Enhanced External Counterpulsation Improves Exercise Tolerance in Patients With Chronic Heart Failure
Arthur M. Feldman, MD, PHD, FACC,* Marc A. Silver, MD, FACC,† Gary S. Francis, MD, FACC,‡ Charles W. Abbottsmith, MD, FACC,§ Bruce L. Fleishman, MD, FACC, Ozlem Soran, MD, MPH, FACC, FESC,¶ Paul-Andre de Lame, MD,# Thomas Varricchione, MBA, RRT,** for the PEECH Investigators
Philadelphia, Pennsylvania; Oak Lawn, Illinois; Cleveland, Cincinnati, and Columbus, Ohio; Pittsburgh, Pennsylvania; Stockton, New Jersey; and Westbury, New York
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 exerciseinducedischemia in patients with coronary artery disease, angina, and normal left ventricularfunction. 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 andprotocol-defined pharmacologic therapy (PT) or PT alone. Two co-primary end points werepre-defined: the percentage of subjects with a 60 s or more increase in exercise duration andthe percentage of subjects with at least 1.25 ml/min/kg increase in peak volume of oxygenuptake (VO2) at 6 months.
RESULTS By the primary intent-to-treat analysis, 35% of subjects in the EECP group and 25% of control subjects increased exercise time by at least 60 s (p _ 0.016) at 6 months. However,there was no between-group difference in peak VO2 changes. New York Heart Association (NYHA) functional class improved in the active treatment group at 1 week (p _ 0.01), 3 months (p _ 0.02), and 6 months (p _ 0.01). The Minnesota Living with Heart Failure score improved significantly 1 week (p _ 0.02) and 3 months after treatment (p _ 0.01).
CONCLUSIONS In this randomized, single-blinded study, EECP improved exercise tolerance, quality of life, and NYHA functional classification without an accompanying increase in peak VO2. (JAm Coll Cardiol 2006;48:1198 –205) © 2006 by the American College of Cardiology Foundation
Benefit and safety of enhanced external counterpulsation in treating coronary artery disease patients with a history of congestive heart failure.
SUNY at Stony Brook, NY, USA. email@example.com
External Counterpulsation (ECP) is utilized to non-invasively 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 ECP 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 previous infarcts and revascularizations. Fewer heart failure patients finished the course of ECP, and exacerbation of heart failure was more frequent, though most 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.
Impairment of Ventilatory Efficiency in Heart Failure
F.X. Kleber, MD; G. Vietzke, MD; K.D. Wernecke, PhD; U. Bauer, MD; C. Opitz, MD; R. Wensel, MD; A. Sperfeld, MD; S. Gla¨ser, MD
BACKGROUND Impairment of ventilatory efficiency in congestive heart failure (CHF) correlates well with symptomatology and contributes importantly to dyspnea.
METHODS and RESULTS We investigated 142 CHF patients (mean NYHA class, 2.6; mean maximum oxygen consumption [V˙ O2max], 15.3 mL O2 z kg21 z min21; mean left ventricular ejection fraction [LVEF], 27%). Patients were compared with 101 healthy control subjects. Cardiopulmonary exercise testing was performed, and ventilatory efficiency was defined as the slope of the linear relationship of V˙ CO2 and ventilation (VE). Results are presented in percent of age- and sex-adjusted mean values. Forty-four events (37 deaths and 7 instances of heart transplantation, cardiomyoplasty, or left ventricular assist device implantation) occurred. AmongV˙ O2max, NYHA class, LVEF, total lung capacity, and age, the most powerful predictor of event-free survival was the VE versusV˙ CO2 slope; patients with a slope #130% of age- and sex-adjusted normal values had a significantly better 1-year event-free survival (88.3%) than patients with a slope .130% (54.7%; P,0.001).
CONCLUSIONS: The VE versus V˙ CO2 slope is an excellent prognostic parameter. It is easier to obtain than parameters of maximal exercise capacity and is of higher prognostic importance than V˙ O2max. (Circulation. 2000;101:2803-2809.)
Ventilatory and Heart Rate Responses to Exercise Better Predictors of Heart Failure Mortality Than Peak Oxygen Consumption
Mark Robbins, MD; Gary Francis, MD; Fredric J. Pashkow, MD; Claire E. Snader, MA; Kathy Hoercher, RN; James B. Young, MD; Michael S. Lauer, MD
BACKGROUND: An abnormally low chronotropic response and an abnormally high ventilatory response (V˙ E/V˙ CO2) to exercise are common in patients with severe heart failure, but their relative prognostic impacts have not been well explored.
METHODS and RESULTS: Consecutive patients with heart failure referred for metabolic stress testing who were not taking b-blockers or intravenous inotropes (n5470) were followed for 1.5 years. The chronotropic index was calculated while peak V˙ O2 and V˙ E/V˙ CO2 were directly measured. Chronotropic index and peak V˙ O2 were considered abnormal if in the lowest 25th percentiles of the patient cohort, whereasV˙ E/V˙ CO2 was considered abnormal if in the highest 25th percentile. For comparative purposes, a group of 17 healthy controls underwent metabolic testing as well. Compared with controls, heart failure patients had markedly abnormal ventilatory and chronotropic responses to exercise. In the heart failure cohort, there were 71 deaths. In univariate analyses, predictors of death included highV˙ E/V˙ CO2, low chronotropic index, low V˙ O2, low resting systolic blood pressure, and older age. Nonparametric Kaplan-Meier plots demonstrated that by dividing the population according to peak V˙ E/V˙ CO2 and peak V˙ O2, it is possible to identify low, intermediate, and very high risk groups. In multivariate analyses, the only independent predictors of death were highV˙ E/V˙ CO2 (adjusted relative risk [RR] 3.20, 95% CI 1.95 to 5.26, P,0.0001) and low chronotropic index (adjusted RR 1.94, 95% CI 1.18 to 3.19, P50.0009).
CONCLUSIONS: The ventilatory and chronotropic responses to exercise are powerful and independent predictors of heart failure mortality. (Circulation. 1999;100:2411-2417.)
Enhanced External Counterpulsation and Future Directions: Step Beyond Medical Management for Patients with Angina and Heart Failure
Manchanda, Aarush and Soran, Ozlem.
Journal of American College of Cardiology 2007;50:1523-31.
Department of Internal Medicine, The George Washington University, Washington D.C.; and the Cardiovascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
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, non-invasive treatment for these angina patients, and now for heart failure patients as well. Recent evidence suggests that enhanced external counterpulation (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 consumption (Vo2), regression of atherosclerosis, and peripheral training effects similar to exercise. Numerous clinical trials in the last 2 decades have shown EECP therapy to be safe and effective for patients with refractory angina with clinical response rate averaging 70% to 80%, which is sustained up to 5 years. It is not only safe in patients with coexisting heart failure, but also is shown to improve quality of life and exercise capacity and to improve left ventricular function long term. Interestingly, EECP therapy has been studied for various potential uses other than heart disease, such as restless leg syndrome, sudden deafness, hepatorenal syndrome, erectile dysfunction, and so on. This review summarizes the current evidence for its use in stable angina and heart failure and its future direction