What You Need To Know: EECP

Written by Shabir

Enhanced External Counterpulsation

Introduction

Even with newer effective anti-anginal agents and the success of coronary artery bypass surgery, the search for an alternative less invasive method of treating angina has always been the goal. There still are a large subset of patients with chronic and end stage angina who are not candidates for routine coronary artery bypass surgery or stenting/angioplasty or those who fail to respond to the routine anti anginal medications. In addition, there are a number of patients who have already undergone their first and second open heart bypass procedures and have become symptomatic after 5-10 years. For all these individuals, different modalities of revascularization have been continuously sought. Now we have EECP.

What is definition of EECP?

Enhanced External Counterpulsation (EECP) is a noninvasive, outpatient procedure to relieve or eliminate angina by improving perfusion in those areas of the heart that are lacking blood. Recent studies indicate that EECP can cause/develop collateral arteries to areas of the heart deprived of a normal blood supply

What is history of EECP?

Enhanced external Counterpulsation, or "EECP", has been used as a non medical treatment for angina in China for about two decades but now has generated a lot of interest in North America.  Enhanced external Counterpulsation (EECP), a noninvasive procedure for outpatient treatment of patients with severe uncontrollable cardiac ischemia. It involves sequential inflation and deflation of blood pressure (compressible) cuffs wrapped around the patient's calves, lower thighs and upper thighs. Over the past decade, developments in the computer technology, refinement of the instrument and understanding of the physiology has led to a more appealing role of this treatment for patients with angina.

What is angina?

Angina, or angina pectoris, is the medical term for chest pain behind the breastbone.  Angina pectoris is Latin for “squeezing” of the chest. It is a specific type of pain in the chest caused by inadequate blood to the heart muscle. Angina, characterized by chest pain, is a symptom of a condition called myocardial ischemia, which occurs when the heart muscle isn't getting as much blood as it needs to function.

What does angina indicate?

Angina is not a disease itself. It is the primary symptom of coronary artery disease.  Angina can also be a warning sign of heart attack. Angina usually indicates a blockage in blood flow to the heart.

What causes Angina?

Blockage of the coronary artery vessels is typically caused by atherosclerosis. Over time lipid plaque accumulates along the vessels and causes obstruction of blood flow to the heart.

How many individuals are affected by angina?

Angina is an indication of ischemic heart disease, which is the number one killer of people in North America. Estimates indicate that at least 6-7 million individuals suffer from angina and close to half a million die each year from heart disease. Angina is a life long disorder and most individuals are no longer able to maintain an active lifestyle.

What can trigger angina?

Angina occurs when the heart needs more oxygen from the blood. Angina can be triggered by:

  • heavy meals
  • smoking
  • extreme cold or hot environments
  • stress
  • exercise

How can one prevent angina?

Prevention of angina involves:

  • not smoking
  • weight control
  • eating a proper diet with low fat
  • controlling blood pressure
  • controlling diabetes


Is there any evidence for EECP benefits?

Enhanced external Counterpulsation has rapidly becoming an increasingly noninvasive treatment option for patients with angina which is refractory to anti anginal medications. Patients who have undergone EECP treatment have shown a marked improvement in their Canadian Cardiovascular Society (CCS) functional angina class, better exercise tolerance, and a decreased use of nitroglycerin. Objective measures of improvement from angina have shown improved time to ST segment depression, improved myocardial perfusion with PET scan at rest and after dipyridamole. These medical benefits have been shown to be present for up to 5 years after treatment. Many of these benefits have been obtained by filling questionnaires (understand that the validity of questionnaires to evaluate disease is close to being considered Crap).

What is explanation for benefit of EECP?

EECP is a noninvasive technique which allows augmentation of diastolic blood flow and coronary blood flow which is akin to the intra-aortic balloon pump (IABP). The technique utilizes the sequential inflation of three sets of blood pressure cuffs which are wrapped around the calves, thighs and buttocks. The timing of inflation and deflation is similar to that for the IABP. The timing of inflation and deflation is linked to the patients’ ECG and blood pressure curve. In simple- all this does is by squeezing the blood from the legs, it pushes all this extra blood to the heart. This extra blood then somehow improves angina and cause more blood vessels to develop in the heart (sounds hogwash).

Are there any trials about EECP?

There have been a few studies in North America which do show that in patients with mild to moderate angina, EECP can effectively and safely improve exercise treadmill parameters as well as medication usage and subjective angina pectoris complaints in patients with chronic stable angina.

There were no serious complications in the studies. Follow up at one year revealed that the above effects were still sustained.

What is current indication for EECP?

Today, the major indication for the use of EECP is in patients with chronic angina which is refractory to medications.

Who is a candidate for EECP?

You may be a candidate if you:

  • Have chronic stable angina
  • Are not receiving adequate relief from angina by taking nitrates
  • Do not qualify as a candidate for invasive procedures (bypass surgery, angioplasty, or stenting)
  • Have end stage coronary artery disease

Who is not a candidate for EECP?

  • Individuals with abnormal heart rhythms
  • Uncontrolled blood pressure
  • Any valvular heart problem (esp. Mitral and aortic regurgitation)
  • Any recent angiogram or angioplasty
  • Any patient who is on a blood thinner
  • Any patient who has a bleeding problem
  • Any patient with a blood clot in the leg
  • Any patient with severe peripheral vascular disease
  • Any diabetic patient with a foot ulcer
  • Any patient with a permanent pacemaker
  • Any patient with an automatic implantable defibrillator
  • Any patient with a recent stroke
  • Any patient with back or neck problems

What preparations are required before EECP?

It is best not to eat a few hours before the treatment. One should wear comfortable loose fitting clothing. You will be asked to lie on a comfortable bed and large blood pressure cuffs will be placed around the calves thighs and buttocks. Your heart rate will be monitored by a set of electrodes placed on the chest. The cuffs are inflated and deflated in a synchronous fashion with the heart rate. The inflation of the cuffs results in a pressure like sensation around the legs and buttocks with every heart beat. This goes on for an hour.

How often is the treatment?

Patients must undergo 35 hours of EECP therapy. Treatment is administered 1-2 hours a day, five days a week, for 7 weeks. Most patients can tolerate only 1 hour of therapy and compliance with therapy is not great (it does not do anything anyway). Some clinics encourage two sessions per day with a break in between.

Can I take a break between sessions?

There is no reason why gaps can not be taken between therapy, but the duration of the time period is questionable. Some claim that a gap of 1-2 days is okay but the purists claim that no gaps are permissible. Others make the patients restart the entire therapy if there is a gap of 5-7 days (wonder if the doctors give you credit for the money already paid-see below for the costs).

What are demonstrated benefits of EECP?

Many of the benefits of patients are derived from questionnaires and the validity of results should always be taken with a grain of salt. However, the benefits reported by the company who manufactures the devices claims that there is:

  • Less need for anti-anginal medication
  • Decrease in symptoms of angina
  • Increased ability to do activities without onset of symptoms
  • Ability to return to the daily life activities

Do all individuals respond to therapy?

Individual response to treatment varies and some patients begin to experience clinical benefits from the first day others only improve towards the end of the treatment. Many feel no improvement

When does one see the benefits of EECP?

EECP requires a minimum of 35 hours of therapy over several months to have any benefit. Treatment protocol is variable but generally requires 1-2 hours on a daily basis for several weeks. Most data indicate that benefits are seen after the first few months.

Can EECP prolong survival?

Whether EECP prolongs survival or improves morbidity over the long term remains unknown. Most likely not.

Can EECP be the sole treatment of angina?

It should be made clear that EECP is not a substitute for other anginal treatments. It can be undertaken as a complimentary treatment only.

What are advantages of EECP over other anginal treatments?

Before one can compare EECP to other treatments, it should be convincingly proven that it has any significant benefit. Today, even the best results indicate that EECP only has marginal benefit. It should not replace conventional treatments for angina. It may be a complimentary therapy to the available treatments for angina.

What other conditions may be treated with EECP?

With the knowledge that EECP has shown some benefits in patients with chronic angina, this modality of treatment is now being investigated in patients with chronic heart failure, post myocardial  angina and other acute coronary syndromes.- But beware- there are no data to substantiate the benefits of EECP in these conditions.

What are long term results of EECP?

The long term benefits of EECP will only be known after prospective controlled clinical trials.

Is EECP safe?

Clinical trails and studies conducted in the United States and China (do the Chinese ever claim anything is ever bad or toxic?) have demonstrated the safety and tolerability of EECP. No major morbidity or mortality has been reported as a result of treatment in clinical centers for patients undergoing EECP.

What does the American college of cardiology say about EECP?

The American College of Cardiology and the American Heart Association currently state that additional data from clinical trials are needed before they can make definitive recommendations on the use of EECP for chronic stable angina; they also conclude that there is insufficient evidence on the effectiveness and safety of EECP to advocate its use in patients with chronic heart failure.

What are other treatments of angina?

Depending on the degree and severity of coronary artery disease, the treatments may include

    1. coronary bypass surgery
    2. coronary angioplasty/stenting
    3. medical therapy



Is EECP funded by medical Insurance?

No, as far all the insurance company and the government is concerned, EECP is equivalent to cosmetic surgery. It is a procedure with minimal therapeutic benefit

Cost
The cost for a one-hour session of EECP varies from $150-250. The cost for a 7 week course (35 hr) is about $3-7000.

Final Word

EECP is akin to a cosmetic procedure still looking for a disease it can cure. Walking is a safer, better and cheaper way to exercise your body. The majority of physicians who recommend EECP are the cardiologist who have these machines in their clinics. Most of the evidence for EECP is extremely weak and borders on JUNK SCIENCE. So before you spend your money on this therapy, seek a second opinion and even then- go take a walk. is

< Prev   Next >