Impact of External Counterpulsation Treatment on Emergency Department Visits and Hospitalizations in Refractory Angina Patients with Left Ventricular Dysfunction
Soran Ozlem, Kennard Elizabeth, Bart Bradley, and Kelsey Sheryl
Congestive Heart Failure. 2007; 13:36-40.
Cardiovascular Institute, University of Pittsburgh Medical Center; the Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA; and Hennepin County Medical Center, Minneapolis, MN.
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≤40%) treated with EECP therapy for refractory angina. Clinical outcomes, number of all-cause ED visits, and hospitalization within the 6 months before EECP were compared with those at 6 month follow-up. Despite the unfavorable risk profile, refractory angina patients with LV dysfunction achieved a substantial reduction in all-cause ED visits and hospitalization rates at 6 month follow-up. EECP therapy offers an effective adjunctive treatment options for this group of patients.
[Effects of enhanced external counterpulsation in atherosclerosis and NF-kappaB expression: a pig model with hypercholesterolemia]
[Article in Chinese]
Zhang Y, He XH, Chen XL, Hu RD, Ma H, Wu GF, He JG, Zhan CY, Jin YF, Fang DQ, Zheng ZS.
Key Laboratory of Assisted Circulation, Cardiovascular Research Institute, First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China.
OBJECTIVE: To study the effects of enhanced external counterpulsation (EECP) on the vascular morphology, and endothelial function using experimentally induced hypercholesterolemic pigs.
METHODS: thirty five male pigs were randomly divided into three groups: 7 normal control animals, 11 hypercholesterolemic animals, and 17 hypercholesterolemic animals receiving EECP. Serum cholesterol was measured. The coronary arteries and aortas were sampled for histopathological and ultrastructural examination. The NF-kappaB protein expression of porcine coronary arteries was investigated by immunoflourescence.
RESULTS: Compared with the normal controls, serum cholesterol levels were significantly higher in the hypercholesterolemic animals with or without EECP. The plaque/intimal area ratio of the aorta decreased significantly in animals receiving EECP [(3.33 +/- 2.40)%, versus (12.03 +/- 7.12)% in those without EECP, P> 0.05]. Lipid deposition, endothelial damage and proliferation of smooth muscle cells were less severe in animal receiving EECP than those not. Moreover, activation and expression of NF-kappaB also decreased significantly (P> 0.05) in animals receiving EECP.
CONCLUSIONS: EECP improves the morphology and function of vascular endothelium, and retards the development and progression of atherosclerosis, likely through the inhibition of NF-kappaB signaling pathway.
PMID: 16630505 [PubMed- in process]
Effect of enhanced external counterpulsation on resting oxygen uptake in patients having previous coronary revascularization and in healthy volunteers.
AB Ochoa, A Dejong, D Grayson, B Franklin, and P McCullough
Am J Cardiol, September 1, 2006; 98(5): 613-5.
Wright-Patterson Medical Center, Wright Patterson AFB, Ohio.
This study analyzed the acute effects of enhanced external counterpulsation (EECP) on oxygen uptake (VO(2)) 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 VO(2) during an EECP treatment session has not been previously reported. We measured VO(2) 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. VO(2) was measured for 10 minutes before EECP, during a 30 minute EECP treatment session, and for 10 minutes after cessation of EECP treatment. Patients with CAD were older (65.9 +/- 12 vs 38.5 +/- 7 years, p= 0.002) and had a higher body mass index (32.0 +/-10.0 vs 25.5 +/- 3.0 kg/m (2), p=0.027) and percent body fat (37 +/- 7% vs 21 +/- 9%, p=0.006). VO(2) at rest, although slightly lower in the CAD group, was not significantly different (2.75 +/-0.54 vs 3.19 +/- 0.51 ml/kg/min, p=0.09). The 2 groups demonstrated a small, sustained increase in VO(2) during EECP treatment (CAD +0.66 +/- 0.56 ml/kg/min, p>0.005; healthy +0.72 +/- 0.40 ml/kg/min, p> 0.001; CAD vs. healthy, p=0.13), which returned to baseline levels during recovery. In conclusion, VO(2) at rest is increased to the same degree during and EECP treatment session in healthy subjects and symptomatic patient with CAD. This effect may contribute to the increased exercise tolerance of patients with refractory angina after receiving EECP therapy
1:Nan Fang Yi Ke Da Xue Xue Bao. 2006 Jul; 26(7): 1003-5.
[Effects of external counterpulsation on shear stress and production of nitric oxide and cGMP in canines with myocardial infarction.]
[Article in Chinese]
Qian XX, Chen YM, Wu WK, Liu Y, Zhou B, Chen L, Zheng ZS.
Department of Cardiology,Third Affiliated Hospital, Sun Yat-sen.
University, Guangzhou 510630, China.
OBJECTIVE: To investigate the effects of external counterpulsation (ECP) on shear stress and signal transduction in canines with myocardial infarction.
METHODS: Nineteen healthy dogs were randomly divided into control, ischemia, and ischemia plus ECP groups. Myocardial infarction was induced in the latter two groups by ligation of the left anterior descending artery (LAD). Serum and aorta NO levels of the dogs were determined by modified nitrate reductase methods, and serum and aorta cyclic guanosine monophosphate (cGMP) levels by radioimmunoassay.
RESULTS: The shear stress in the truncus brachiocephalicus decreased after LAD ligation, but increased significantly after 2 h of ECP treatment. Serum and aorta NO levels in ECP and control groups were significantly higher than those in the ischemic group (P>0.05). Serum and aorta cGMP levels in control group and ECP group after LAD ligation were also significantly higher than those in the ischemic group (P>0.05).
CONCLUSION: ECP can increase the shear stress and increase NO and cGMP levels in dogs with myocardial ischemia, which might be an important mechanism of ECP protection of the myocardium
Effects of external counterpulsation in plasma nitric oxide and endothelin-1 levels
Akthar M, Wu GF, Du ZM, Zheng ZS, Michaels AD
Department of Medicine, Division of Cardiology, University of California at San Francisco Medical Center, USA
Am J Cardiol. 2006 Jul 1; 98(1):28-30. Epub 2006 May 3.
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 six 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 the baseline (43.6 =/- 4.3 vs 27.1 +/- 2.6 mumol/L, p Our data provides neurohormonal evidence to support hypothesis that EECP improves endothelial function.
Circulation 2002 Sep 3; 106 (10): 1237-42
Left ventricular systolic unloading and augmentation of intracoronary pressure and Doppler flow during enhanced external counterpulsation
Michaels AD, Accad M, Ports TA, Grossman W.
Division of Cardiology, Department of Medicine, University of California at San Francisco Medical Center, San Francisco, Calif 94143-0124, USA. firstname.lastname@example.org
BACKGROUND: External Counterpulsation provides beneficial effects for patients with chronic, symptomatic angina pectoris. The physiological effects of ECP have not been studied directly. Intracoronary and left ventricular hemodynamics in the cardiac catheterization laboratory was examined during ECP.
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 ECP, 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, ECP resulted in a dramatic increase in diastolic (71 +/-10mm Hg at baseline to 137 +/- 21 mm Hg during ECP; +93%; P<0.001) and mean intracoronary pressures (88+/- to 102 +/-16 mm Hg; +16%; P=0.006) with a decrease in systolic pressure (116 +/-20 to 99+/-26 mm Hg; -15%; 0.002). The intracoronary Doppler measure of average peak velocity increased from 11+/- 5 cm/s at baseline to 23 +/-5 cm/s during ECP (+109%; P=0.001). The TIMI frame count, a quantitative angiographic measure of coronary flow, showed a 28% increase in coronary flow during ECP compared with baseline (P=0.001).
CONCLUSIONS: ECP significantly increased diastolic and mean pressure, reduced systolic pressure in the central aorta and the coronary artery. Coronary artery flow, determined by both Doppler and angiographic techniques, is increased during ECP. The combined effects of systolic unloading and increased coronary perfusion pressure provide evidence that ECP may serve as a potential mechanical assistance device.
Sheng Wu Yi Gong Cheng Xue Za Zhi 2002 Jun; 19(2): 196-9
[Effects of external Counterpulsation on the pulsatility of blood pressure and blood flow in dogs]
[Article in Chinese]
Liu L, Wu G, Zhou S, Zheng Z, Jin Y, Yang S, Zhan C, Fang D, Qian X.
Department of Cardiology, Zhujiang Hospital, First Military Medical University, Guangzhou 510280. email@example.com
This study measured pulsatile arterial blood flow and the effects that ECP has on arterial blood pressure and blood flow in dogs. They would also like to determine how vascular endothelial function may be affected by ECP. Common carotid artery blood pressure and blood flow were measured in 6 beagle dogs that had suffered from an acute myocardial infarction 6 weeks before. Pressure was measured from the right common carotid artery to measure blood pressure. Blood flow was measured in the left common carotid artery by an electromagnetic blood flow probe under anesthesia before and during ECP. Blood pulse pressure, pulsatility index (ratio of peak pressure to end diastolic pressure) and standard deviation of blood pressure were calculated to evaluate the pulsatility of arterial blood pressure. Blood pulse flow, pulsatility index (ratio of peak flow to trough flow) and standard deviation of blood flow were calculated to evaluate the pulsatility of blood flow. Mean vascular resistance (MVR) was calculated as MVR= mean blood pressure/ mean blood flow. Blood pulse pressure, pulsatility index and standard deviation of blood pressure was elevated from 30+/-9 mmHg, 1.26+/-0.05 and 8.7+/-2.5 mmHg to 43+/-8 mmHg (P<0.05), 1.54+/-0.13 and 12.4+/-2.0 mmHg (P<0.05) before and during ECP, respectively. Blood pulse flow, pulsatility index and standard deviation of blood flow were elevated from 317+/-48 ml/min, 2.85+/-0.21 and 96+/-21 ml/min to 447+/-88 ml/min, 4.56+/-90 and 131+/-39 ml/min before and during ECP (P<0.05). MVR was decreased from 578+/ -72 before ECP to 476+/-85 Wood units during ECP (P<0.05). These data demonstrate that ECP gives an elevation of pulsatility to blood pressure and blood flow, thus it may lead to the decrease of vascular resistance.
J Investig Med 2002 Jan;50(1):25-32
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, Fleishman B, Crawford L, McKiernan T, Nesto R, Ferrans CE, Keller S.
Columbia-Presbyterian Medical Center, Columbia University, New York, USA. firstname.lastname@example.org
BACKGROUND: The Multicenter Study of Enhanced External Counterpulsation (MUST-EECP) was the first prospective, randomized, blinded, sham-controlled study of External Counterpulsation (ECP) in the treatment of chronic stable angina. It was previously stated that ECP therapy lengthens the time to exercise-induced myocardial ischemia and reduces angina. We now illustrate the effects of ECP therapy versus a sham-treated control group in terms 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 decide whether a 35-hour course of ECP affects the HQOL of patients with symptomatic coronary artery disease, 12 months following treatment.
METHODS: Seventy-one of the 139 patients enrolled in MUST-EECP provided patient-completed questionnaires at baseline, at the end of treatment, and 12 months post-treatment. The Medical Outcomes Study 36-Item Short-Form Health Survey and the Quality of Life Index-Cardiac Version III were used to evaluate effects on HQOL.
RESULTS: Both groups HQOL scores at baseline were alike. Post-treatment, and at 12-month follow up, patients who had active-CP reported greater improvement than those who had inactive-CP in all nine quality of life scales, including ability to do everyday activities, ability to work, bodily pain, confidence in health, energy, ability to engage in social activities with family and friends, anxiety and depression, and quality of life issues from the effects of angina on health and functioning. Despite small sample sizes, active-CP patients showed significantly greater improvement at 12 months following treatment in bodily pain, social functioning, and quality of life specific to cardiac patients compared with inactive-CP patients.
CONCLUSION: Up to a year after ECP therapy there was significant health-related quality of life improvements measured. Improvements in this controlled study are consistent with HQOL changes reported in case series and patient registries. Larger studies are warranted.
Angiology 2001 Oct;52(10):653-8
Acute hemodynamic effects and angina improvement with enhanced external counterpulsation.
Stys T, Lawson WE, Hui JC, Lang G, Liuzzo J, Cohn PF.
Department of Surgery, SUNY at Stony Brook, NY, USA.
External Counterpulsation is a noninvasive treatment for coronary artery disease. The mechanism of action is thought 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 post-treatment improvement in Canadian Cardiovascular Society angina class (CCS). Women and the elderly underwent planned subgroup analysis. The ER was computed during the first and last hours of a 35-hour course of ECP treatment. After ECP, 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 old (p=NS). The first and final ER was 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 in men and women and across a broad range of ages. The hemodynamic effect of ECP (ER) does not predict improvement in CCS and may indicate that other factors, such as neurohormonal changes, could have a significant role in mediating the observed ECP benefits.
Clin Cardiol 2001 Jun; 24 (6):435-42
The International EECP Patient Registry (IEPR): design, methods, baseline, characteristics, and acute results.
Barsness G, Feldman AM, Holmes DR Jr, Holubkov R, Kelsey SF, Kennard ED; International EECP Patient Registry Investigators.
Mayo Clinic Foundation, Rochester, Minnesota, USA.
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 consists of all patients starting ECP therapy for treatment of angina pectoris in participating centers.
HYPOTHESIS: The study was started to determine whether ECP is safe and effective treatment for patients with angina pectoris regardless of their suitability for revascularization by more traditional processes.
METHODS: After 18 months of operation, 43 clinical centers representing over half of clinical sites using the ECP system supplied cases. ECP can be used for patients not eligible for either coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI), or for those who favor noninvasive treatment to avoid or delay revascularization. In this report, patients considered to be candidates for revascularization are compared with those not considered suitable.
RESULTS: Of the 978 patients analyzed, 70% had Canadian Cardiovascular Society Classification class III or IV angina before starting treatment, and 62% used nitroglycerin. 81% (most) had been previously revascularized, and 69% were thought to be unsuited for either PCI or CABG at the beginning of ECP. A full treatment course (usually 35 h) was completed in 86%, of whom 81% reported improvement of at least one angina class immediately after the last treatment.
CONCLUSION: ECP has demonstrated to be safe and effective in a wide population.
Clin Cardiol 2001 Jun;24(6):453-8
Does higher diastolic augmentation predict clinical benefit form 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.
Department of Medicine, University of California San Francisco Medical Center, 94143-0124,USA.
BACKGROUND: External Counterpulsation (ECP) has shown to be an effective treatment for stable angina in patients with coronary disease. The hemodynamic effects of ECP 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 who undergo ECP 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 ECP.
METHODS: We analyze 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 recorded from finger plethysmography. Six-month clinical outcomes were obtained by telephone interview.
RESULTS: At the end of ECP treatment, 370 (37%) patients had a greater DA ratio (defined as > or +1.5) and 634 (63%) had a lower DA ratio (defined as < 1.5). Factors associated with a lower DA ratio included age > or = 65 years (p<0.001), female gender (p<0.001), left ventricular ejection fraction 35% (p<0.05), hypertension (p<0.01), previous coronary bypass surgery (p<0.01), noncardiac vascular disease (p<0.001), multivessel disease (p<0.01), congestive heart failure (p<0.01), current smoking (p<0.01), unsuitability for further revascularization (p<0.001), and higher baseline angina class (p<0.001). There were no significant differences in regards to diabetes mellitus, prior coronary angioplasty, prior myocardial infarction, or antianginal medication used between patients with higher or lower DA ratios. Based on multiple logistic regression model, independent producer of a DA radio < 1.5 at the end of ECP includes current smoking (ratio 3.3;95% confidence intervals 2.0-5.4); multivessel disease (1.7;1.3-2.3); female gender (2.2;1.7-3.0); no prior EECP (1.9; 1.1-3.3); noncardiac vascular disease (2.3;1.7-2.9); age > or = 65 years (1.7; 1.4-2.2), and patients unsuitable for revascularization (1.6; 1.2-2.0). At the end of therapy, there were no significant differences in myocardial infarction, revascularization rates, or nitroglycerin use with respect to higher DA ratios. At 6-month follow-up, patients with higher DA had a trend toward a greater reduction in angina class compared with those with lower DA (p=0.069). There was a significantly higher rate of unstable angina and congestive heart failure in the group not achieving higher augmentation (p<0.05).
CONCLUSIONS: Patients who are younger, male, nonsmoking, and without multivessel coronary or noncardiac vascular disease are most likely to have a higher DA with ECP. Patients with higher DA were inclined to have a greater reduction in angina class at 6-month follow-up compared with those with lower DA ratios. There is evidence that higher DA ratios are linked with improved short- or long-term clinical outcomes, indicating that clinical benefit from ECP is associated with the magnitude of DA.
Ann Biomed Eng 2001 Apr; 29(4):284-97
Numerical simulation of enhanced external counterpulsation.
Ozawa ET, Bottom KE, Xiao X, Kamm RD.
Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, US
External counterpulsation (ECP) is a noninvasive, counterpulsative treatment that gives temporary help to the failing heart. This is done by sequentially inflating cuffs on the lower extremity out-of-phase with the left ventricle. Optimization of the method needs consideration of the hemodynamics created by ECP and the course of action providing patient benefit. A computational model based on the governing one-dimensional equations is cultivated that stimulates cardiovascular hemodynamics during ECP. The model includes a 30-element arterial system including the left ventricle, bifurcations, and peripheral arterial vessels. The effects of vessel collapse as external pressure is applied, arterial refilling on pressure release, changes in aortic pressure, and shear stress created in the arteries are each assessed. Device parameters are systematically modified to determine their effect on the system’s performance. Results show the potential for significant collapse and shear augmentation throughout the arteries of the lower extremity. Performance is strongly influenced by the mean level of external pressurization and the timing of cuff inflation, but less by the relative timing and pressure differences between cuff segments.
Curr Interv Cardiol Rep 2001 Feb;3(1):37-43
Enhanced External Counterpulsation in Unrevascularizable Patients.
Mayo Clinic and Foundation, 200 First Street, SW, Rochester, MN 55905, USA. email@example.com
External Counterpulsation (ECP) is a noninvasive outpatient therapy for the treatment of chronic angina. ECP produces an acute hemodynamic effect that is similar to the invasive intra-aortic balloon pump. Three sets of cuffs on the upper thigh, lower thigh, and calves of each leg inflate with compressed air during the diastolic phase of the cardiac cycle and deflate in early systole. This quick inflation and deflation raises diastolic aortic pressure, increases coronary perfusion pressure, and gives improved afterload reduction and increased venous return with a subsequent increase in cardiac output. External Counterpulsation provides long-term symptom relief in patients with ischemic heart disease in several case series, and in a randomized trial. Up to 80% of patients chosen for treatment have a positive clinical response, and an associated objective improvement has been shown by functional imaging in many case series. Treatment course is comprised of 35 1-hour sessions lasting a 7-week period. This is usually tolerable with a low risk of harmful events. Development and enhancement of collateral channels, as well as peripheral conditioning and neurohumoral effects, may play a role in providing symptomatic relief. Studies are ongoing to determine the mechanism of action and to further define subsets of patients who might beat an advantage.
J Am Coll Cardiol 2001 Jan; 37(1):93-9
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, Matsumo T, Murohara T, Imaizumi T.
Deparment of Internal Medicine III, Kurume University School of Medicine, Japan.
OBJECTIVES: We studied whether External Counterpulsation (ECP) improves myocardial ischemia, exercise tolerance and cardiac function in patients with coronary artery disease (CAD).
BACKGROUND: External Counterpulsation lowers angina and raises exercise tolerance in patients with CAD. Some objective improvements of ischemia by ECP have been reported, but they should be confirmed further. Less documented have been the detailed effects of hemodynamics.
METHODS: 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: External Counterpulsation improved all exercise test parameters (p<0.05): exercise duration, time to 1-mm ST segment depression, rate-pressure product at peak exercise and rate-pressure product at 1-mm ST segment depression. More important was the prevalence of exercise-induced reversible perfusion defects by thallium scintigraphy decreased after treatment (p<0.01). External Counterpulsation did not change systolic function but improved diastolic filling, left ventricular (LV) end-diastolic pressure (p<0.05) by cardiac catheterization and LV peak filling rate end-diastolic volume/s (p<0.05) by radionuclide scintigraphy. These hemodynamic improvements were related to decreased plasma brain natriuretic peptides levels after ECP (p<0.05).
CONCLUSIONS: Thus, ECP treatment reduced myocardial ischemia by thallium scintigraphy in association with improved LV diastolic filling in patients with stable CAD and improves exercise tolerance.
Mayo Clin Proc 2000 Sep;75(9):961-5
Noninvasive revascularization by enhanced external counterpulsation: a case study and literature review.
Singh M, Holmes DR Jr, Tajik AJ, Barsness GW.
Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, Minn 55905, USA.
Close to 8 million people in the United States suffer from symptoms of coronary artery disease (CAD). Regrettably, the population of patients with ischemic coronary diseases is not readily amenable to surgical or percutaneous revascularization continues to grow. Patients who are not candidates for standard revascularization procedures and in whom aggressive medical therapy fails to control symptoms, External Counterpulsation (ECP) is an innovative, noninvasive outpatient treatment to advance quality of life by decreasing ischemic symptoms and permit increased activity. We report the case of a 56 year-old woman with severe, symptomatic CAD receiving maximal medical therapy who underwent a course of ECP therapy because she was not a good candidate for other forms of revascularization. The patient showed improvement in her anginal symptoms and complete resolution of myocardial ischemia on repeat nuclear stress imaging. This case suggests that ECP is a safe and effective method of reducing symptoms of myocardial ischemia in patients for whom standard percutaneous or surgical revascularization is not suitable.
Clin Cardiol 2000 Apr;23(4):254-8
Long-term prognosis of patients with angina treated with enhanced external counterpulsation: five-year follow-up study.
Lawson WE, Hui JC, Cohn PF.
Division of Cardiology, SUNY at Stony Brook 11794, USA.
BACKGROUND: External Counterpulsation (ECP) is a noninvasive treatment for coronary artery disease (CAD) that has been used successfully in patients not responding to medical and/or surgical therapy.
HYPOTHESIS: The study was undertaken to assess the effect of EECP on long-term prognosis in such patients.
METHODS: Major adverse cardiovascular events (MACE) were tracked in 33 patients with CAD treated with ECP. Patients were subgrouped based on whether or not they demonstrated an early improvement in radionuclide stress perfusion imaging (Responders vs. Nonresponders) and followed for MACE over a mean follow-up of 5 years. Patient population characteristics included 73% with multivessel disease; 45% with prior myocardial infarction(s); and 61% who had undergone either coronary artery bypass grafting (CABG) or percutaneous transluminal coronary angioplasty (PTCA), or both.
RESULTS: There were 26 of 33 (79%) Responders, and 7 of 33 (21%) Nonresponders. Subsequent MACE over the 5-year follow-up included four deaths and eight patients with cardiovascular events [acute myocardial infarct (4), new CABG or PTCA (6), valve replacement (1), unstable angina (1)]. Nonresponders had significantly (p<0.01) more MACE (6/7 or 86%) than Responders (6/26 or 23%). On the whole, 21 or the 33 (64%) patients stayed alive and without MACE and the need for revascularization 5 years post ECP treatment.
CONCLUSION: This study proposes that for most patients who show improvement in radionuclide stress perfusion post treatment, ECP may be a successful, lasting therapy.
Treatment benefit in the enhanced external counterpulsation consortium.
Lawson WE, Hui JC, Lang G.
Division of Cardiology and Department of Surgery, SUNY at Stony Brook, NY, USA. firstname.lastname@example.org
The percent study used a cohort of 2,289 consecutive patients enrolled in the External Counterpulsation (ECP) Consortium to assess whether results of university studies showing ECP safety and effectiveness in treating angina can be generalized. ECP was well endured and found to be safe 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 not dependent of provider setting or experience, women responded as well as men, and even though younger patients demonstrated a greater likelihood of improvement, ECP was effective in patients ranging from 19 to 97 years. These findings may indicate extending ECP treatments to a broader range of patients.
Heart Dis 1999 Sep-Oct;1(4):221-5
External counterpulsation for the treatment of myocardial ischemia.
State University of New York Health Sciences Center at Stony Brook, Stony Brook, New York 11794-8171, USA.
External Counterpulsation (ECP) is a procedure that uses three sets of cuffs to squeeze the vascular beds of the leg and thigh in sequential manner timed to the patient’s electrocardiogram (ECG). Results of nonrandomized studies performed at the State University of New York Health Sciences Center at Stony Brook and a multicenter randomized study performed at seven centers throughout the United States indicate that the procedure has beneficial hemodynamic and clinical effects in selected patients with chronic angina that is refractory to standard medical and surgical therapy.
External Counterpulsation improved myocardial perfusion and coronary flow reverse in patients with chronic stable angina; evaluation by (13)N- ammonia positron emission tomography.
Masuda D, Nohara R, Hirai T, Kataoka K, Chen LG, Hosokawa R, Inubushi M, Tadamura E, Fujita M, Sasayama S.
Department of Cardiovascular Medicine, Graduate School Medicine, Kyote University, Japan.
AIMS: The mechanisms by which external counterpulsation therapy exerts its beneficial effects on chronic and symptomatic stable angina is largely unknown. To clarify the mechanism of action of 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 external counterpulsation therapy for 35 1 hour sessions. They underwent a treadmill exercise test and (13)N-ammonia positron emission tomography, both at rests and with dipyridamole, before and after 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 ischemic regions, particularly the anterior region, myocardial perfusion at rest and with dipyridamole and coronary flow reserve improved significantly after therapy (at rest: 0.71+/-0.26 to 0.86+/-0.31; P<0.05, with dipyridamole: 1.26+/-0.65 to 1.84+/-0.94; P<0.02, coronary flow reserve: 1.75+/-0.24 to 2.08+/-0.28; P<0.04). Exercise time was prolonged and the time to 1-mm ST depression improved markedly (P<0.01). After therapy, nitric oxide levels increased (P<0.02) and neurohumoral factors decreased.
CONCLUSIONS: External Counterpulsation therapy improved myocardial perfusion at rest with dipyridamole and was associated with an increased exercise tolerance with (13)N-ammonia positron emission tomography and increased nitric oxide levels. These results suggest that one of the external counterpulsation mechanisms is development and recruitment of collateral vessels. Copyright 2001. The European Society of Cardiology.
PMID: 11482918 [PubMed-indexed for MEDLINE]
IABP assistance: a test bench for the analysis of its effects on ventricular energetics and hemodynamics.
Ferrari G, Gorczynska K, Mimmo R, De Lazzari C, Clemente F, Tosti G, Guaragno M.
CNR ITBM, Department of Cardiovascular Engineering, Via G.B. Morgagni, 30/e 00161 Roma, Italy.email@example.com
IABP assistance is frequently used to support heart recovery, improving coronary circulation and reestablishing the balance between oxygen availability and consumption. Hemodynamics and energetic parameters (endocardial viability ratio, ventricular energetics) are used to evaluate its effectiveness which depends on internal (timing, balloon volume and position) and external factors (circulatory conditions). Considering short, medium and long term effects of IABP, the first depends on its mechanical action, the latter on the changes induced in circulatory parameters. The analysis of the first is important because conditions for the onset of a virtuous cycle able to support ventricular recovery are created. Simulation systems could be helpful in this analysis for the implicit reliability and reproducibility of the experiments, provided that they are able to reproduce both hemodynamics phenomena and energetic relationships. The aim of this paper is to present a system originally developed to test mechanical heart assist devices and modified for IABP testing. Data reported here are obtained from in vitro experiments. A partial verification, obtained from the literature is presented.
PMID:11429876 [PubMed-indexed for MEDLINE]
Improvement of fractional flow reserve and collateral low by treatment with External Counterpulsation (Art.Net.-2 Trial)
E. E.Buschmann*,†, W. Utz*,‡,1, N. Pagonas†, J. Schulz-Menger*,‡, A. Busjahn§, J. Monti*,W. Maerz¶, . le Noble**, L. Thierfelder*, R. Dietz†, V. Klauss††, M. Gross* and I.R. Buschmann†,‡‡ On behalf of the rteriogenesis Network (Art. Net.) Franz-Volhard-Klinik, Department for Cardiology, Helios-Klinikum Buch, Berlin, †Charite´ , Universitaetsmedizin Berlin,Arteriogenesis Research Group, CC13, Center for Cardiovascular Research (CCR) & Experimental and Clinical Research Center (ECRC) & Internal Medicine (Department for Cardiology), Berlin, ‡Franz-Volhard-Klinik, Cardiac Magnetic Imaging, Helios-Klinikum Buch, Berlin, §HealthTwiSt GmbH, Berlin – Buch, ¶Synlab laboratory services, Eppelheim, **Max- elbrueck-Center for Molecular Medicine, Angiogenesis and Cardiovascular Pathology, Berlin, ††Medizinische Poliklinik der Universita¨t Mu¨ nchen; Campus Innenstadt, Dept. for Cardiology, Mu¨ nchen, ‡‡Department for Internal Medicine (Cardiology), University Clinic Freiburg, Freiburg i.Br., Germany
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 methodsA total of 23 patients (age 61 ± 2Æ5 years) with stable coronary artery disease and at least one haemodynamic 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 evaluated. All patients underwent a cardiac catheterization at baseline and after 7 weeks, with invasive measurements of the pressure-derived collateral flow index (CFIp, primary endpoint) and fractional flow reserve (FFR).
ResultsIn the ECP group, the CFIp (from 0Æ08 ± 0Æ01 to 0Æ15 ± 0Æ02; P < 0Æ001) and FFR (from 0Æ68 ± 0Æ03 to 0Æ79 ± 0Æ03; P = 0Æ001) improved significantly, while in the control group no change was observed. Only the ECP group showed a reduction of the Canadian Cardiovascular Society (CCS, P = 0Æ008) and New York Heart Association (NYHA, P < 0Æ001) classification.
ConclusionIn this study, we provide direct functional evidence for the stimulation of coronary arteriogenesis via ECP in patients with stable coronary artery disease. These data might open a novel noninvasive and preventive treatment avenue for patients with non-acute vascular stenotic disease.
Eur J Clin Invest 2009