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PubMed2004

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 undergone angioplasty, and 67% had undergone bypass surgery. The mean ejection fraction was 44% (range 25-60%). Following EECP, most patients (82%) had at least a one full class improvement in their anginal pattern. In most patients, there was substantial baseline conduction system disease present: a mean QRS of 105 +/- 19 ms. It is to be noted that there was no significant change in heart rate (HR), PR, QRS, or QT(c) intervals before and after EECP in either clinical responders or nonresponders. When analyzed by response to EECP, ejection fraction, or history of revascularization, there were still no detectable changes in ECG parameters (all P = NS). CONCLUSIONS: While EECP remains an effective treatment for severe CAD, it does not prompt early electrical remodeling of the heart.

Coronary Circulation↗

PubMed2005

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 CBFVmean 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 CBFVmean oscillations. RESULTS: EECP increased HR and BPmean, while transfer function gain and phase shift remained stable. CONCLUSIONS: Stable gain and phase values suggest that EECP does not compromise CA and, therefore, does not seem to bear cerebrovascular risks.

Adult↗

PubMed1991

Extraaortic counterpulsation with a latissimus dorsi flap: hemodynamic effects in a heart failure model.

The aim of this study was to evaluate the hemodynamic effects of extraaortic counterpulsation with a latissimus dorsi (LD) neurovascular flap in a canine heart failure model. Five dogs (8-18 kg) had a left LD neurovascular muscle flap raised. The muscle was brought into the chest through the second interspace and wrapped around the aorta. Parameters studied were heart rate (HR), systolic pressure (SP), diastolic pressure (DP) pulmonary artery pressure (PAP), mixed venous oxygen saturation (MVO2), and cardiac output (CO). Baseline measurements were obtained with the muscle nonstimulated and stimulated by a prototype burst stimulation. The only parameter that changed significantly with muscle stimulation was DP (55.8 +/- 3.8 mmHg to 72.4 +/- 4.8 mmHg, p less than 0.05). Propranolol (3-4 mg/kg) and verapamil (2-3 mg) were given intravenously to induce heart failure. Mean blood pressure decreased from 64.12 +/- 5.03 mmHg to 43.3 +/- 9.28 mmHg (p less than 0.05). Repeat measurements were obtained. With stimulation of the muscle flap there was an increase in DP from 36.8 +/- 9.2 mmHg to 55.4 +/- 19.3 mmHg (p less than 0.05). Although CO increased from 8% to 18% in all animals (1.42 +/- 0.33 L/mm to 1.58 +/- 0.34 L/mm) this did not reach statistical significance. This data indicates that both DP and CO can be improved by this method of cardiac assist in a heart failure model.

Animals↗

PubMed2003

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 revascularisation, and spinal cord stimulation. EECP produces an acute haemodynamic 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 well defined. At present, EECP use should be limited to patients with debilitating (functional class III and IV) refractory angina pectoris who are not candidates for revascularisation, are symptomatic despite being on maximal antianginal pharmacotherapy, and have no contraindications to EECP use.

Angina Pectoris↗

PubMed1999

Stabilisation of medically refractory ventricular arrhythmia by intra-aortic balloon counterpulsation.

OBJECTIVE: To review the efficacy of intra-aortic balloon counterpulsation (IABCP) in medically refractory ventricular arrhythmia. DESIGN: Retrospective analysis of the outcome of patients with ventricular arrhythmia treated with IABCP after transfer between 1992 and 1997. SETTING: Tertiary cardiac referral centre. PATIENTS: 21 patients (mean age 58 years) who underwent IABCP for control of ventricular arrhythmia. All had significant left ventricular impairment (mean ejection fraction 28.6%); 18 had coronary artery disease. RESULTS: Before IABCP, 10 patients had incessant monomorphic ventricular tachycardia and 11 had paroxysmal ventricular tachycardia and/or ventricular fibrillation (VT/VF). IABCP resulted in suppression of ventricular arrhythmia in 18 patients, of whom 13 were weaned from IABCP. After stabilisation of ventricular arrhythmia, 10 patients were maintained on medical treatment alone and one underwent endocardial resection. IABCP was maintained until cardiac transplantation in five patients. One patient had a fatal arrest before discharge and one died from progressive heart failure. IABCP failed to control ventricular arrhythmia in three patients and was subsequently discontinued. A cardiac assist device was employed in one of these until cardiac transplantation; the other two were eventually stabilised on medical treatment. Nineteen patients were discharged from hospital. Overall survival was 95% at mean follow up of 25.7 months. CONCLUSIONS: IABCP can be an effective means of controlling refractory ventricular arrhythmia, allowing time for the institution of more definitive treatment.

Adult↗

PubMed2005

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, P < 0.05; alpha-actin, 11.8 +/- 5.3 vs. 3.4 +/- 1.2, P < 0.05). The positive-stained area per squared micrometer also increased significantly (alpha-actin, 6.6 x 10(3) +/- 2.9 x 10(3) microm2 vs. 0.6 x 10(3) +/- 0.5 x 10(3) microm2, P < 0.05; vWF, 5.7 x 10(3) +/- 1.9 x 10(3) microm2 vs. 1.7 x 10(3) +/- 1.4 x 10(3) microm2, P < 0.05). Immunohistochemical staining and reverse transcriptase PCR analysis documented a significant increase in VEGF expression. These factors associated with angiogenesis corresponded to improved myocardial perfusion by 99mTc-sestamibi single-photon emission computed tomography. Angiogenesis may be a mechanism of action for the improved myocardial perfusion demonstrated after EECP therapy.

Animals↗

PubMed2000

Treatment benefit in the enhanced external counterpulsation consortium.

The present study utilized a cohort of 2,289 consecutive patients enrolled in the Enhanced External Counterpulsation (EECP) Consortium to evaluate whether results of university studies showing EECP safety and effectiveness in treating angina can be generalized. EECP was found to be safe and well tolerated with a 4.0% rate of adverse experiences. Angina class improved in 74% of patients with limiting angina (Canadian Cardiovascular Society, CCS, functional class II-IV), with patients most impaired at baseline demonstrating the greatest improvement (39.5% of patients in CCS III and IV improved 2 or more classes). Efficacy was independent of provider setting or experience, women responded as well as men, and although younger patients demonstrated a greater likelihood of improvement, EECP was effective in patients ranging from 19 to 97 years. Extending the benefit of EECP treatment to a wider range of patients may be indicated based on these findings.

Adult↗

PubMed1998

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.

Adult↗

PubMed2001

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 the heart failure cohort. At 6 months, patients with congestive heart failure maintained their reduction in angina but were significantly more likely to have experienced a MACE end point.

Aged↗

PubMed2003

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 patients. Treatment with EECP resulted in sustained, and often progressive, reduction in angina over the succeeding 6 months. Given the findings of this study, it is interesting to speculate on the possibility of using EECP as the primary revascularization intervention after medical therapy proves unsatisfactory.

Angina Pectoris↗

PubMed2005

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 I 2.1, CI 0.93-4.81; class II 0.62, CI 0.43-0.87; class III 0.80, CI 0.62-1.01) and no history of congestive heart failure (odds ratio 1.41, CI 1.14-1.74).

Adult↗

PubMed2006

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 month and 0.33 +/- 0.10 (p = 0.03) at 6 months following EECP treatment. LV ejection fraction marginally improved from 56.7 +/- 7.7% to 57.6 +/- 5.9% (p = 0.382) at 1 month and to 60.1 +/- 8.6% (p = 0.062) at 6 months after EECP therapy, although not statistically significant. We concluded that EECP improved LV function, shown as the reduction of lung/heart ratio at stress, in patients with coronary artery disease, up to 6 months after EECP treatment.

Coronary Artery Disease↗

PubMed2006

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 frames during the cardiac cycle. Carotid vascular resistance was calculated as the ratio between mean arterial pressure and mean common carotid blood flow. RESULTS: No significant between-group differences were seen in clinical characteristics or carotid hemodynamics at baseline. The beta stiffness index and carotid vascular resistance were significantly reduced after 35 h of active EECP (p < 0.01), and the decrease was significantly different when compared with controls (p < 0.05 for beta stiffness index and p < 0.001 for carotid vascular resistance). These reductions persisted after multiple covariate adjustment. CONCLUSIONS: This study suggests that EECP exerts clear arterial effects on large and small vessels of the carotid circulation. The combined effects on arterial stiffness and vascular resistance are of particular interest in cardiovascular disease involving reduction in blood flow, in which techniques that increase regional blood flow may be beneficial.

Adult↗

PubMed2006

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 their initial EECP course, vs. 21.7% in the Incomplete group (p < 0.001). After repeat treatment, 66.2% of the Incomplete group achieved at least one CCS class reduction vs. 69.4% of the Complete group (p = NS) undergoing retreatment. The independent predictors for those who return to successfully complete their second course were patients who stopped their first course because of clinical events, and candidacy for coronary artery bypass grafting at the time of initial treatment. CONCLUSION: The results of retreatment of those who failed to complete their initial EECP course were comparable to those who completed their initial treatment, with similar reductions of CCS angina class.

Aged↗

PubMedDate not supplied

Improved exercise tolerance following enhanced external counterpulsation: cardiac or peripheral effect?

The effect of treatment with enhanced external counterpulsation (EECP) on exercise hemodynamics and myocardial stress perfusion in 27 patients with chronic stable angina was studied. A majority (22/27 or 81%) of patients improved their exercise tolerance after EECP treatment, and a similar percentage (21/27 or 78%) of patients improved their radionuclide stress perfusion images. Post-EECP maximal exercise heart rate and blood pressure, while demonstrating a linear relation with exercise duration, did not increase significantly despite the increased exercise duration. This suggests that the increase in exercise duration after treatment with EECP is due to both improved myocardial perfusion and altered exercise hemodynamics. EECP therapy thus appears to exert a "training' effect, decreasing peripheral vascular resistance and the heart rate response to exercise. Coronary disease patients may improve their exercise tolerance after EECP because of both improved myocardial perfusion and a decrease in cardiac work load.

Aged↗

PubMed2002

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 mm Hg during EECP; +93%; P<0.0001) and mean intracoronary pressures (88+/-9 to 102+/-16 mm Hg; +16%; P=0.006) with a decrease in systolic pressure (116+/-20 to 99+/-26 mm Hg; -15%; P=0.002). The intracoronary Doppler measure of average peak velocity increased from 11+/-5 cm/s at baseline to 23+/-5 cm/s during EECP (+109%; P=0.001). The TIMI frame count, a quantitative angiographic measure of coronary flow, showed a 28% increase in coronary flow during EECP compared with baseline (P=0.001). CONCLUSIONS: EECP unequivocally and significantly increases diastolic and mean pressures and reduces systolic pressure in the central aorta and the coronary artery. Coronary artery flow, determined by both Doppler and angiographic techniques, is increased during EECP. The combined effects of systolic unloading and increased coronary perfusion pressure provide evidence that EECP may serve as a potential mechanical assist device.

Adult↗

PubMedDate not supplied

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.

Aged↗

PubMed2001

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 men and 92% of women (p = NS), and in 89% of patients < or = 66 years and 88% of patients > 66 years old (p = NS). The initial and final ER were similar in patients with and without improvement in CCS. Significant first-hour ER differences were seen between men and women (0.96 +/- 0.03 vs 0.76 +/- 0.04, p<0.005), and between ages < or = 66 and > 66 years old (1.04 +/- 0.04 vs 0.81 +/- 0.03, p<0.0001). However, all subgroups responded equally well to EECP treatment. EECP is effective in improving CCS in chronic stable angina patients; it has comparable effects in men and women and across a broad range of ages. The hemodynamic effect of EECP (ER) does not predict improvement in CCS and may indicate that other factors, such as neurohormonal changes, may have a significant role in mediating the observed EECP benefits.

Adult↗