Enhanced External Counter-Pulsation:

An Adjunctive Therapy for Angina and

Congestive Heart Failure

M. Saleem Seyal, M.D., F.A.C.C., F.A.C.P.

Despite use of effective medications and a myriad of revascularization procedures, many patients with ischemic heart disease continue to experience angina and have congestive heart failure (CHF).  Recurrent angina can be attributed to diminishing effectiveness of medications, progression of obstructive coronary artery disease, or incomplete revascularization.  Disabling angina, even though stable, can be a major source of frustration and can interfere with quality of life.  Enhanced External Counter-Pulsation (EECP), introduced in 1995, offers a novel, non-invasive method in an outpatient setting to relieve angina as its primary indication.  In June 2002, EECP was approved by the FDA for the treatment of congestive heart failure as well.

The concept of counterpulsation was introduced in the 1950's and involves increasing aortic pressure to improve coronary blood flow during diastole and decreasing the afterload during systole.  Intra-aortic balloon counterpulsation (IABP) is an established, albeit, invasive modality in the setting of unstable angina, cardiogenic shock, and severe left ventricular dysfunction.  Non-invasive counterpulsation in its current evolved form - EECP- consists of sequentially inflating and deflating a series of cuffs which squeeze vascular beds in the calves, lower thighs, and upper thighs synchronized to the cardiac cycle, thus augmenting diastolic blood pressure, improving coronary blood flow, increasing cardiac output, and reducing afterload.  Treatment sessions last one to two hours and are given several times a week during the course of therapy.  There is evidence that collateral channels are opened by repeated augmentation of coronary perfusion by enhanced external counterpulsation.

In patients with chronic stable angina refractory to standard optimal therapy, the benefits of EECP have been confirmed in clinical studies and the salutary effect may last up to three years.  Radionuclide stress testing has shown improved myocardial perfusion after EECP treatment.  Exercise tolerance has been reported to improve along with reduction in the frequency and intensity of angina and need for antianginal medications.  Treatment with EECP has also been shown to improve the patient's psychological state and feeling of well-being.

Patient Selection and Treatment Protocol

EECP is not a replacement for conventional treatment, but rather an adjunctive therapeutic option for patients with refractory angina and CHF despite optimal therapy.  Contraindications include:

1)  cardiac catheterization within two weeks

2)  cardiac dysryhthmias including atrial fibrillation, atrial flutter, ventricular tachycardia 

3)  aortic valve regurgitation

4)  active thrombophlebitis

5)  severe peripheral arterial disease

6)  uncontrolled hypertension (BP> 180/110)

7)  pregnancy

8)  bleeding tendencies (prothrombin time> 15 seconds)

A total of thirty-five treatment sessions are recommended, each lasting for one to two hours, at least five times per week.

In summary, EECP offers a novel, non-invasive complementary treatment modality for patients with angina pectoris and CHF in a select group of patients.