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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 were tested by repeated measures analysis. Results: Fifty patients were included in the study. The mean age was 63 years, and 72% were male. The Canadian Cardiovascular Society Angina Grading Scale class improved from a mean of 2.6 to 1.5. The mean daytime ABPs were 114/69, 114/70, 115/71, 114/70, and 116/71 mm Hg and the mean nighttime ABPs were 107/63, 108/63, 106/62, 108/63, and 107/62 mm Hg at 2 months before the EECP course, just before the EECP course, just after the EECP course, and at 3 and 12 months after EECP, respectively (all P > 0.10). Further, when controlling for quartiles of baseline ABP level, no significant change in ABP was found. Conclusions: Enhanced external counterpulsation treatment has no lasting effect on ABP. The study was supported by a grant from the Danish Heart Foundation (grant no. 06-10-B551-A1204-22346) and from “Ringkobing Amts Sundhedsvidenskabelige Forskningsfond.” The authors have no other funding, financial relationships, or conflicts of interest to disclose.

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 had either acute coronary syndrome alone (n = 4), cardiogenic shock alone (n = 3), or both (n = 3). The cardiac indications for study enrollment included: acute inferior wall ST-segment elevation myocardial infarction with cardiogenic shock (n = 2), non-ST-segment elevation myocardial infarction with postinfarction angina (n = 2) or heart failure (n = 1), unstable angina with refractory rest angina (n = 2), cardiogenic shock from ischemic cardiomyopathy with severe mitral regurgitation (n = 1), and cardiogenic shock from nonischemic cardiomyopathy (n = 2). No adverse events were recorded during or as a consequence of EECP therapy, including no bleeding complications, no heart failure exacerbations, and no skin breakdown. The portable EECP unit did not interfere with ongoing critical care nursing. Conclusions EECP is safe and feasible for acute bedside therapy of critically ill patients with acute coronary syndrome and/or cardiogenic shock who are not candidates for IABP. Copyright © 2007 Wiley Periodicals, Inc.

Cardiovascular Division, SUNY Stony Brook, Stony Brook, New York; *Graduate School of Public Health and †Cardiology Division,University of Pittsburgh, Pittsburgh, Pennsylvania; ‡Division of Cardiology, UCSF, San Francisco, California, USA. IEPR data c ollect-ed at the University of Pittsburgh, Graduate School of Public Health, Pittsburgh, Pennsylvania, USASummaryBackground: In the International Enhanced External Coun-terpulsation Patient Registry (IEPR), approximately 85% ofthe patients treated are in Canadian Cardiovascular Society(CCS) class III–IV with no option for further invasive coro-nary revascularization procedures.Hypothesis: This study sought to determine whether it isclinically important to establish whether the observed durablereduction in disabling severe angina with enhanced externalcounterpulsation (EECP) treatment can be extended to thosewith less severe CCS class II angina, who also have no optionfor further revascularization.Methods: This study evaluated the immediate response,durability and clinical events over a 2-year period after EECPtreatment in 112 patients with Canadian Cardiovascular So-ciety (CCS) class II angina versus 1,346 patients with classIII–IV angina using data from the International EECP PatientRegistry (IEPR). Results: Treatment with EECP significantly (by at leastone CCS class) reduced angina frequency, nitroglycerin use,and improved quality of life in both groups. At 2-year follow-up, 74% of class II and 70% of class III–IV patients remainedfree of major adverse cardiovascular events (MACE) andcontinued to demonstrate a durable CCS class improvementover baseline. Conclusion: The robust effectiveness of EECP as a nonin-vasive device, together with its relatively low start-up and re-current costs, makes it an attractive consideration for treatingpatients with milder refractory angina in addition to the patientwith severely disabling angina treated in current practice.Key words: noninvasive, 2-year outcome, enhanced externalcounterpulsation, anginaIntroductionEnhanced external counterpulsation (EECP) is a noninva-sive device for the treatment of patients with coronary arterydisease. It consists of three pair of pneumatic cuffs wrappedaround the lower extremities. The cuffs inflate sequentially atthe beginning of diastole and deflate during systole, producingsystolic unloading and diastolic augmentation as well as in-creasing venous return.

Summary 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 postEECP 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 functional angina class. There is a significant improvement in their total treadmill times (357 ± 93 to 449 ± 97 s, p < 0.001). There was a significant change in their peak double products, from 18,891 ± 3,939 pre-EECP to 20,464 ± 4,305 post-EECP ETT (p < 0.03). Pre EECP, 16 patients had ST-segment depression on their initial ETT. After EECP, 13 of these patients (80%) either no longer had ST depression or had a significant increase in their time to ST depression (229 ± 52 to 315 ± 60 s, p < 0.001). The radionuclide perfusion scores also showed a significant reduction in ischemic segments (16.36 ± 10.52 to 14 ± 10.9, p < 0.05). Conclusions:Patients treated with EECP demonstrated a reduction in angina symptoms, improvement in exercise capacity, increase in time to ST-segment depression, and decrease in perfusion defects despite performing at a higher workload.

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 recorded from finger plethysmography. Six-month clinical outcomes were obtained by telephone interview. Results: At the end of EECP treatment, 370 (37%) patients had a higher DA ratio (defined as ≥ 1.5) and 634 (63%) had a lower DA ratio (defined as < 1.5). Factors associated with a lower DA ratio included age ≥ 65 years (p < 0.001), female gender (p < 0.001), left ventricular ejection fraction < 35% (p < 0.05), hypertension (p < 0.01), prior 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 regarding diabetes mellitus, prior coronary angioplasty, prior myocardial infarction, or antianginal medication use between patients with higher or lower DA ratios. Based on a multiple logistic regression model, independent predictors of a DA ratio < 1.5 at the end of EECP included current smoking (odds 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 ≥ 65 years (1.7; 1.4–2.2), and patients not suitable for revascularization (1.6; 1.2–2.0). By 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 higher DA with EECP. Patients with higher DA tended 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 associated with improved short- or long-term clinical outcomes, suggesting that clinical benefit from EECP is associated with the magnitude of DA.

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 and unique therapy in our clinical armamentarium.

Background: Comorbid aortic stenosis (AS) has been considered a precaution when applying enhanced external counterpulsation (EECP) to individuals with angina due to concerns about treatment-related hemodynamic changes. Hypothesis: The aim of this study was to determine whether EECP safely reduces symptoms of myocardial ischemia and 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% CI: 74.9% to 96.1%) improved in angina class (P < 0.0001). There was no statistical difference between the percentages in patients with and without AS (P = 0.54). CCS angina class outcome was not associated with AS severity (P = 0.55). The percentage of patients with diastolic augmentation ratio ≥1.0 was 16.3% in both groups at baseline and improved to 39.5% in AS patients and 37.2% in non-AS patients after EECP (both P = 0.002). The average decreases in systolic blood pressure in subjects with AS (−15 mm Hg, 95% CI: 11 to 20, P < 0.0001) and without AS (−18 mm Hg, 95% CI: 14 to 22, P < 0.0001) were similar (P = 0.31). No major adverse cardiac events were reported. Conclusions: Angina patients with AS who undergo EECP had clinically important symptomatic and hemodynamic improvements comparable to their non-AS counterparts. Clin. Cardiol. 2012 doi: 10.1002/clc.22073 The authors have no funding, financial relationships, or conflicts of interest to disclose.

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 years. Eighty‐eight percent had a prior percutaneous or surgical revascularization and 82% were unsuitable for further coronary intervention. Immediately post‐EECP, the proportion of patients with severe angina (Canadian Cardiovascular Angina Classification [CCS] III/IV) were reduced from 89% to 25%, p

Enhanced external counterpulsation (EECP) is an effective noninvasive treatment for chronic stable angina. Despite intensive risk factor modification, a patient required two surgical coronary revascularizations and seven multivessel angioplasties over a 26‐monfh period, demonstrating recurrent unstable angina and persistent thallium perfusion defects despite revascularization. Post EECP, angina was relieved, thallium defects were resolved, and the patient has remained asymptomatic for 36 months.

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.

Background: Initial intra‐aortic balloon pump (IABP) catheters were of large caliber and their utilization resulted in a high incidence of complications, including limb ischemia, bleeding and thrombosis, peripheral neurologic sequelae, and infection. Despite eventual decrease in the size of IABP catheters, the complication rate has remained high. Hypothesis: The study was undertaken to determine whether use of recently available low‐profile IABP catheters would result in a lower incidence of vascular and bleeding complications. Methods: We prospectively evaluated the incidence of complications when consecutively using the low‐profile (8F) IABP catheter inserted mostly sheathlessly in 161 acute cardiac patients between January 1, 2000 and April, 2003. Results: Complications encountered included mild transient limb ischemia in two patients (1.2%), minor bleeding episodes in four patients (2.4%), one major puncture site bleeding (0.6%), and a pseudoaneurysm treated percutaneously in two patients (1.2%). Two patients (1.2%) suffered limb ischemia due to embolization or local thrombosis requiring vascular intervention. These complications were milder and their incidence remarkably lower than those reported previously when IABP catheters larger than 8F were used. Conclusion: Utilization of low‐profile IABP 8F catheters in a sheathless technique entails an exceedingly low complication rate despite an acute presentation, intense anticoagulant and antiaggregant therapy, frequent comorbidity, advanced age, severe coronary disease, and reduced cardiac function in a large proportion of treated patients.

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.

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.

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.

Background: Enhanced external counterpulsation (EECP) 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 evaluate 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 EECP. 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

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 assessed by Doppler echocardiography to determine whether there was an optimal EECP effectiveness ratio that maximizes the hemodynamic effects of EECP. With increasing DA/SU there was an initial positive linear increase in both systolic and diastolic flow volume. Systolic flow maximized at an effectiveness ratio of 1.5 and diastolic flow at a ratio of 2.0. Result: Therefore, effectiveness ratios (DA/SU) in the range of 1.5-2.0 are optimal for maximizing the hemodynamic effects of EECP.