular Cell Release of Coagulation Factors BACKGROUND Enhanced external counterpulsation (EECP), a noninvasive treatment for patients with angina pectoris, provides long-term benefits of decreased anginal frequency and improved exercise tolerance. Previous studies have suggested that shear stress may result in angiogenesis and alter endothelial hemostatic factor release. Whether EECP therapy effects an alteration in endothelial cell proliferation and function remains unclear. The level of vascular endothelial growth factor (VEGF) and four other endothelial hemostatic factors (tissue plasminogen activator, plasminogen activator inhibitor-1, von Willebrand factor, and D-dimers) were measured in patients before and after 35 hours of EECP treatment. METHODS Plasma levels of endothelial growth and hemostatic factors were assessed using the standard enzyme-linked immunosorbent method. RESULTS No significant difference in the hemostatic factors and VEGF after... read more

Current Nonpharmacologic Management of Coronary Artery Disease: Focus on External Counterpulsation

Conti CR, Current Treatment Options in Cardiovascular Medicine, 2005, 2005 May;7(1):81-86 abstract
Current Nonpharmacologic Management of Coronary Artery Disease: Focus on External Counterpulsation The basic principle of enhanced external counterpulsation (EECP) is diastolic augmentation of arterial pressure, lowering of systolic arterial pressure along with increasing venous return. EECP is a noninvasive procedure involving sequential inflation and rapid deflation of compressive cuffs wrapped around the patient's calves, thighs, and lower abdomen, timed to the cardiac cycle using the electrocardiogram. Theoretically, this should result in decreased myocardial oxygen demand and an increased coronary blood flow. Long-term benefits may be the result of the opening of dormant coronary collateral circulation, but this is theory and not proven. Extracardiac factors, such as peripheral arterial stiffness, endothelial dysfunction, and elevated myocardial oxygen demand, are also the therapeutic targets for EECP. There is some evidence that long-term benefits may... read more

Predictors of Benefit in Angina Patients One Year After Completing Enhanced External Counterpulsation: Initial Responders to Treatment Versus Nonresponders

Lawson WE, Hui JCK, Kennard ED, Barsness G, Kelsey SF, Cardiology, 2005, 2005 Apr 13;103(4):201-206 abstract
Predictors of Benefit in Angina Patients One Year After Completing Enhanced External Counterpulsation: Initial Responders to Treatment Versus Nonresponders Enhanced external counterpulsation (EECP) has been shown to reduce Canadian Cardiovascular Society angina class. This study examines the factors that affect the reduction at 1 year, especially in patients who do not demonstrate an initial response. The data of 2,007 consecutive patients enrolled in the International EECP Patient Registry were analyzed. After 36.6 +/- 4.9 h of EECP, angina was reduced by at least one class in 82.7%. At 1 year, 35.4% of initial nonresponders and 70.6% of responders remained improved by at least one angina class and free of major adverse cardiovascular events. Multivariate predictors of 1-year benefit are initial response to treatment (odds ratio 4.5, 95% CI 3.5-5.8), baseline angina class compared with class IV (odds ratios: class... read more

Treating Heart Failure With Enhanced External Counterpulsation (EECP): Design of the Prospective Evaluation of EECP in Heart Failure (PEECH) Trial

Feldman AM, Silver AM, Francis GS, de Lame P, Parmley WW, Journal of Cardiac Failure, 2005, 2005 Apr;11(3):240-245 abstract
Treating Heart Failure With Enhanced External Counterpulsation (EECP): Design of the Prospective Evaluation of EECP in Heart Failure (PEECH) Trial Background Enhanced external counterpulsation (EECP) treatment can improve exercise tolerance in patients with ischemic heart disease; however, the possible benefits of EECP in patients with stable heart failure (HF) and left ventricular dysfunction (LVD) are unclear. An open pilot study showed significant increases in exercise tolerance in HF patients undergoing EECP. Thus a larger, controlled study of EECP in patients with stable HF (New York Heart Association [NYHA] classes II and III) and LVD was undertaken. Methods and Results The PEECH trial is a controlled, randomized, single-blind, parallel-group, multicenter study of 187 patients with symptomatic but stable HF (NYHA classes II and III) and an LV ejection fraction _35% was designed to assess the efficiency of EECP in patients with... read more

Enhanced external counterpulsation improves systolic function by echocardiography in patients with coronary artery disease

Rohit R. Arora, MD, Santos Lopez, MD, and Mohammed Saric, MD, Heart Lung®, 2005, 2005;34:122–5 abstract
Enhanced external counterpulsation improves systolic function by echocardiography in patients with coronary artery disease Method 14 consecutive patients with coronary artery disease and refractory angina pectoris were selected for EECP treatment if they met the following criteria: (1) age between 21 and 81 years; (2) symptoms consistent with Canadian Cardiovascular Society Classification angina levels I, II or III; (3) documented evidence of coronary artery disease; and (4) exercise treadmill test (ETT) positive for ischemia. Patients were excluded if they had medical conditions that contraindicated EECP or that might interfere with study. The subjects received 35 hours of EECP treatment. All patients underwent resting and dobutamine stress echocardiography (DSE) before and after EECP therapy. Two-dimensional and Doppler echocardiography examinations were performed with Acuson Sequoia machines (Mountain View, CA) equipped with a variable-frequency phased-array transducer (2.5... read more

Enhanced External Counter Pulsation (EECP) as a Novel Treatment for Restless Legs Syndrome (RLS): A Preliminary Test of the Vascular Neurologic Hypothesis for RLS

Rajaram SS, Shanahan J, Ash C, Walters AS, Weisfogel G, Sleep Medicine, 2005, 2005 Mar;6(2):101-106. Epub 2005 Jan 24 abstract
Enhanced External Counter Pulsation (EECP) as a Novel Treatment for Restless Legs Syndrome (RLS): A Preliminary Test of the Vascular Neurologic Hypothesis for RLS BACKGROUND AND PURPOSE Enhanced external counter pulsation (EECP) is used to treat angina. With sustained treatment this increases collateral circulation to the coronary arteries as well as to the body as a whole. We found some patients who underwent EECP for angina or congestive heart failure who also coincidentally had severe Restless Legs Syndrome (RLS). Case reports are presented. PATIENTS AND METHODS Six patients with RLS (1F, 5M, ages 55-80) underwent EECP treatment. All patients were given the International RLS Study Group rating scale for RLS (the IRLS) before and immediately after 35 days of EECP treatment. RESULTS The average IRLS rating scale score of the six patients before treatment was 28.8 (range 23-35), which indicates frequent and moderate to... read more

An Update on Enhanced External Cunterpulsation.

Shea ML, Conti CR, Arora RR, Clinical Cardiology, 2005, 2005 Mar;28(3):115-118 abstract
An Update on Enhanced External Cunterpulsation. The development of advanced revascularization techniques has resulted in the growth of a subset of patients with coronary artery disease who are nonrevascularizable and are considered to have refractory angina. Enhanced external counterpulsation (EECP) has been developed for the management of these patients with chronic, refractory disease. Evidence has shown that through improvement of vascular endothelial function and recruitment of collateral vessels, EECP provides many clinical benefits. These patients experience sustained decreases in angina, improvement in exercise time, improved myocardial perfusion, and enhanced quality of life. Furthermore, EECP appears to be safe and effective in the treatment of angina in patients with impaired systolic function and has similar potential in patients with congestive heart failure. ... read more

Enhanced External Counterpulsation: A New Technique to Augment Renal Function in Liver Cirrhosis

Werner D, Trägner P, Wawer A, Porst H, Werner DG, Gross P, Nephrology Dialysis Transplantation, 2005, 2005 Mar 23; [Epub ahead of print] abstract
Enhanced External Counterpulsation: A New Technique to Augment Renal Function in Liver Cirrhosis BACKGROUND Advanced liver cirrhosis is characterized by cardiovascular changes, such as low arterial blood pressure, peripheral vasodilation and renal vasoconstriction. As a consequence, renal hypoperfusion, impaired diuresis and natriuresis and eventual hepatorenal syndrome may ensue. Previous studies using head-out water immersion to increase central blood volume have demonstrated the functional nature of the renal abnormalities. Enhanced external counterpulsation (EECP) is a new non-invasive cardiac assist device to augment diastolic blood pressure by electrocardiogram-triggered diastolic inflation and deflation of cuffs wrapped around the lower extremities. We investigated whether EECP would improve renal dysfunction of liver cirrhosis. METHODS Twelve healthy controls and 19 patients with liver cirrhosis were observed during 2 h of baseline followed by 2 h of EECP. The following... read more

Angina Patients with Diastolic Versus Systolic Heart Failure Demonstrate Comparable Immediate and One-Year Benefit from Enhanced External Counterpulsation

Lawson WE, Silver MA, Hui JCK, Kennard ED, Kelsey SF, Journal of Cardiac Failure, 2005, 2005 Feb;11(1):61-66 abstract
Angina Patients with Diastolic Versus Systolic Heart Failure Demonstrate Comparable Immediate and One-Year Benefit from Enhanced External Counterpulsation BACKGROUND Enhanced external counterpulsation (EECP) is effective in treating angina in coronary artery disease patients. Whether EECP produces similar immediate and sustained benefits and freedom from adverse events (MACE) at 1 year in patients with severe systolic dysfunction versus diastolic dysfunction is unknown. METHODS AND RESULTS Data of 746 angina patients with a history of heart failure enrolled in the International EECP Registry were divided into 2 groups: left ventricular ejection fraction (LVEF) < or =35% (S) and LVEF >35% (D). Mean LVEF was 51.0 +/- 10.2% in diastolic dysfunction (n=391) versus 26.3 +/- 6.9% in systolic dysfunction (n=355). At baseline, 92.0% of diastolic dysfunction and 90.9% of systolic had Canadian Cardiovascular Society Class III/IV angina with similar number of... read more

Frequency and Efficacy of Repeat Enhanced External Counterpulsation for Stable Angina Pectoris (from the International EECP Patient Registry)

Michaels AD, Barsness GW, Soran O, Kelsey SF, Kennard ED, Hui JCK, and Lawson WE for the International EECP Patient Registry Investigators, American Journal of Cardiology, 2005, 2005 Feb;95(3):394-397 abstract
Frequency and Efficacy of Repeat Enhanced External Counterpulsation for Stable Angina Pectoris (from the International EECP Patient Registry) We assessed the frequency, efficacy, predictors, and long-term success of repeat enhanced external counterpulsation (EECP) therapy in relieving angina in a large cohort of patients who had chronic angina pectoris and had undergone a full course of EECP. Within 2 years of the initial course of EECP, the rate of repeat EECP was 18%, which occurred at a mean interval of 378 days after initial EECP. Of those who underwent repeat EECP, 70% had a decrease of >1 angina class at the end of repeat EECP with similar decreases in nitroglycerin use. ... read more

Enhanced External Counterpulsation Does Not Compromise Cerebral Autoregulation

Marthol H, Werner D, Brown CM, Hecht M, Daniel WG, Hilz MJ, Acta Neurologica Scandinavica, 2005, 2005 Jan;111(1):34-41 abstract
Enhanced External Counterpulsation Does Not Compromise Cerebral Autoregulation OBJECTIVES Enhanced external counterpulsation (EECP) rhythmically augments blood pressure (BP) by diastolic lower-body compression. Recently, we showed decreased mean cerebral blood flow velocity (CBFVmean) in young healthy persons during EECP, but unchanged CBFVmean in atherosclerotic patients. In this study, we assessed EECP effects on dynamic cerebral autoregulation (CA). MATERIAL& METHODS In 23 healthy persons and 15 atherosclerotic patients we monitored heart rate (HR), mean BP (BPmean) and CBFVmean before and during 5 min EECP. We analyzed spectral powers of HR, BPmean and CBFV mean in the low (LF: 0.04-0.15 Hz) and high (HF: 0.15-0.5 Hz) frequency ranges to determine CA from the LF-transfer function gain and phase shift between BPmean and CBFV mean oscillations. RESULTS EECP increased HR and BPmean,... read more

2004

Effects of Enhanced External Counterpulsation on Hemodynamics and its Mechanism-Relation to Neurohormonal Factors

Taguchi I, Ogawa K, Kanaya T, Matsuda R, Kuga H, Nakatsugawa M, Circulation Journal, 2004, 2004 Nov;68(11):1030-1034 abstract
Effects of Enhanced External Counterpulsation on Hemodynamics and its Mechanism-Relation to Neurohormonal Factors BACKGROUND The hemodynamic effects of enhanced external counterpulsation (EECP) and its mechanism(s) were investigated in relation to neurohumoral factors in patients with acute myocardial infarction (AMI). METHODS AND RESULTS Twenty-four patients with AMI were studied before, during and after EECP treatment for 60 min. Heart rate (HR), right atrial pressure (RAP), pulmonary capillary wedge pressure (PCWP) and cardiac index (CI) were determined. In addition, circulating concentrations of neurohumoral factors were determined at each time point. HR did not change following EECP treatment. However, RAP and PCWP increased significantly and CI was significantly elevated during EECP and thereafter. Blood atrial natriuretic peptide (ANP) concentration was significantly increased 15 and 60 min after the start of EECP treatment, but brain natriuretic peptide... read more

Angina Pectoris: A Review of Current and Emerging Therapies

Parker JO, American Journal of Managed Care, 2004, 2004 Oct;10(11 Suppl):S332-338 abstract
Angina Pectoris: A Review of Current and Emerging Therapies Angina pectoris is a debilitating indication of the presence of ischemic heart disease that affects millions of Americans. Although a number of pharmacologic treatments are available, the annual number of revascularization surgeries continues to rise in the United States. Other management strategies, such as spinal cord stimulation, enhanced external counterpulsation, metabolic modulators, and gene therapy, are being explored. ... read more

Current and Future Treatment Strategies for Refractory Angina

Yang EH, Barsness GW, Gersh BJ, Chandrasekaran K, Lerman A, Mayo Clinic Proceedings, 2004, 2004 Oct;79(10):1284-1292 abstract
Current and Future Treatment Strategies for Refractory Angina Patients with refractory angina are not candidates for revascularization and have both class III or IV angina and objective evidence of ischemia despite optimal medical therapy. An estimated 300,000 to 900,000 patients in the United States have refractory angina, and 25,000 to 75,000 new cases are diagnosed each year. This review focuses on treatment strategies for refractory angina and includes the mechanism of action and clinical trial data for each strategy. The pharmacological agents that have been used are ranolazine, ivabradine, nicorandil, L-arginine, testosterone, and estrogen; currently, only L-arginine, testosterone, and estrogen are approved by the Food and Drug Administration. Results with the noninvasive treatments of enhanced external counterpulsation and transcutaneous electrical nerve stimulation are provided. Invasive treatment strategies including... read more

Accelerated Reperfusion of Poorly Perfused Retinal Areas in Central Retinal Artery Occlusion and Branch Retinal Artery Occlusion After a Short Treatment with Enhanced External Counterpulsation

Werner D, Michalk F, Harazny J, Hugo C, Daniel WG, Michelson G, Retina, 2004, 2004 Aug;24(4):541-547 abstract
Accelerated Reperfusion of Poorly Perfused Retinal Areas in Central Retinal Artery Occlusion and Branch Retinal Artery Occlusion After a Short Treatment with Enhanced External Counterpulsation BACKGROUND To date, no satisfactory therapy has become available for patients with acute central retinal artery occlusion (CRAO) or branch retinal artery occlusion (BRAO). Enhanced external counterpulsation (EECP) is a new noninvasive procedure that increases perfusion of inner organs. In the current study, the authors measured the impact of EECP on reperfusion in ischemic retinal tissue. METHODS In a prospective, randomized study, 20 patients with CRAO or BRAO were included. Ten patients were given hemodilution therapy and 2 hours of EECP, and 10 patients were given regular hemodilution therapy only. Quantification of changes in retinal perfusion was carried out by means of scanning laser Doppler flowmetry (in arbitrary units). RESULTS Enhanced external counterpulsation caused no observable adverse events. A significant... read more

Effectiveness of Enhanced External Counterpulsation in Patients with Left Main Disease and Angina

Lawson WE, Hui JCK, Barsness GW, Kennard ED, Kelsey SF for the IEPR Investigators, Clinical Cardiology, 2004, 2004 Aug;27(8):459-463 abstract
Effectiveness of Enhanced External Counterpulsation in Patients with Left Main Disease and Angina Background Enhanced external counterpulsation (EECP) is a noninvasive device that uses three pairs of sequentially inflated pneumatic cuffs applied to the lower extremities and synchronized with the heart beat to provide diastolic augmentation, increase coronary blood pressure and flow, venous return and cardiac output, and decrease afterload. Hypothesis This study examines the safety and effectiveness of EECP therapy in patients with significant left main coronary artery disease (LMD). Methods In all, 2,861 patients enrolled in the International EECP Patient Registry (IEPR) were divided into three groups, those without LMD (n = 2,377), those with LMD and prior CABG (n = 431), and those with unbypassed LMD (n = 53). Results Patients with LMD, with or without prior CABG, were significantly... read more

Enhanced External Counterpulsation Therapy: Significant Clinical Improvement without Electrophysiologic Remodeling

Henrickson CA, Chandra-Strobos N, Annals of Noninvasive Electrocardiology, 2004, 2004 Jul;9(3):265-269 abstract
Enhanced External Counterpulsation Therapy: Significant Clinical Improvement without Electrophysiologic Remodeling BACKGROUND Enhanced external counterpulsation therapy (EECP), in addition to improving coronary flow and increasing the time to ischemia, noninvasively alters hemodynamics in patients with severe coronary artery disease (CAD). Other treatments that alter hemodynamics, for example, balloon valvuloplasty, left ventricular assist devices, and pharmacologic antagonism of the rennin-angiotensin system, promote electrophysiologic remodeling, as evidenced by alterations in the QT interval. METHODS We studied 28 patients who completed a 7-week, 35-hour session of EECP to assess whether such therapy would also result in electrophysiologic remodeling. RESULTS All patients had class II-III angina, imaging-proven ischemia, and severe, near-inoperable CAD. Of 28 patients, with a mean age 62 +/- 13 years (mean +/- SD), 78% were male, 46% diabetic, 82% hypertensive, 60% had... read more

Enhanced External Counterpulsation Improves Skin Oxygenation and Perfusion

Hilz MJ, Werner D, Marthol H, Flachskampf FA, Daniel WG, European Journal of Clinical Investigation, 2004, 2004 Jun;34(6):385-391 abstract
Enhanced External Counterpulsation Improves Skin Oxygenation and Perfusion BACKGROUND Enhanced external counterpulsation (EECP) augments diastolic and reduces systolic blood pressures. Enhanced external counterpulsation has been shown to improve blood flow in various organ systems. Beneficial effects on skin perfusion might allow EECP to be used in patients with skin malperfusion problems. This study was performed to assess acute effects of EECP on superficial skin blood flow, transdermal oxygen and carbon dioxide pressures. MATERIALS AND METHODS We monitored heart rate, blood pressure, transdermal blood flow as well as oxygen and carbon dioxide pressures in 23 young, healthy persons (28 +/- 4 years) and 15 older patients (64 +/- 7 years) with coronary artery disease before, during and 3 min after 5 min EECP. Friedman test was used to compare... read more

Successful Treatment of Symptomatic Coronary Endothelial Dysfunction with Enhanced External Counterpulsation

Bonetti PO, Gadasalli SN, Lerman A, Barsness GW, Mayo Clinic Proceedings, 2004, 2004 May;79(5):690-692 abstract
Successful Treatment of Symptomatic Coronary Endothelial Dysfunction with Enhanced External Counterpulsation Enhanced external counterpulsation (EECP) is a valuable therapeutic option for patients with coronary artery disease and refractory angina. Although the exact mechanisms by which this technique exerts favorable effects remain unclear, improvement in endothelial function is considered a potential mechanism contributing to the clinical benefit associated with EECP. We describe a young woman with severely symptomatic coronary endothelial dysfunction in the absence of obstructive coronary artery disease who experienced a dramatic and sustained reduction in symptoms in response to a standard 35-hour course of EECP. ... read more

Enhanced external counterpulsation in ischemic heart disease and congestive heart failure

Lisa Mielniczuk, Luís Beck da Silva, Haissam Haddad, Canadian Medical Association J., 2004, 2004 April13;170(8): 1223-1224 abstract
Enhanced external counterpulsation in ischemic heart disease and congestive heart failure Recently published clinical trial demonstrated improved exercise tolerance and quality of life after EECP for patients with New York Heart Association class II–III heart failure (average ejection fraction of 23%) secondary to ischemic or dilated cardiomyopathy. There were no significant adverse events reported. Furthermore, data from the International EECP Patient Registry show that that patients with reduced left ventricular function (< 35%) achieved similar reductions in angina as those with preserved ejection fraction. The cost is currently estimated to be US$5000–$7000 for a 35-treatment session. However, if found to be effective and safe, EECP could result in an enormous cost savings by reducing the amount of medication patients require and the occurrence of adverse events secondary to medication interactions that... read more

Improvement of Oxygen Metabolism in Ischemic Myocardium as a Result of Enhanced External Counterpulsation with Heparin Pretreatment for Patients with Stable

Masuda D, Fujita M, Nohara R, Matsumori A, Sasayama S, Heart Vessels, 2004, 2004 Mar;19(2):59-62 abstract
Improvement of Oxygen Metabolism in Ischemic Myocardium as a Result of Enhanced External Counterpulsation with Heparin Pretreatment for Patients with Stable Enhanced external counterpulsation (EECP) is noninvasive, safe, and effective for stable angina. We have reported that the development of functional collateral vessels is one of the mechanisms of EECP therapy using ammonia positron emission tomography (PET). The efficacy of heparin treatment on collateral growth is shown in several clinical studies. We evaluated whether EECP combined with intravenous heparin injection is effective for exercise capacity and oxygen metabolism of ischemic myocardium in stable angina. Eleven patients with stable angina were treated with conventional EECP therapy (C group). Seven patients with stable angina were treated with EECP therapy with 5000 IU heparin pretreatment (H group). At baseline and after the completion of treatment H, 7 patients underwent 11C-acetate PET to examine the... read more

Effect of Enhanced External Counterpulsation on Dobutamine-induced Left Ventricular Wall Motion Abnormalities in Severe Chronic Angina Pectoris

Bagger JP, Hall RJ, Koutroulis G, Nihoyannopoulos P, American Journal of Cardiology, 2004, 2004 Feb 15;93(4):465-467 abstract
Effect of Enhanced External Counterpulsation on Dobutamine-induced Left Ventricular Wall Motion Abnormalities in Severe Chronic Angina Pectoris We studied the effect of enhanced external counterpulsation (EECP) in 23 consecutive patients with stable angina pectoris who had a positive dobutamine stress echocardiogram. After EECP, stress-induced wall motion score (WMS) improved by > or =2 grades in 43% of the patients (n = 10); the average improvement was 5.3 +/- 3.8 compared with -0.6 +/- 3.0 in the remaining 13 patients (p = 0.007). The diastolic/systolic augmentation ratio increased by 217% in response to the full course of EECP (p = 0.0002) among patients with improved WMS, and by 71% (p = 0.004) among the other patients; the increase was greater among patients with improved WMS than among patients with no improvement (p = 0.01). After EECP, Canadian Cardiovascular... read more

Two-Year Outcomes After Enhanced External Counterpulsation for Stable Angina Pectoris (from the International Patient Registry [IEPR]

Michaels AD, Linnemeier G, Soran O, Kelsey SF, Kennard ED, American Journal of Cardiology, 2004, 2004 Feb 15;93(4):461-464 abstract
Two-Year Outcomes After Enhanced External Counterpulsation for Stable Angina Pectoris (from the International Patient Registry [IEPR] We assessed the long-term outcomes of enhanced external counterpulsation in relieving angina and improving the quality of life in a large cohort of patients with chronic angina pectoris. Seventy-three percent had a reduction by > or =1 angina class at the end of treatment, and 50% reported an improvement in the quality-of-life assessment after enhanced external counterpulsation; these results were sustained at 2-year follow-up. ... read more

A New Treatment Modality in Heart Failure Enhanced External Counterpulsation (EECP)

Soran O, Cardiology in Review, 2004, 2004 Jan-Feb;12(1):15-20 abstract
A New Treatment Modality in Heart Failure Enhanced External Counterpulsation (EECP) Heart failure remains a significant health problem in the United States and in the world. Despite a surfeit of recent diagnostic and therapeutic advances, patients with heart failure remain inadequately helped. The overwhelming need for new and better therapies continues to stimulate scientists to investigate new technologies. Over the past several years the use of enhanced external counterpulsation as a treatment for chronic angina has steadily increased. Recently, its potential role in heart failure management has been shown. We review the role of enhanced external counterpulsation in heart failure management as an emerging noninvasive outpatient therapy. ... read more

2003

Enhanced External Counterpulsation as Initial Revascularization Treatment for Angina Refractory to Medical Therapy

Fitzgerald CP, Lawson WE, Hui JCK, Kennard ED; IEPR Investigators, Cardiology, 2003, 2003 Nov;100(3):129-135 abstract
Enhanced External Counterpulsation as Initial Revascularization Treatment for Angina Refractory to Medical Therapy Enhanced external counterpulsation (EECP) is effective in patients with angina refractory to medical therapy or revascularization. However, as a noninvasive treatment it should perhaps be considered the first-line treatment with invasive revascularization reserved for EECP failures or high-risk patients. The International EECP Patient Registry was used to analyze a cohort of patients with prior percutaneous coronary intervention (PCI) and/or coronary artery bypass graft (CABG) (n = 4,454) compared with a group of patients (PUMPERS) who were candidates for PCI and/or CABG and chose EECP as their initial revascularization treatment (n = 215). The PUMPERS responded to treatment with EECP with decreased anginal episodes and nitroglycerin use and with improvement in their Canadian Cardiovascular Society functional class, similarly to previously revascularized... read more

Functional Status Improvement After Enhanced External Counterpulsation (EECP) for Treatment of Chronic Angina Pectoris

Kennard ED, Linnemeier G, Kelsey SF, Proceedings of the 5th International Congress on Coronary Artery Disease – Frontiers in Coronary Artery Disease, 2003, 2003 Oct 19-21;(Florence, Italy):187-189 abstract
Functional Status Improvement After Enhanced External Counterpulsation (EECP) for Treatment of Chronic Angina Pectoris The International EECP Patient Registry (IEPR) collects data from 60 sites on consecutive chronic angina patients treated with EECP. The Duke Activity Index (DASI), a 12 item patient completed questionnaire, was used to measure functional capacity in patients before and after a course of EECP treatment. The Canadian Cardiovascular Society Classification (CCSC) of angina was used to monitor changes in angina. The majority of patients had severe angina, had prior invasive revascularization, but were not suitable for bypass surgery or percutaneous intervention. Functional status measured by the DASI questionnaire was poor at baseline, but improved significantly after EECP treatment. Co-morbidities although predictive of low baseline DASI, were not associated with failure to achieve functional improvement. ... read more

Enhanced External Counterpulsation for the Relief of Angina in Patients with Diabetes: Safety, Efficacy and 1-Year Clinical Outcomes

Linnemeier G, Rutter MK, Barsness G, Kennard ED, Nesto RW; IEPR Investigators, American Heart Journal, 2003, 2003 Sep;146(3):453-458 abstract
Enhanced External Counterpulsation for the Relief of Angina in Patients with Diabetes: Safety, Efficacy and 1-Year Clinical Outcomes BACKGROUND Patients with diabetes are at greater risk for coronary events, yet they are less likely to benefit from revascularization than those without diabetes. Enhanced external counterpulsation has recently emerged as a treatment option for select patients with chronic stable angina. METHODS We examined baseline characteristics, angina response, and cardiac outcomes of patients with diabetes mellitus treated with Enhanced External Counterpulsation (EECP) for chronic stable angina. Data were collected from patients enrolled in the International EECP Patient Registry (IEPR) before and after a course of EECP, and at 1 year after completion of treatment. RESULTS Of 1532 IEPR patients studied, 43% had diabetes mellitus at baseline. Patients with diabetes were experiencing, on average, 11 episodes of angina per week. Most... read more

Analysis of Baseline Factors Associated with Reduction in Chest Pain in Patients with Angina Pectoris Treated by Enhanced External Counterpulsation

Lawson WE, Kennard ED, Hui JCK, et al, The American Journal of Cardiology, 2003, 2003 Aug 15;92(4):439-443 abstract
Analysis of Baseline Factors Associated with Reduction in Chest Pain in Patients with Angina Pectoris Treated by Enhanced External Counterpulsation Data from the International Enhanced External Counterpulsation (EECP) Patient Registry were analyzed To determine which patient characteristics influence improvement in angina class with EECP treatment. Patients with severe disabling angina at baseline, men, and those without a history of smoking are more likely to improve their angina class after EECP, whereas those with diabetes mellitus, prior bypass surgery, and heart failure were less likely to benefit.   ... read more

Enhanced External Counterpulsation for Refractory Angina Pectoris

Sinvhal RM, Gowda RM, Khan IA, Heart, 2003, 2003 Aug;89(8):830-833 abstract
Enhanced External Counterpulsation for Refractory Angina Pectoris Enhanced external counterpulsation (EECP) is a non-invasive outpatient treatment used for angina pectoris. In patients with intractable angina refractory to aggressive surgical and medical treatment, several novel strategies are considered including EECP, transmural laser revascularization, and spinal cord stimulation. EECP produces an acute hemodynamic effect that is presumed to be similar to that produced by the invasive intra-aortic balloon pump. By applying a series of compressive cuffs sequentially from the calves to the thigh muscles upon diastole and rapidly deflating the cuffs in early systole, an increase in diastolic and decrease in systolic pressure is created. Although data indicate improvement in angina in patients undergoing EECP, the role of EECP in the treatment of angina pectoris has not yet been... read more

Enhanced External Counterpulsation for Ischemic Heart Disease: What’s Behind the Curtain?

Bonetti PO, Holmes DR Jr, Lerman A, Barsness GW, Journal of the American College of Cardiology, 2003, 2003 Jun 4;41(11):1918-1925 abstract
Enhanced External Counterpulsation for Ischemic Heart Disease: What’s Behind the Curtain? Enhanced external counterpulsation (EECP) has been shown to reduce angina and to improve objective measures of myocardial ischemia in patients with refractory angina. Prospective clinical studies and large treatment registries suggest that a course of EECP is associated with prolongation of the time to exercise-induced ST-segment depression and resolution of myocardial perfusion defects, as well as with enhanced exercise tolerance and quality of life. With a growing knowledge base supporting the safety and beneficial clinical effects associated with EECP, this therapy can be considered a valuable treatment option, particularly in patients who have exhausted traditional revascularization methods and yet remain symptomatic despite optimal medical care. However, although the concept of external counterpulsation was introduced almost four decades ago, and despite... read more

Exercise Capability and Myocardial Perfusion in Chronic Angina Patients Treated with Enhanced External Counterpulsation

Tartaglia J, Stenerson Jr J, Charney R, et al, Clinical Cardiology, 2003, 2003 Jun;(26):287-290 abstract
Exercise Capability and Myocardial Perfusion in Chronic Angina Patients Treated with Enhanced External Counterpulsation BACKGROUND Enhanced external counterpulsation (EECP) has been shown to improve treadmill times and myocardial perfusion. However, improvement in perfusion defects has been demonstrated only in patients exercised to the same cardiac workload on the post-EECP as the pre-EECP stress test. HYPOTHESIS This study was to determine the effect of EECP on exercise capacity and myocardial perfusion by comparing results of maximal exercise radionuclide testing pre- and post-EECP treatment. METHODS This prospective study included 25 patients with angina who had performed maximal symptom-limited exercise tolerance tests (ETT) with Bruce protocol and radionuclide perfusion single-photon emission computed tomography (SPECT) study prior to and at completion of EECP treatment. RESULTS After 35 h of EECP, 23 patients (93%) improved by at least one... read more

Changes of Cerebral Blood Flow Velocities During Enhanced External Counterpulsation

Werner D, Marthol H, Brown CM, Daniel WG, Hilz MJ, Acta Neurologica Scandinavica, 2003, 2003 Jun;107(6):405-411 abstract
Changes of Cerebral Blood Flow Velocities During Enhanced External Counterpulsation Objectives Intra-aortic counterpulsation is the most frequently used cardiac assist device. However, there are only few studies of the effects of counterpulsation on cerebral blood flow and these report conflicting outcomes. The new enhanced external counterpulsation (BECP) technique reproduces non-invasively the effects of intra-aortic counterpulsation. In this study, we evaluated effects of EECP on blood pressure (BP) and on cerebral flow velocity (CBFV). Subjects and methods Twenty-three healthy controls and 15 atherosclerotic patients each underwent a 5-min session of EECP. Before, during and after EECP we monitored heart rate, beat-to-beat radial artery BP and CBFV. Results EECP induced a second increase in BP and CBFV during diastole with a significant increase of mean BP and a decrease of systolic BP... read more

Enhanced External Counterpulsation Improves Endothelial Function in Patients with Symptomatic Coronary Artery Disease

Bonetti PO, Barsness GW, Keelan PC, et al, Journal of the American College of Cardiology, 2003, 2003 May 21;41(10):1761-1768 abstract
Enhanced External Counterpulsation Improves Endothelial Function in Patients with Symptomatic Coronary Artery Disease OBJECTIVES The goal of this study was to examine the effect of enhanced external counterpulsation (EECP) on endothelial function. BACKGROUND Enhanced external counterpulsation improves symptoms and exercise tolerance in patients with symptomatic coronary artery disease (CAD). However, the exact mechanisms by which this technique exerts its clinical benefit are unclear. METHODS Reactive hyperemia-peripheral arterial tonometry (RH-PAT), a noninvasive method to assess peripheral endothelial function by measuring reactive hyperemic response in the finger, was performed in 23 patients with refractory angina undergoing a 35-h course of EECP. In each patient RH-PAT measurements were performed before and after the first, at midcourse, and the last EECP session. In addition, RH-PAT response was assessed one month after completion of EECP therapy; RH-PAT index,... read more

Enhanced External Counterpulsation in the Management of Angina in the Elderly

Linnemeier G, Michaels AD, Soran O, et al, American Journal of Geriatric Cardiology, 2003, 2003 Mar-Apr;12(2):90-6 abstract
Enhanced External Counterpulsation in the Management of Angina in the Elderly This study was undertaken to determine whether enhanced external counterpulsation is a safe and effective treatment for angina in octogenarians. In this prospective observational study, demographic and clinical outcome data on patients consecutively enrolled in the International EECP Patient Registry was examined. Of the 3037 patients analyzed, 249 (8%) were >/=80 years old. Octogenarians were more likely to be female and have a history of congestive heart failure (41% vs. 29%; p<0.001). They were less likely to have had previous revascularization. Fewer patients in the octogenarian group (76% vs. 84%; p<0.01) completed a course of treatment. Of those octogenarian patients who completed treatment, 76% reported a reduction in angina and quality of life improved significantly. Adverse events related to treatment... read more

Enhanced External Counterpulsation

Lam L, Mahmood S, Asian Cardiovascular & Thoracic Annals, 2003, 2003 Mar;11(1):92-94 abstract
Enhanced External Counterpulsation Enhanced external counterpulsation is a noninvasive technique designed to increase myocardial perfusion and reduce cardiac workload in patients with coronary artery disease. Recent trials have documented beneficial hemodynamic effects. Stress testing and radionuclide imaging have demonstrated improvements in functional capacity and myocardial perfusion. This procedure may be the therapeutic choice for patients with severe diffuse disease or in whom repeat revascularization is not possible. The relatively low cost of the technique makes it feasible for patients in developing countries. ... read more

2002

A Historical Overview of Enhanced External Counterpulsation

DeMaria AN, Clinical Cardiology, 2002, 2002 Dec;25(12 Suppl 2):II3-5 abstract
A Historical Overview of Enhanced External Counterpulsation Angina remains a significant health problem in the United States and the world. Although there are a variety of pharmacologic and interventional therapies to treat angina, many patients are not adequately helped by these treatments. Enhanced external counterpulsation (EECP) is an effective, noninvasive technique designed to decrease the frequency and duration of anginal episodes, as well as increase exercise duration in patients with acute angina. Since the early 1960s, the technology of EECP has been thoroughly refined. In addition, a number of important clinical trials have provided evidence for its effectiveness. Continuing research is needed to determine the best patients for EECP and its appropriate clinical application. ... read more

A Review of Enhanced External Counterpulsation Clinical Trials

Beller GA, Clinical Cardiology, 2002, 2002 Dec;25(12 Suppl 2):II6-10 abstract
A Review of Enhanced External Counterpulsation Clinical Trials A variety of clinical trials of enhanced external counterpulsation (EECP) have been conducted since the 1960s. The vast majority of these studies have investigated the use of EECP in patients with angina pectoris. Only one of these trials was randomized. These clinical trials have demonstrated the benefits of EECP in terms of reduction in anginal episodes, increased exercise times, and improvement in health-related quality of life scores. The International EECP Patient Registry, through its phase I and II enrollment, is expanding the data set on outcomes after EECP treatment. ... read more

Enhanced External Counterpulsation: Mechanism of Action

Feldman AM, Clinical Cardiology, 2002, 2002 Dec;25(12 Suppl 2):II11-15 abstract
Enhanced External Counterpulsation: Mechanism of Action The mechanisms accounting for the salutary benefits of enhanced external counterpulsation (EECP) remain largely unknown. Emerging data now point to three possible hypotheses to explain its efficacy. These possible explanations include enhanced diastolic flow, changes in the neurohumoral milieu, and changes in ventricular function independent of changes in cardiac load. While each of these three hypotheses may help explain the mechanism behind EECP's effects, more clinical studies are required to refine these proposed explanations. ... read more

Current Use of Enhanced External Counterpulsation and Patient Selection

Lawson WE, Clinical Cardiology, 2002, 2002 Dec;25(12 Suppl 2):II16-21 abstract
Current Use of Enhanced External Counterpulsation and Patient Selection Most patients who receive enhanced external counterpulsation (EECP) have symptomatic coronary artery disease. These patients have either responded poorly to pharmacologic therapy or are poor candidates for revascularization procedures. Such patients receive a variety of consistent benefits from EECP treatment. As more is learned about EECP, patients once excluded from early clinical trials are now able to take advantage of EECP. Nevertheless, EECP is not suitable for some patients. It has a favorable adverse event profile for most patients undergoing the treatment. Medicare reimbursement coverage limitations remain an obstacle to having a broad cross-section of patients benefit from EECP. ... read more

Treatment Options for Angina Pectoris and the Future Role of Enhanced External Counterpulsation

Holmes DR Jr, Clinical Cardiology, 2002, 2002 Dec;25(12 Suppl 2):II22-25 abstract
Treatment Options for Angina Pectoris and the Future Role of Enhanced External Counterpulsation Patients with coronary artery disease have a variety of treatment options available to them. These include medications to control anginal episodes and, when appropriate, revascularization interventions in the form of coronary artery bypass graft and angioplasty. Despite advances in the treatment of angina, a substantial number of patients continue to have symptoms that can significantly impair their quality of life. These patients may benefit from enhanced external counterpulsation (EECP). With recent results of the latest clinical trial of EECP just published, the role of EECP, including its position in the hierarchy of treatment options, needs to be seriously considered. ... read more

Ongoing and Planned Studies of Enhanced External Counterpulsation

Conti CR, Clinical Cardiology, 2002, 2002 Dec;25(12 Suppl 2):II26-28 abstract
Ongoing and Planned Studies of Enhanced External Counterpulsation There is strong, continued interest in enhanced external counterpulsation (EECP) as evidenced by current, ongoing clinical trials. Many of these have been designed to support the current indications of EECP, mainly its application in the treatment of symptomatic coronary artery disease. An exciting area in this regard is how EECP may help control blood glucose in patients with angina and diabetes mellitus. A variety of planned or ongoing exploratory studies are also helping to explain the mechanism of action behind EECP. Two clinical trials are now investigating a new indication for EECP in patients with congestive heart failure, including the important randomized Prospective Evaluation of EECP in Congestive Heart failure (PEECH) trial. ... read more

Enhanced External Counterpulsation - A Therapeutic Option for Patients with Chronic Cardiovascular Problems

Linnemeier G, Journal of Cardiovascular Management, 2002, 2002 Nov-Dec;13(6):20-25 abstract
Enhanced External Counterpulsation - A Therapeutic Option for Patients with Chronic Cardiovascular Problems EECP is a non-invasive outpatient treatment for cardiovascular disease refractory to medical and/or surgical therapy. It has been cleared by the Food and Drug Administration for the treatment of a variety of cardiac conditions including congestive heart failure and chronic stable angina. A course of therapy consists of 35 one-hour treatments given once or twice daily. Augmented diastolic pressure and retrograde flow improve myocardial perfusion, while systolic unloading reduces cardiac workload and oxygen requirements. As a result of this treatment, most patients experience increased time to onset of ischemia, increased exercise tolerance, a reduction in the number and severity of anginal episodes, and improved quality of life. Evidence has been presented that this effect lasts well beyond the immediate post-treatment... read more

Enhanced External Counterpulsation as Treatment for Chronic Angina in Patients with Left Ventricular Dysfunction: A Report from the International EECP Patient Registry (IEPR)

Soran O, Kennard ED, Kelsey SF, et al, Congestive Heart Failure, 2002, 2002 Nov-Dec;8(6):297-302 abstract
Enhanced External Counterpulsation as Treatment for Chronic Angina in Patients with Left Ventricular Dysfunction: A Report from the International EECP Patient Registry (IEPR) The International Enhanced External Counterpulsation (EECP) Patient Registry tracks acute and long-term outcome for consecutive patients treated for chronic angina. Although EECP has previously been shown to be a safe and effective treatment for angina, little information is available on its use in patients with left ventricular (LV) dysfunction. This report compares the acute outcome and 6-month follow-up for a group of patients with severe LV dysfunction and a group of patients without LV dysfunction. Of 1,402 patients in the registry recruited in 1998-1999 who had recorded values of LV ejection fraction (LVEF) at baseline, 1,090 (77.7%) had preserved LV function (LVEF >35%) and 312 (22.3%) had LV dysfunction (LVEF </=35%). Six-month follow-up was available on 84% of these patients.... read more

Left Ventricular Systolic Unloading and Augmentation of Intracoronary Pressure and Doppler Flow During Enhanced External Counterpulsation

Michaels AD, Accad M, Ports TA, Grossman W, Circulation, 2002, 2002 Sep 3;106(10):1237-1242 abstract
Left Ventricular Systolic Unloading and Augmentation of Intracoronary Pressure and Doppler Flow During Enhanced External Counterpulsation BACKGROUND Enhanced external counterpulsation (EECP) is a noninvasive, pneumatic technique that provides beneficial effects for patients with chronic, symptomatic angina pectoris. However, the physiological effects of EECP have not been studied directly. We examined intracoronary and left ventricular hemodynamics in the cardiac catheterization laboratory during EECP. METHODS AND RESULTS Ten patients referred for diagnostic evaluation underwent left heart catheterization and coronary angiography from the radial artery. At baseline and then during EECP, central aortic pressure, intracoronary pressure, and intracoronary Doppler flow velocity were measured using a coronary catheter, a sensor-tipped high-fidelity pressure guidewire, and a Doppler flow guidewire, respectively. Similar to changes in aortic pressure, EECP resulted in a dramatic increase in diastolic (71+/-10 mm Hg at baseline to 137+/-21... read more

Experience with Enhanced External Counterpulsation (EECP) in Coronary Artery Disease

Crawford LE, Today’s Therapeutic Trends, 2002, 2002;20(3):243-252 abstract
Experience with Enhanced External Counterpulsation (EECP) in Coronary Artery Disease Enhanced external counterpulsation is a non-invasive cardiac assist procedure that has been shown to significantly reduce the symptoms of recurring cheat pain, shortness of breath and fatigue experienced by patients with moderate to severe angina pectoris as the result of coronary artery disease. EECP treatment, which has been in wide use for more than a decade, has proven to be a highly effective and safe alternative for patients who are not appropriate candidates for the traditional revascularization procedures of coronary angioplasty or bypass graft (CABG) surgery. The recent 2002 annual meeting of the American College of Cardiology featured a comprehensive session on the clinical experience gained with use of external counterpulsation, presented by leading authorities in cardiovascular medicine from major... read more

Enhanced External Counterpulsation in Patients with Heart Failure: A Multicenter Feasibility Study

Soran O, Fleishman B, Demarco T, Grossman W, et al, Congestive Heart Failure, 2002, 2002 Jul-Aug;8(4)204-8, 227 abstract
Enhanced External Counterpulsation in Patients with Heart Failure: A Multicenter Feasibility Study To assess the feasibility of using enhanced external counterpulsation to treat patients with heart failure, 26 patients with stable heart failure (New York Heart Association classes II-III), with a left ventricular ejection fraction at or below 35%, and without fluid overload, were treated with enhanced external counterpulsation (1 hour daily, 5 days a week, to a total of 35 hours). Patients were followed for 6 months after completing the course of enhanced external counterpulsation. The primary parameter was safety as reflected by adverse events or by changes in laboratory parameters. Secondary end points included changes in exercise capacity and quality of life. There were no clinically significant problems associated with the administration of enhanced external counterpulsation. Significant improvements were seen... read more

Relation of the Pattern of Diastolic Augmentation During a Course of Enhanced External Counterpulsation (EECP) to Clinical Benefit [from the International EECP Patient Registry (IEPR)

Lakshmi MV, Kennard ED, Kelsey SF, et al, American Journal of Cardiology, 2002, 2002 Jun 1;89(11):1303-1305 abstract
Relation of the Pattern of Diastolic Augmentation During a Course of Enhanced External Counterpulsation (EECP) to Clinical Benefit [from the International EECP Patient Registry (IEPR) Among 2,486 patients enrolled in the International EECP Patient Registry (IEPR) who underwent EECP therapy for symptomatic coronary artery disease, the median diastolic augmentation (DA) ratio increased from 0.7 to 1.0 from the beginning to the end of treatment. Patients who had the greatest increase in the DA ratio had the greatest reduction in angina class, whereas those with a relative decrease in the DA ratio had the lowest reduction in angina class immediately after EECP and at 6 months of follow-up. These data suggest that improved vascular tone during EECP treatment may play a mechanistic role in the relation between DA and clinical benefit with EECP. ... read more

Comparison of Patients Undergoing Enhanced External Counterpulsation and Percutaneous Coronary Intervention for Stable Angina Pectoris

Holubkov R, Kennard ED, Foris J, et al, The American Journal of Cardiology, 2002, 2002 May 15;89:1182-1186 abstract
Comparison of Patients Undergoing Enhanced External Counterpulsation and Percutaneous Coronary Intervention for Stable Angina Pectoris Enhanced external counterpulsation (EECP) has recently emerged as a treatment option for angina in selected patients suitable for revascularization with percutaneous coronary intervention (PCI). We compared baseline characteristics and 1-year outcome in 2 cohorts of PCI candidates presenting with stable symptoms: 323 patients treated with EECP in the International EECP Patient Registry (IEPR), and 448 NHLBI Dynamic Registry patients treated with elective PCI. Compared with patients receiving PCI, IEPR patients had a higher prevalence of many risk factors including prior PCI (53.0% vs 33.3%, p <0.001), prior coronary artery bypass grafting (42.1% vs 18.6%, p <0.001), prior myocardial infarction (56.4% vs 27.8%, p <0.001), history of congestive heart failure (16.8% vs 9.2%, p <0.01), and history of diabetes (37.9% vs... read more

Effects of Enhanced External Counterpulsation on Stress Radionuclide Coronary Perfusion and Exercise Capacity in Chronic Stable Angina Pectoris

Stys TP, Lawson WE, Hui JCK, et al, The American Journal of Cardiology, 2002, 2002 Apr 1;89(7):822-824 abstract
Effects of Enhanced External Counterpulsation on Stress Radionuclide Coronary Perfusion and Exercise Capacity in Chronic Stable Angina Pectoris Enhanced external counterpulsation (EECP) is an effective noninvasive treatment for patients with coronary artery disease (CAD). EECP has been demonstrated to improve anginal class and time to ST-segment depression during exercise stress testing. This study assesses the efficacy of EECP in improving stress-induced myocardial ischemia using radionuclide perfusion treadmill stress tests (RPSTs). The international study group enrolled patients from 7 centers with chronic stable angina pectoris and a baseline ischemic pre-EECP RPST. Patients' demographic and clinical characteristics were recorded. A baseline pre-EECP maximal RPST was performed within 1 month before EECP treatment. The results were compared with a follow-up RPST performed within 6 months of completion of a 35-hour course of EECP. Four centers performed post-EECP RPST to the same... read more

Effects of Enhanced External Counterpulsation on Health-Related Quality of Life Continue 12 Months After Treatment: A Substudy of the Multicenter Study of Enhanced External Counterpulsation

Arora RR, Chou TM, Jain D, et al, Journal of Investigative Medicine, 2002, 2002 Jan;50(1):25-32 abstract
Effects of Enhanced External Counterpulsation on Health-Related Quality of Life Continue 12 Months After Treatment: A Substudy of the Multicenter Study of Enhanced External Counterpulsation BACKGROUND The Multicenter Study of Enhanced External Counterpulsation (MUST-EECP) was the first prospective, randomized, blinded, sham-controlled study of enhanced external counterpulsation (EECP) in the treatment of chronic stable angina. We previously reported that EECP therapy lengthens the time to exercise-induced myocardial ischemia and reduces angina. We now describe the effects of EECP therapy versus a sham-treated control group in terms of patients' functioning, their senses of well-being and other Health-Related Quality Of Life (HQOL) parameters from baseline to end of treatment and from baseline to 12 months after treatment. OBJECTIVE To determine whether a 35-hour course of EECP affects the HQOL of patients with symptomatic coronary artery disease, 12 months following treatment. METHODS Seventy-one of the 139 patients enrolled in... read more

2001

Acute and Chronic Hemodynamic Effects of Enhanced External Counterpulsation in Patients with Angina Pectoris

Arora RR, Carlucci ML, Malone AM, et al, Journal of Investigative Medicine, 2001, 2001 Nov;49(6):500-504 abstract
Acute and Chronic Hemodynamic Effects of Enhanced External Counterpulsation in Patients with Angina Pectoris BACKGROUND Enhanced external counterpulsation (EECP) is an effective noninvasive treatment for patients with angina pectoris. However, the hemodynamic effects of EECP are still unknown and have been theorized to simulate the clinical use of the intra-aortic balloon pump, enhancing cardiac output, stroke volume, and retrograde aortic diastolic flow. METHODS Twelve hemodynamic parameters were measured, using the BioZ System (CardioDynamics International Corporation, San Diego, Calif) after 1 hour (n=22) and after 35 hours (n=16) of EECP treatment compared with baseline. The BioZ System noninvasively measures hemodynamic parameters using the thoracic electrical bioimpedance method. RESULTS One hour of EECP treatment revealed a significant decrease in cardiac output, stroke volume, contractility, afterload, preload, and myocardial energy production, but systolic time ratios and thoracic... read more

Acute Hemodynamic Effects and Angina Improvement with Enhanced External Counterpulsation

Stys T, Lawson WE, Hui JCK, Lang G, Liuzzo J, Cohn PF, Angiology, 2001, 2001 Oct;52(10):653-658 abstract
Acute Hemodynamic Effects and Angina Improvement with Enhanced External Counterpulsation Enhanced external counterpulsation (EECP) is an effective noninvasive treatment for coronary artery disease. The mechanism of action is felt to be hemodynamic. The complex hemodynamic effects have been simply quantified by calculating a previously described effectiveness ratio (ER). The EECP Clinical Consortium, a clinical registry of 37 centers, prospectively enrolled 395 chronic stable angina patients (79 women, 316 men, mean age 66 years) to examine the relation of the ER to posttreatment improvement in Canadian Cardiovascular Society angina class (CCS). Women and the elderly underwent planned subgroup analysis. The ER was calculated during the first and last hours of a 35-hour course of EECP treatment. After EECP, CCS improved by at least 1 class in 88% of patients, 87% of... read more

A Report from the International Enhanced External Counterpulsation Registry (IEPR)

Holubkov R, Kennard E, Kelsey S, Soran O., Advances in Coronary Artery Diseases-4th International Congress on Coronary Artery Disease, 2001, 2001 Oct 21-24;(Prague, Czech Republic):387-391 abstract
A Report from the International Enhanced External Counterpulsation Registry (IEPR) Since 1998 the International Enhanced External Counterpulsation Patient Registry (IEPR) has collected data on baseline characteristics, safety and acute and long-term outcome of consecutively enrolled patients undergoing EECP for chronic angina. The majority of patients receiving EECP have severe angina, have had previous revascularization, and are no longer suitable for either bypass surgery or percutaneous intervention. Patients show a high rate of comorbid conditions such as diabetes, and congestive heart failure. After a mean treatment time of 34 hours, 72% of patients showed reduction in angina. Major adverse coronary events during treatment period are infrequent. On a sample of patients followed to one year, the majority maintain their reduction in angina without occurrence of any major coronary event. ... read more

Benefit and Safety of Enhanced External Counterpulsation in Treating Coronary Artery Disease Patients with a History of Congestive Heart Failure

Lawson WE, Kennard ED, Holubkov R, Kelsey SF, Strobeck JE, Soran O, Feldman AM, Cardiology, 2001, 2001;96(2):78-84 abstract
Benefit and Safety of Enhanced External Counterpulsation in Treating Coronary Artery Disease Patients with a History of Congestive Heart Failure Enhanced external counterpulsation (EECP) is used to noninvasively treat refractory angina patients, including those with a history of heart failure. The International EECP Patient Registry was used to examine the benefit and safety of EECP treatment, including a 6-month follow-up, in 1,957 patients, 548 with a history of heart failure. The heart failure cohort was older, with more females, a greater duration of coronary artery disease, more prior infarcts and revascularizations. Significantly fewer heart failure patients completed the course of EECP, and exacerbation of heart failure was more frequent, though overall major adverse cardiac events (MACE, i.e. death, myocardial infarction, revascularization) during treatment were not significantly different. The angina class improved in 68%, with comparable quality of life benefit, in... read more

Changes in Ocular Blood Flow Velocities During External Counterpulsation in Healthy Volunteers and Patients with Atherosclerosis

Werner D, Michelson G, Harazny J, Michalk F, Voigt JU, Daniel WG, Graefe’s Archive for Clinical and Experimental Ophthalmology, 2001, 2001 Aug;239(8):599-602 abstract
Changes in Ocular Blood Flow Velocities During External Counterpulsation in Healthy Volunteers and Patients with Atherosclerosis Background External counterpulsation (ECP) is a new noninvasive means of augmenting organ perfusion by applying ECG triggered diastolic pressure to the vascular bed of the lower limbs. In this study, effects of ECP on changes of ocular blood flow velocities were studied. Method Mean, systolic and diastolic flow velocities of the ophthalmic artery were measured by Doppler sonography before and during ECP. Twelve healthy volunteers (age 31.3±4.3 years) and 12 patients with severe atherosclerosis (inclusion criteria: two atherosclerotic risk factors, at least one severe coronary stenosis, age 62.1±5.3 years) were included in the study. Results In healthy subjects, ECP changed diastolic flow velocity of the ophthalmic artery non-significantly from 21.6±7.7 to 23.7±10.S•cmls. Systolic flow velocity decreased significantly from 36.1±13.6 to... read more

Enhanced External Counterpulsation Improved Myocardial Perfusion and Coronary Flow Reserve in Patients with Chronic Stable Angina; Evaluation by 13N-Ammonia Positron Emission Tomography

Masuda D, Nohara R, Hirai T, Kataoka K, Chen LG, Hosokawa R, Inubushi M, Tadamura E, Fujita M, Sasayama S, European Heart Journal, 2001, 2001 Aug;22(16):1451-1458 abstract
Enhanced External Counterpulsation Improved Myocardial Perfusion and Coronary Flow Reserve in Patients with Chronic Stable Angina; Evaluation by 13N-Ammonia Positron Emission Tomography AIMS The mechanism by which enhanced external counterpulsation therapy exerts its beneficial effects on chronic and symptomatic stable angina is largely unknown. To clarify the mechanism of action of enhanced external counterpulsation, we used(13)N-ammonia positron emission tomography to evaluate myocardial perfusion. METHODS AND RESULTS This was not a randomized controlled study. Eleven patients (eight male, age: 61.6+/-9.7) with angina pectoris underwent enhanced external counterpulsation therapy for 35 1 h sessions. They underwent a treadmill exercise test and(13)N-ammonia positron emission tomography, both at rest and with dipyridamole, before and after enhanced external counterpulsation therapy. Neurohumoral factors and nitric oxide were also evaluated. Myocardial perfusion increased at rest after therapy (0.69+/-0.27 to 0.85+/-0.47 ml x min(-1) x g(-1), P<0.05). In ischaemic regions,... read more

Safety and Effectiveness of Enhanced External Counterpulsation in Improving Angioplasty Restenosis

Stys TP, Lawson WE, Hui JCK, Tartaglia JJ, Subramanian R, Du ZM, Zhang MQ, Proceedings of the 2nd International Congress on Heart Disease – New Trends in Research, Diagnosis and Treatment (International Academy of Cardiology), 2001, 2001 Jul 21-24;(Washington DC, USA):369-372 abstract
Safety and Effectiveness of Enhanced External Counterpulsation in Improving Angioplasty Restenosis Clinical restenosis following coronary artery angioplasty (PTCA) occurs in up to 30% of the patients within 6 months of treatment. Endothelial dysfunction in diseased and/or mechanically injured arteries may be a key factor in the process. Enhanced External Counterpulsation (EECP) is an effective noninvasive treatment for coronary artery disease (CAD), which has recently been shown to augment nitric oxide (NO) production. Thus, we postulate that EECP would reduce the restenosis rates after PTCA through its effects on endothelial function. 24 patients (pts) one-month post successful PTCA were randomized to EECP (15 pts) or Control (9 pts). At 6 month follow-up MACE and recurrence of ischemia in the PTCA related regions demonstrated by scintigraphy were observed in 13% of the EECP... read more

Effects of Enhanced External Counterpulsation on Renin-Angiotensin System on Experimental AMI

Lu L, Zheng ZS, Wu WK, Lawson WE, Hui JCK, Proceedings of the 2nd International Congress on Heart Disease – New Trends in Research, Diagnosis and Treatment (International Academy of Cardiology), 2001, 2001 Jul 21-24;(Washington DC, USA):275-279 abstract
Effects of Enhanced External Counterpulsation on Renin-Angiotensin System on Experimental AMI The effects of enhanced external counterpulsation (EECP) on Renin-Angiotensin System (RAS) activity in acute MI (AMI) were studies in 18 dogs divided into three groups: Control (N=6), AMI (N=6) and AMI+EECP (N=6). The LAD in AMI groups was occluded, with EECP performed 60-180 minutes post occlusion in the AMI+EECP group. Plasma renin activity, angiotensin II, angiotensin converting enzyme were measured at baseline, 60, 120, and 180 minutes. Baseline values were similar. AMI significantly increased RAS activity and this activity increased with occlusion time. However, EECP reversed RAS changes towards control values. EECP decreases in RAS activity may be mediated by hemodynamic effects and shear stress induced increase in nitric oxide, and may potentially alter cardiovascular remodeling post AMI. ... read more

Predictors of Adverse Outcomes in Treating Angina Patients with Enhanced External Counterpulsation

Lawson WE, Fleishman B, Manzo K, Kennard ED, Holubkov R, Kelsey SF, Proceedings of the 2nd International Congress on Heart Disease – New Trends in Research, Diagnosis and Treatment (International Academy of Cardiology), 2001, 2001 Jul 21-24;(Washington DC, USA):231-234 abstract
Predictors of Adverse Outcomes in Treating Angina Patients with Enhanced External Counterpulsation Patient characteristics, including demographics, cardiac history and function, medical treatment of 2,899 patients from the International EECP Patient Registry (IEPR) were used to determine patient characteristics in predicting unfavorable events. Diabetes mellitus and multivessel coronary artery disease (CAD) were potent predictors of MACE (death, MI, CABG, PCI) during the course of EECP treatment. In the present group of high risk, largely unrevascularizable patients treated with EECP, the overall risk of MACE was low, even in the diabetic and multivessel CAD groups. ... read more

The International EECP Patient Registry (IEPR): Design, Methods, Baseline Characteristics and Acute Results

Barsness G, Feldman AM, Holmes Jr. DR, Holubkov R, Kelsey SF, Kennard ED, Clinical Cardiology, 2001, 2001 Jun;24(6):435-442 abstract
The International EECP Patient Registry (IEPR): Design, Methods, Baseline Characteristics and Acute Results Background In 1998, the International EECP Patient Registry (IEPR) was organized to document patient characteristics, safety, and efficacy during the treatment period, and long-term outcomes. All centers with EECP facilities were invited to join the voluntary Registry. The Registry population comprises all patients starting EECP therapy for treatment of angina pectoris in participating centers. Hypothesis The study was undertaken to determine whether EECP is a safe and effective treatment for patients with angina pectoris regardless of their suitability for revascularization by more conventional techniques. Methods After 18 months of operation, 43 clinical centers representing over half of clinical sites using the EECP system contributed cases. The data reported here were collected before the first EECP treatment and upon completion of... read more

Does Higher Diastolic Augmentation Predict Clinical Benefit from Enhanced External Counterpulsation?: Data from the International EECP Patient Registry (IEPR)

Michaels AD, Kennard ED, Kelsey SE, Holubkov R, Soran O, Spence S, Chou TM, Clinical Cardiology, 2001, 2001 Jun;24(6):453-458 abstract
Does Higher Diastolic Augmentation Predict Clinical Benefit from Enhanced External Counterpulsation?: Data from the International EECP Patient Registry (IEPR) BACKGROUND Enhanced external counterpulsation (EECP) has been demonstrated to be an effective treatment for stable angina in patients with coronary disease. The hemodynamic effects of EECP are maximized when the ratio of diastolic to systolic pressure area is in the range of 1.5 to 2.0. HYPOTHESIS It is hypothesized that patients undergoing EECP who are able to achieve higher diastolic augmentation (DA) ratios may derive greater clinical benefit. This study examines the relationship between the DA ratio and clinical outcomes in patients undergoing EECP. METHODS We analyzed demographic, noninvasive hemodynamic, and clinical outcome data on 1,004 patients enrolled in the International EECP Patient Registry (IEPR) for treatment of chronic angina between January 1998 and August 1999. Blood pressure waveforms were... read more

Numerical Simulation of Enhanced External Counterpulsation

Ozawa ET, Bottom KE, Xiao X, Kamm RD, Annals of Biomedical Engineering, 2001, 2001 Apr;29(4):284-297 abstract
Numerical Simulation of Enhanced External Counterpulsation Enhanced external counterpulsation (EECP) is a noninvasive, counterpulsative method to provide temporary aid to the failing heart by sequentially inflating cuffs on the lower extremity out-of-phase with the left ventricle. Optimization of the method necessitates consideration of the hemodynamics created by EECP and the mode of action providing patient benefit. A computational model based on the governing one-dimensional equations is developed that simulates cardiovascular hemodynamics during EECP. The model includes a 30-element arterial system including the left ventricle, bifurcations, and peripheral arterial vessels. Effects of vessel collapse as external pressure is applied, arterial refilling on pressure release, changes in aortic pressure, and shear stress generated in the arteries are each investigated. Device parameters are systematically varied to determine their effect... read more

Psychosocial Effects of Enhanced External Counterpulsation in the Angina Patient: A Second Study

Springer S, Fife A, Lawson W, Hui JCK, Jandorf L, Cohn PF, Fricchione G, Psychosomatics, 2001, 2001 Mar-Apr;42(2):124-132 abstract
Psychosocial Effects of Enhanced External Counterpulsation in the Angina Patient: A Second Study Enhanced external counterpulsation (EECP) is a noninvasive technique that has shown promise in the treatment of ischemic coronary artery disease. Patients undergoing EECP were tested for alterations in psychosocial state associated with treatment. Overall perception of health and quality of life improved with EECP. There was also significant improvement in levels of depression, anxiety, and somatization but no change in levels of anger or hostility. On most measures, change was more significant for subjects who showed objective evidence of resolution of ischemia. Given the known predictive relationship between depression and mortality from cardiac disease, the improvement in depression scores through EECP indicates a finding of potential importance that may warrant further study in future research.   ... read more

Enhanced External Counterpulsation in Unrevascularizable Patients

Barsness GW, Current Interventional Cardiology Reports, 2001, 2001 Feb; 3(1):37-43 abstract
Enhanced External Counterpulsation in Unrevascularizable Patients Enhanced external counterpulsation (EECP) is a noninvasive outpatient therapy for the treatment of chronic angina. EECP treatment produces an acute hemodynamic effect that is similar to that produced by the invasive intra-aortic balloon pump. Three sets of cuffs on the upper thigh, lower thigh, and calves of each leg are inflated with compressed air during the diastolic phase of the cardiac cycle and are deflated in early systole. This rapid inflation and deflation raises diastolic aortic pressure, increases coronary perfusion pressure, and provides improved afterload reduction and increased venous return with a subsequent increase in cardiac output. Enhanced external counterpulsation has been shown to provide long-term symptom relief in patients with ischemic heart disease in several case series, as well... read more

Enhanced External Counterpulsation Improves Exercise Tolerance, Reduces Exercise-Induced Myocardial Ischemia and Improves Left Ventricular Diastolic Filling in Patients with Coronary Artery Disease

Urano H, Ikeda H, Ueno T, Matsumoto T, Murohara T, Imaizumi T, Journal of the American College of Cardiology, 2001, 2001 Jan; 37(1):93-99 abstract
Enhanced External Counterpulsation Improves Exercise Tolerance, Reduces Exercise-Induced Myocardial Ischemia and Improves Left Ventricular Diastolic Filling in Patients with Coronary Artery Disease OBJECTIVES We examined whether enhanced external counterpulsation (EECP) improves myocardial ischemia, exercise tolerance and cardiac function in patients with coronary artery disease (CAD). BACKGROUND Enhanced external counterpulsation reduces angina and improves exercise tolerance in patients with CAD. Some objective improvements of ischemia by EECP have been reported, but they should be confirmed further. Detailed hemodynamic effects of EECP have been less well documented. METHODS Enhanced external counterpulsation was performed for a total of 35 h in patients with stable CAD (n = 12) who showed evidence of exercise-induced myocardial ischemia despite conventional medical or surgical therapies. All patients had significant stenotic lesions in major coronary arteries. RESULTS Enhanced external counterpulsation improved all exercise test parameters (p < 0.05): exercise duration,... read more

2000

Enhanced External Counterpulsation for Chronic Myocardial Ischemia

Lawson WE, Hui JCK, The Journal of Critical Illness, 2000, 2000 Nov 15(11):629-636 abstract
Enhanced External Counterpulsation for Chronic Myocardial Ischemia Enhanced external counterpulsation (EECP) produces sequenced compression of the lower extremities during diastole. The" milking" effect on the arterial beds of the lower extremities augments aortic diastolic pressure and thereby increases coronary perfusion pressure and blood flow. The simultaneous compression of venous beds increases venous return and cardiac filling pressure. EECP treatment of patients with chronic angina can improve myocardial perfusion as demonstrated by radionuclide stress imaging, time to significant ST-segment depression during exercise testing, and functional status. EECP may be especially worth considering for patients with severe, diffuse coronary artery disease in whom targets for surgical revascularization are lacking and those who have persistent angina after 1 or more revascularization procedures. ... read more

Treatment benefit in the enhanced external counterpulsation consortium

Lawson WE, Hui JCK, Lang G, Cardiology, 2000, 2000; 94:31-35 abstract
Treatment benefit in the enhanced external counterpulsation consortium Patient Population 2289 consecutive patients with angina pectoris, CCS functional Classes I-IV, who have EECP at 84 participating centers (university medical centers, hospitals, clinics, physician’s offices and rehabilitation facilities) were included in this study. Treatment protocol Patients were treated with daily 1- to 2-hour EECP sessions 5 days a week to a total of 35 hours. Measurement: Classification of angina before and after EECP, intervening major adverse cardiovascular events, other adverse events. Results 74% of CCS Class II-IV patients improved their functional class; 39.5% of Class III-IV patients improved 2 or more classes. There was a low incidence of morbidity (4%, mostly related to skin and musculoskeletal trauma). Safety and efficacy across a broad population with angina is demonstrated.   ... read more

Noninvasive Revascularization by Enhanced External Counterpulsation: A Case Study and Literature Review

Singh M, Holmes Jr. DR, Tajik AJ, Barsness GW, Mayo Clinic Proceedings, 2000, 2000 Sep;75(9):961-965 abstract
Noninvasive Revascularization by Enhanced External Counterpulsation: A Case Study and Literature Review Nearly 8 million people in the United States suffer from symptoms of coronary artery disease (CAD). Unfortunately, the population of patients with ischemic coronary disease that is not readily amenable to surgical or percutaneous revascularization continues to grow. For patients who are not candidates for standard revascularization procedures and in whom aggressive medical therapy fails to control symptoms, enhanced external counterpulsation (EECP) is a new, noninvasive outpatient method to improve quality of life by decreasing ischemic symptoms and permit increased activity. We report the case of a 56-yearold woman with severe, symptomatic CAD receiving maximal medical therapy who underwent a course of EECP therapy because she was not a good candidate for other forms of revascularization. She demonstrated dramatic improvement... read more

Comparison of hemodynamic effects of Enhanced External Counterpulsation and intra-aortic balloon pumping in patients with acute myocardial infarction

Taguchi I, Ogawa K, Oida A, et al, The American Journal of Cardiology, 2000, 2000; 86 (November 15) :1139-1141 abstract
Comparison of hemodynamic effects of Enhanced External Counterpulsation and intra-aortic balloon pumping in patients with acute myocardial infarction Patient Population 39 patients with acute myocardial infarction (MI); all patients underwent balloon angioplasty within 12 hours of onset of chest pain and all patients were given heparin while in the coronary care unit. 12 received intra-aortic balloon pumping (IABP), 27 received EECP, 4 did not complete treatment with EECP. Treatment Protocol: Either IABP or EECP for sixty minutes. Measurements Heart rate, right atrial pressure, pulmonary capillary wedge pressure, cardiac index, area under artery pressure tracing in systole, area under artery pressure tracing in diastole, systolic systemic vascular resistance. All parameters were measured at baseline, at 15 minute intervals during treatment, and 60 minutes after the end of treatment. Results No adverse effects, including bleeding from cannulation sites or interference... read more

Long-term prognosis of patients with angina treated with enhanced external counterpulsation: five-year follow-up study

Lawson WE, Hui JCK, Cohn PF, Clinical Cardiology, 2000, 2000;23(4):254-258 abstract
Long-term prognosis of patients with angina treated with enhanced external counterpulsation: five-year follow-up study Patient Population A cohort of 33 consecutive patients with CAD and stable, but limiting angina who were treated with EECP between 1989 and 1991 and followed for a mean of 5 years (4-7 years). Patients were divided into 2 groups: those with evidence of improved myocardial perfusion (Responders) and those without (Nonresponders). Treatment Protocol Daily 1- to 2-hour sessions 5 days a week for a total treatment course of 35 hours. Measurements: Radionuclide stress tests pre- and post-EECP, major adverse cardiovascular events (MACE) during follow up. Results 79% of patients demonstrated improved perfusion post-EECP. Overall, 64% were alive and without interim cardiovascular events or need for revascularization at a mean follow-up of 5 years. Death and MACE was significantly lower... read more

1999

Pneumatic External Counterpulsation: A New Noninvasive Method to Improve Organ Perfusion

Werner D, Schneider M, Weise M, Nonnast-Daniel B, Daniel WG, American Journal of Cardiology, 1999, 1999 Oct 15;84(8):950-952 abstract
Pneumatic External Counterpulsation: A New Noninvasive Method to Improve Organ Perfusion Patient Population This study was undertaken to evaluate hemodynamics effects after 1-hour of EECP in volunteers. Treatment Protocol: 1-hour of EECP. Measurements Changes in flow volumes in carotid, vertebral, hepatic, renal and internal iliac were measured by duplex sonography, and stroke volume was measured by echocardiography. Results This study showed that EECP leads to significant increase in perfusion of brain, liver, kidneys and myocardium. Increase in flow volume is accompanied by an increase in mean arterial pressure by 15% and a down regulation of vasoconstrictive hormones endothelin and renin by 75 to 80%. ... read more

Enhanced External Counterpulsation: The Howard County Experience in the First 18 Patients

Gloth S, Oken HA, Maryland Medical Journal, 1999, 1999 Jul-Aug;48(4):155-156 abstract
Enhanced External Counterpulsation: The Howard County Experience in the First 18 Patients Enhanced external counter pulsation is a noninvasive therapy that uses sequentially inflated pneumatic cuffs on the lower extremities to enhance coronary artery diastolic flow and decrease left ventricular afterload. We studied its effect on 18 patients with persistent angina despite maximal medical, surgical and catheter-based interventions. After enhanced external counter pulsation all subjects improved their functional class. Treatment with enhanced external counter pulsation improved functional class significantly from baseline 3.1 ± 0.6 to 1.6 ± 0.5 (p < .001). These results are consistent with the national experience. Growing physician awareness, recent Medicare approval status, and subsequent reimbursement will hopefully increase the use of this therapy. ... read more

Enhanced External Counterpulsation

Caldwell CR, St. Pierre M, Talley JD, Journal of the Arkansas Medical Society, 1999, 1999 Jul;96(2):54-56 abstract
Enhanced External Counterpulsation This is a case report on a 63-year-old male referred with severe substernal chest discomfort, present at rest with minimal exercise (Canadian Cardiovascular Society grade IV angina). He had sustained three prior myocardial infarctions and underwent two coronary artery bypass grafting procedures. He had a permanent cardiac pacemaker. His medications included aspirin, long-acting nitrates, a calcium-channel blocker and an HMG-CoA reductase inhibitor. He took 10-20 sublingual nitroglycerin tablets daily to relieve his chest discomfort. His physical and laboratory examinations were unremarkable. He completed 35-treatment course of enhanced external counterpulsation (EECP) therapy over a seven-week period. He had no side efforts from the therapy and achieved appropriate level of diastolic to systolic augmentation during treatment. He is now doing well and... read more

Treatment of stable angina

Thadani U, Current Opinion of Cardiology, 1999, 1999;14(4):349-358 abstract
Treatment of stable angina In addition to symptomatic relief of symptoms and an increase in angina-free walking time with antianginal drugs or revascularization procedures, the recent emphasis of treatment has been to reduce adverse clinical outcomes (coronary death and myocardial infarction). The role of smoking cessation, aspirin, treatment of elevated lipids, and treatment of high blood pressure in all patients and of beta-blockers and angiotensin-converting enzyme inhibitors in patients with diminished systolic left ventricular systolic function in reducing adverse outcomes has been well established. What is unknown, however, is whether any anti-anginal drugs (beta-blockers, long-acting nitrates, calcium channel blockers) affect adverse outcomes in patients with stable angina pectoris. Recent trials evaluated the usefulness of suppression of ambulatory ischemia in patients with stable angina pectoris,... read more

The Multicenter study of enhanced external counterpulsation (MUST-EECP): Effect of EECP on exercise-induced myocardial ischemia and anginal episodes

Arora RR, Chou TM, Jain D, et al, The Journal of the American College of Cardiology, 1999, 1999;33(7):1833-1840 abstract
The Multicenter study of enhanced external counterpulsation (MUST-EECP): Effect of EECP on exercise-induced myocardial ischemia and anginal episodes OBJECTIVES The purpose of this study was to assess safety and efficacy of enhanced external counterpulsation (EECP). BACKGROUND Case series have shown that EECP can improve exercise tolerance, symptoms and myocardial perfusion in stable angina pectoris. METHODS A multicenter, prospective, randomized, blinded, controlled trial was conducted in seven university hospitals in 139 outpatients with angina, documented coronary artery disease (CAD) and positive exercise treadmill test. Patients were given 35 h of active counterpulsation (active CP) or inactive counterpulsation (inactive CP) over a four- to seven-week period. Outcome measures were exercise duration and time to $1-mm ST-segment depression, average daily anginal attack count and nitroglycerin usage. RESULTS Exercise duration increased in both groups, but the between-group difference was not significant (p<0.3).... read more

Improvement of regional myocardial and coronary blood flow reserve in a patient treated with enhanced external counterpulsation - evaluation by Nitrogen-13 Ammonia PET

Masuda D, Nohara R, Inada H, et al, Japanese Circulation Journal, 1999, 1999; 63(5): 407-411 abstract
Improvement of regional myocardial and coronary blood flow reserve in a patient treated with enhanced external counterpulsation - evaluation by Nitrogen-13 Ammonia PET Enhanced external counterpulsation (EECP) is a noninvasive treatment for chronic stable angina, which works by recruiting and developing the coronary collateral vessels. Coronary perfusion and coronary flow reserve (CFR) were evaluated by nitrogen-13 (13N) ammonia positron emission tomography (PET) in a patient who had undergone EECP. The patient, who had 3-vessel coronary artery disease, required a percutaneous transluminal coronary angioplasty (PTCA) for the right coronary artery. The PTCA was successful, but 6 months later he again felt chest oppression. The coronary angiography showed re-stenosis at the PTCA site, and other progressive coronary stenosis. The patient was again treated with EECP for 35 h. The 13N-ammonia PET was performed both at baseline and during dipyridamole provocation, before and after EECP treatment.... read more

Enhanced external counterpulsation in the management of patients with cardiovascular disease

Soran OZ, Crawford LE, Schneider VM, et al, Clinical Cardiology, 1999, 1999;22:173-178 abstract
Enhanced external counterpulsation in the management of patients with cardiovascular disease Studies over the past several decades support the hypothesis that enhanced external counterpulsation (EECP) can provide long-term benefits in patients with angina secondary to chronic coronary disease. Numerous non-sham controlled trials have recently been substantiated by a multicenter, randomized trial. Although the mechanism by which this mechanical treatment effects an alteration in cellular processes within the myocardium remains unclear, recent scientific investigations suggest that shear stress induced by chronic exposure to EECP might result in the release of a variety of growth factors and the subsequent stimulation of angiogenesis in the coronary beds. Ongoing clinical trials in patients with significant left ventricular dysfunction, an international registry, and additional clinical trials may help to elucidate further the role of this novel... read more

Emerging treatments for refractory angina

Cohn PF, American College of Cardiology - Current Journal Review 1999, 1999, January/February:44-46 abstract
Emerging treatments for refractory angina This article summarizes current invasive and non-invasive techniques and among them EECP available today to treat patients with residual angina in spite of revascularization and optimal drug treatment and/or in patients in whom revascularization cannot be done. ... read more

1998

Enhanced external counterpulsation as a new treatment modality for patients with erectile dysfunction

Froschermaier SE, Werner D, Leike S, et al, Urologia Internationalis, 1998, 1998;61:168-171 abstract
Enhanced external counterpulsation as a new treatment modality for patients with erectile dysfunction Enhanced external counterpulsation (EECP) is a noninvasive treatment modality, which can increase arterial blood flow in peripheral and coronary arterial disease. Several studies have demonstrated an increase in the flow of the internal iliacal artery and in carotid and renal perfusion during EECP treatment. We investigated the effect of EECP in patients with erectile dysfunction (ED). Thirteen patients were treated with EECP for 20 days, 1 h per day. Patients reported a significant improvement of penile rigidity after completion of the EECP treatment and a significant improvement of penile peak systolic flow was measured by Doppler sonography. No adverse effects were observed. In conclusion, EECP seems to be an effective treatment modality in patients with ED. ... read more

Prior revascularization increases the effectiveness of enhanced external counterpulsation

Lawson W, Hui J, Guo T, et al, Clinical Cardiology, 1998, 1998; 21: 841-844 abstract
Prior revascularization increases the effectiveness of enhanced external counterpulsation Background and hypothesis: Enhanced external counterpulsation (EECP) is an effective noninvasive treatment for chronic angina. However, its usefulness has been felt to be limited in patients with angiographically demonstrated triple vessel coronary artery disease (CAD), in accord with the hypothesis that a patent vessel is necessary for transmission of the EECP-augmented coronary artery pressure and volume to the distal coronary vasculature. Methods: The effect of revascularization [coronary artery bypass grafting (CABG)] prior to EECP was examined in 60 patients with CAD and chronic angina (35 without and 25 with prior CABG). Patients were grouped by the extent of CAD (single-, double-, triple-vessel disease in the unrevascularized group) and by the extent of residual disease (number of stenotic native vessels unbypassed... read more

Maximizing the hemodynamic benefit of enhanced external counterpulsation

Suresh K, Simandl S, Lawson WE, Clinical Cardiology, 1998, 1998;21:649-653 abstract
Maximizing the hemodynamic benefit of enhanced external counterpulsation Background: Enhanced external counterpulsation (EECP) has been demonstrated to be an effective treatment for angina and exertional ischemia in patients with coronary disease. Hypothesis: It is hypothesized that the ability of EECP to enhance the recruitment or development of coronary collaterals in coronary artery disease may be determined by the relative magnitude of diastolic augmentation (DA) and systolic unloading (SU). This study examines the relation between the proposed EECP effectiveness ratio (DA/SU), as assessed by finger plethysmography, and changes in descending aortic flow as assessed by Doppler echocardiography in 15 patients during EECP. Methods: Varying external cuff pressures (0-275 mmHg) were used to generate a range of DA/SU ratios. The effect on aortic antegrade systolic and retrograde diastolic flow was... read more

Enhanced external counterpulsation

Chou TM, ACC Educational Highlights, 1998, (Summer) 6-9 abstract
Enhanced external counterpulsation This paper summarizes the status of EECP in the treatment of patients with angina pectoris. It underlines the fact that this treatment is particularly indicated in patients at high risk for revascularization or for whom revascularization is not technically possible. ... read more

The emerging role of enhanced external counterpulsation in cardiovascular disease management

Strobeck JE, Baklajian R, Hannon JC, The Journal of Cardiovascular Management 1998, 1998, September/ October:23-29 abstract
The emerging role of enhanced external counterpulsation in cardiovascular disease management The article, through case studies, presents EECP as a convenient adjunct to the anti-ischemia armamentarium available at outpatient centers managing heart disease insofar as EECP is a non-invasive therapy that significantly improves myocardial perfusion and angina symptoms. ... read more

1997

Enhanced External Counterpulsation: Chronicle of a New Approach to the Therapy of Angina Pectoris

Amsterdam EA, Cardiovascular Reviews and Reports, 1997, 1997 Nov; 18(11):15-16, 19 abstract
Enhanced External Counterpulsation: Chronicle of a New Approach to the Therapy of Angina Pectoris This paper is presented as an overview of the Enhanced External Counterpulsation papers published in the October and November 1997 issue of Cardiovascular Reviews and Reports. ... read more

Historical Review of the Development of Enhanced External Counterpulsation Technology and its Physiologic Rationale

Soroff HS, Hui JCK, Giron F, Cardiovascular Reviews and Reports, 1997, 1997 Nov;18(11):34-36, 39 abstract
Historical Review of the Development of Enhanced External Counterpulsation Technology and its Physiologic Rationale This review traces the evolution of external counterpulsation from its beginning to the early 1990s. The term counterpulsation derives from the dual hemodynamic goals of this treatment: to reduce the afterload of the left ventricle and to augment diastolic pressure. The studies summarized in this review demonstrate clinical benefits in the treatment of angina, acute myocardial infarction, and cardiogenic shock. It has been demonstrated that an external counterpulsation treatment system is highly effective when a series of 3 pneumatic cuffs is wrapped securely around the lower extremities and buttocks, inflating in a distal to proximal sequence, and deflating simultaneously timed to cardiac systole. Sequential inflation augments diastolic perfusion pressure; simultaneous deflation decreases peripheral vascular resistance, significantly decreasing cardiac workload. This... read more

Case Studies: Enhanced External Counterpulsation

Tartaglia J, Stenerson JF, Cardiovascular Reviews and Reports, 1997, 1997 Nov;18(11):26, 29-33 abstract
Case Studies: Enhanced External Counterpulsation The effectiveness of EECP, a noninvasive outpatient treatment for angina pectoris, is described in this series of case reports from a community hospital. In a diverse patient population, EECP appears to provide significant relief of angina pectoris even in cases when CAD is fairly advanced and when other revascularization procedures have failed. The procedure appears most effective when at least one patent conduit, either graft or native coronary artery), can provide sufficient coronary flow to ischemic areas of myocardium. The benefits appear to be sustained over time. ... read more

The Emerging Role of Enhanced External Counterpulsation in Cardiovascular Disease Management

Strobeck JE, Baklajian R, Hannon JC, Cardiovascular Reviews and Reports, 1997, 1997 Nov;18(11):20-25 abstract
The Emerging Role of Enhanced External Counterpulsation in Cardiovascular Disease Management EECP is a unique outpatient noninvasive treatment used to improve myocardial perfusion thereby reducing symptoms of obstructive CAD. EECP is a key component in the cardiovascular disease management program offered at The Heart-Lung Center, a comprehensive cardiopulmonary care center in Hawthorne, NJ. The center provides cost-effective preventive, educational and diagnostic services and treatments that have been shown to provide benefits in the evidence-based literature. EECP is used to stabilize the coronary circulation in patients with severe CAD. For many of the patients with chronic progressive CAD treated at the Heart-Lung Center, EECP has contributed to stabilization when maximal medical therapy and/or invasive procedures have proven inadequate. We believe this approach will translate into a reduction in hospital ER visits, in... read more

Psychosocial Aspects of Enhanced External Counterpulsation

Fricchione GL, Hui JCK, Fife A, Jandorf L, Vaccaro B, Burger L, Lawson WE, Cohn P, Cardiovascular Reviews and Reports, 1997, 1997 Oct;18(10):37-41 abstract
Psychosocial Aspects of Enhanced External Counterpulsation EECP (Vasomedical) is a noninvasive treatment that has shown promise in the treatment of ischemic coronary artery disease. Compared to the psychosocial sequelae of coronary bypass surgery and coronary angioplasty, EECP may offer certain psychosocial advantages that would contribute to improved quality of life in angina patients. Overall health perception and overall well being are enhanced greatly in subjects who show objective improvement in ischemia, and also in those without objective evidence of improvement. There are also improvements in depression scores in both subject groups. Given the predictive relationship between depression and mortality from cardiac disease, this may be an important finding to study further. ... read more
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