Enhanced External Counterpulsation In Patients Research Articles

Safety and effectiveness of enhanced external counterpulsation (EECP) in refractory angina patients: A systematic reviews and meta-analysis.

Enhanced external counterpulsation (EECP) is believed to be a non-invasive treatment for coronary artery disease and angina. The aim of this study was to determine the safety and effectiveness of EECP in refractory angina patients through a systematic reviews and meta-analysis. We conducted a comprehensive search of the literature published on PubMed, Cochrane library, Scopus, ScienceDirect, Trip Database and Google Scholar databases using appropriate keywords and specific strategy with no time limit. Having selected and screened the studies based on the defined inclusion and exclusion criteria and evaluating their quality based on the Cochrane checklist. For the meta-analysis,the Mantel-Haenszel method or the generic Inverse Variance was used. Analyses were done with Review Manager 5.2 software. A number of 299 studies were initially reviewed and finally, seventeen studies were included in the meta-analysis based on the inclusion and exclusion criteria. Also, thirteen outcomes were analyzed and the results of meta-analysis in twelve outcomes including (Systolic Blood Pressure (7 studies), Diastolic Blood Pressure (7 studies), Pulse Pressure (4 studies), Mean Arterial Pressures (4 studies), Heart Rate (6 studies), Angina episodes (7 studies), Walking distance (2 studies),Canadian Cardiovascular Society classification (6 studies), Flow-Mediated Dilation (3 studies), Daily Nitrate Usage (4 studies), Exercise Treadmill Test-Time (2 studies), ST-segment depression (2 studies)demonstrated a significant clinical advantage in the EECP treatment effectiveness in patients with angina. No significant difference was observed regarding EECP usefulness (P = 0.18) in the outcome of brachial artery diameter (2 studies). Based on the meta-analysis, the results indicate the safety and effectiveness of EECP in patients with angina pectoris and indicate the usefulness of this treatment in these patients. In general, the authors believe that the general conclusion in this regard requires some studies with a large sample size and a control group assignment.

Abstract P100: Enhanced External Counterpulsation Reduces Central Blood Pressure In Stable Angina Patients: A Meta Analysis

Introduction: Emerging evidence suggests central systolic blood pressure (cSBP) and augmentation index are superior predictors of adverse cardiovascular outcomes as compared to peripheral systolic blood pressure (pSBP). Enhanced external counterpulsation (EECP) is a non-invasive treatment modality approved for the management of refractory angina. The degree of benefit from EECP on central hemodynamics and arterial stiffness remains unknown. This meta-analysis evaluated the effect of EECP on peripheral (office) blood pressure and central hemodynamic parameters. Methods: A comprehensive literature search was conducted in Pubmed, CINAHL, and Cochrane Library databases. All prospective clinical trials assessing the impact of EECP in patients with stable angina and CAD were included. Studies were excluded for not completing a full course of EECP, having a baseline peripheral systolic blood pressure &lt100 mmHg, or not reporting adequate data for analysis. The primary endpoint was the change in cSBP before and after EECP. The change in pSBP, pDBP, cDBP, and augmentation index before and after EECP were also assessed. The weighted mean difference using the DerSimonian and Laird random-effect model was utilized for determining the change in each parameter before and after EECP. Statistical heterogeneity was evaluated using the Egger’s bias statistic. Results: Five studies containing 137 unique patients were included for the cSBP analysis. cSBP was reduced significantly by -7.56 mmHg (95% CI -11.83 to -3.28; Cochrane Q=1.81) post-EECP. In the same set of studies, pSBP was reduced significantly by -9.65 mmHg (95% CI -14.32 to -4.98) post-EECP. pDBP [-4.67 mmHg (95% CI -8.56 to -0.77)] was reduced post-EECP, while no changes were evident in cDBP. Augmentation index was reduced by -3.74% (95% CI -7.05 to -0.43) post-EECP. Two studies included a sham-EECP intervention arm and demonstrated no significant changes in cSBP [0.67 mmHg (95% CI -5.66 to 7.01)] or other parameters. Conclusion: EECP significantly reduced cSBP and pSBP by approximately 8 mmHg and 10 mmHg respectively. EECP also demonstrated a mild improvement in arterial stiffness, which translates to reduced wasted left ventricular energy and myocardial oxygen demand. In patients with stable angina and CAD, EECP exerts beneficial effects in both peripheral and central hemodynamics but whether these benefits are sustained over a longer duration need further exploration.

Enhanced external counterpulsation: A unique treatment for the "No-Option" refractory angina patient.

What is known and objectivesCoronary artery disease (CAD) is the leading cause of death in the United States. For patients on whom guideline‐driven measures have been tried, enhanced external counterpulsation (EECP) is the only truly noninvasive and safe intervention for which a reduction of angina symptoms and nitrate use, increased exercise tolerance, and improvement in myocardial ischaemia have been shown. The objective of this study was to demonstrate, by way of literature review, the efficacy of EECP as a treatment modality for the relief of refractory angina and improvement in quality of life in CAD patients.MethodsThis article reviewed the safety and efficacy of EECP in patients with refractory angina, by conducting a sweeping search and analysis of existing published literature.Results and DiscussionCritical review of a multitude of studies revealed that EECP consistently reduces angina pectoris, extends time to exercise‐induced ischaemia, decreases dependency on nitroglycerine for frequent chest pain, increases maximum workload, and improves the quality of life in patients with symptomatic stable angina. The literature reviewed also indicated that EECP is well‐tolerated by the vast majority of patients, with relatively few adverse events reported.ConclusionThe present study suggests that EECP is a safe and likely best available method of treatment for patients presenting with symptomatic CAD not amenable to further revascularization.

Effectiveness of Enhanced External Counterpulsation Treatment on Symptom Burden, Medication Profile, Physical Capacity, Cardiac Anxiety, and Health-Related Quality of Life in Patients With Refractory Angina Pectoris.

Patients with refractory angina pectoris experience recurrent symptoms that limit their functional capacity, including psychological distress and impaired health-related quality of life (HRQoL), despite optimized medical therapy. Enhanced external counterpulsation (EECP) is an evidence-based alternative noninvasive treatment. Although physical well-being and mental well-being are equally important components of health, few studies have investigated the psychological effects of EECP in patients with refractory angina pectoris. The aim of this study was to evaluate the effects of EECP treatment in patients with refractory angina pectoris regarding medication profile, physical capacity, cardiac anxiety, and HRQoL. This quasi-experimental study with 1-group pretest-posttest design includes a 6-month follow-up of 50 patients (men, n = 37; mean age, 65.8 years) who had undergone 1 EECP course. The following pretreatment and posttreatment data were collected: medication use, 6-minute walk test results, functional class according to the Canadian Cardiovascular Society, and self-reported (ie, questionnaire data) cardiac anxiety and HRQoL. In addition, the questionnaires were also completed at a 6-month follow-up. After EECP treatment, patients used significantly less nitrates (P < .001), walking distance increased on average by 46 m (P < .001), and Canadian Cardiovascular Society class improved (P < .001). In addition, all but 1 subscale of cardiac anxiety and all HRQoL components improved significantly (P < .05). The positive effects for cardiac anxiety and HRQoL were maintained at the 6-month follow-up. Enhanced external counterpulsation treatment resulted in reduced symptom burden, improved physical capacity, and less cardiac anxiety, leading to increased physical activity and enhanced life satisfaction for patients with refractory angina pectoris. Enhanced external counterpulsation treatment should be considered to improve the life situation for these patients.

Refractory angina frequencies during 7 weeks treatment by enhanced external counterpulsation in coronary artery disease patients with and without diabetes

Background:Refractory angina is a clinical diagnosis which implies to chronic pain due to coronary artery insufficiency and it is often resistant to routine cardiac treatment. The present study conducted to compare changes in refractory angina frequencies during 7 weeks treatment by enhanced external counterpulsation (EECP) in coronary artery disease (CAD) patients with and without diabetes.Methods:In this retrospective study, 94 CAD patients (30 diabetics vs. 64 nondiabetics) who referred to cardiac rehabilitation department of Imam Ali Hospital of Kermanshah, Iran, during January 2006–2014 were assessed. The interventional method was EECP and medical records and frequencies of self-reported chest pain were research instruments. Data were analyzed through Chi-square test, mixed repeated measures, and Bonferroni test.Results:Frequencies of pain in both diabetic and nondiabetic groups during 7 weeks had linear reduction, but this reduction was significant only among nondiabetic patients (P < 0.0005). Furthermore, the significant reduction in frequencies of pain among this group begins after the 5th week.Discussion:Diabetes is one of the obstacles to the successful control of pain frequencies by the EECP in patients with CAD. Future studies may pay attention to the confounding role of diabetes in improving the severity of chest pain.

Enhanced external counterpulsation in rehabilitation of erectile dysfunction: a narrative literature review.

BackgroundEnhanced external counterpulsation (EECP) is a noninvasive treatment option widely applied in patients with erectile dysfunction (ED). The aim of this study is to review the efficacy of EECP in patients suffering from ED.MethodsPubMed, MEDLINE, Google Scholar, Tripdatabase, Scopus, and Cochrane library databases were searched for articles with the following search terms: enhanced external counterpulsation and erectile dysfunction. No restrictions with respect to study setting, date of publication, and language were imposed.ResultsFrom an initial set of 208 records, 4 studies were selected after a final review. A total of 177 patients with a mean age of 59.98 years were included in these studies, with 20–35 hours per week of EECP treatment. Three studies used the International Index of Erectile Function questionnaire and one applied a four-item questionnaire and a peak systolic flow measurement. All of these parameters were significantly improved after the EECP treatment.ConclusionTo the best of our knowledge, this is the first study reviewing the clinical effectiveness of EECP in patients with ED. According to the articles reviewed in this study, an improvement in erectile function after EECP treatment courses has been observed in patients with and without coronary artery disease without any significant adverse effects.

Enhanced external counterpulsation (EECP) in rehabilitation of erectile dysfunction: A narrative literature review

Enhanced external counterpulsation (EECP) is a noninvasive treatment option which has been recently applied in patients with erectile dysfunction (ED). The aim of this study was to review the efficacy of EECP in patients suffering from ED. PubMed, MEDLINE, Google Scholar, Tripdatabase, Scopus and Cochrane library databases were searched for articles with the following search terms: Enhanced external counterpulsation, erectile dysfunction. No restrictions with respect to study setting, date of publication or language were imposed. From an initial set of 208 records, four studies were selected after final review. Total number of 177 patients was included in these studies with the treatment duration with EECP ranging from 20 to 35 hours weekly. Peak systolic flow, quality of erection, International index of erectile function (IIEF) and overall satisfaction were all significantly increased after EECP treatment. To the best of our knowledge, this is the first study reviewing the clinical effectiveness of EECP in patients with ED. According to the articles mentioned in this study, an enhancement in erectile function after EECP treatment courses has been observed in patients both with and without coronary artery disease without any significant adverse effects.

Efficacy of Enhanced External Counterpulsation in Patients With Chronic Refractory Angina on Canadian Cardiovascular Society (CCS) Angina Class: An Updated Meta-Analysis.

A growing number of patients with chronic artery disease suffer from angina, despite the optimal medical management (ie, β-blockers, calcium channel blockers, and long-acting nitrates) and revascularization. Currently, enhanced external counterpulsation (EECP) therapy has been verified as a noninvasive, safe therapy for refractory angina. The study was designed to evaluate the efficacy of EECP in patients with chronic refractory angina according to Canadian Cardiovascular Society (CCS) angina class.We identified systematic literature through MEDLINE, EMBASE, the Cochrane Clinical Trials Register Database, and the ClinicalTrials. gov Website from 1990 to 2015. Studies were considered eligible if they were prospective and reported data on CCS class before and after EECP treatment. Meta-analysis was performed to assess the efficacy of EECP therapy by at least 1 CCS angina class improvement, and proportion along with the 95% confidence interval (CI) was calculated. Statistical heterogeneity was calculated by I2 statistic and the Q statistic. Sensitivity analysis was addressed to test the influence of trials on the overall pooled results. Subgroup analysis was applied to explore potential reasons for heterogeneity.Eighteen studies were enrolled in our meta-analysis. Pooled analysis showed 85% of patients underwent EECP had a reduction by at least one CCS class (95%CI 0.81–0.88, I2 = 58.5%, P < 0.001). The proportion of patients enrolled at primarily different studies with chronic heart failure (CHF) improved by at least 1 CCS class was about 84% after EECP (95%CI 0.81–0.88, I2 = 32.7%, P = 0.1668). After 3 large studies were excluded, the pooled proportion was 82% (95%CI 0.79–0.86, I2 = 18%, P = 0.2528). Funnel plot indicated that some asymmetry while the Begg and Egger bias statistic showed no publication bias (P = 0.1495 and 0.2859, respectively).Our study confirmed that EECP provided an effective treatment for patients who were unresponsive to medical management and/or invasive therapy. However, the long-term benefits of EECP therapy needed further studies to evaluate in the management of chronic refractory angina.

Relation between N-terminal pro-brain natriuretic peptide levels and response to enhanced external counterpulsation in chronic angina pectoris

Although enhanced external counterpulsation (EECP) provides symptom reduction in many patients with severe angina pectoris, one-quarter of patients fail to respond. Earlier reports have not clearly established whether and how EECP responders may be identified pre-hoc. We hypothesized that clinical and biochemical data may be used to predict EECP response. We explored a database of n=53 patients who had undergone clinically indicated EECP during 35 1-h sessions in our unit (65±7 years; 49 male), and sought to clarify which factors are predictive of response. Efficiency of counterpulsation was measured as the diastolic augmentation (DA) ratio, and was recorded both at beginning and end of the EECP treatment course. An increase in 6-min walk (6MW) distance of 5% was indicative of clinical response. Response occurred in 28 patients (53%; nonresponse in n=25, 47%). Responders had shorter baseline 6MW distance (377±81 vs. 445±62 m; P<0.01), lower left ventricular ejection fraction (48±9 vs. 54±8%; P<0.05), frequently had an increase in DA ratio during the EECP treatment course (23/28 vs. 5/28 with unchanged or decreased DA ratio; P<0.05), and higher levels of N-terminal pro-brain natriuretic peptide [NT-proBNP; 256 (123-547) vs. 62 (26-444) ng/l, P<0.01]. In multivariate logistic regression, response was independently predicted by baseline 6MW distance and baseline NT-proBNP levels (P<0.05 for both; model sensitivity: 82%, specificity: 72%, accuracy: 79%). There is larger clinical benefit of EECP in patients with greater functional impairment and higher levels of NT-proBNP.

Enhanced External Counterpulsation in Patients with Coronary Artery Disease-Associated Erectile Dysfunction. Part II: Impact of Disease Duration and Treatment Courses

Enhanced external counterpulsation (EECP) is a noninvasive outpatient treatment used for patients with intractable angina refractory to aggressive surgical and medical treatment. Recent results have demonstrated a positive impact of EECP on patients with ischemic heart disease (IHD)-associated erectile dysfunction (ED). To assess the effect of IHD duration and number of EECP courses on efficacy and satisfaction rate of EECP on patients with IHD-associated ED. We compared pre- and post-EECP responses to erectile function (EF) domain, Q3 and Q4 of the International Index of Erectile Function score in patients who received one or two courses of EECP and those who had <5- or >or=5-years duration of IHD. As mentioned in part I a total of 44 male patients with intractable angina caused by coronary insufficiency were enrolled in this study. Treatment course of EECP consists of 35 1-hour sessions over 7 weeks. Another 35 1-hour sessions over another 7 weeks were offered to patients who received one course and required a second course because of no or minimal improvement from class IV to class III angina after the first course. Patients who received only one course (N = 34) had significantly higher EF domain, Q3 and Q4, in pre- and post-EECP results than patients who received two courses (N = 10) after they completed the first course. Patients who had <5-years duration of IHD had significantly higher pre- and post EECP than patients who had >or=5 years regarding EF domain, Q3 and Q4. Considering the global efficacy question, overall satisfaction, and angina, there were significant improvements of post EECP in patients with <5 years than in patients with >or=5-years duration of IHD. The efficacy and satisfaction rate of EECP in patients with IHD-associated ED were negatively influenced by longer duration of IHD and requirement of a second course of EECP.

Enhanced External Counterpulsation in Patients with Coronary Artery Disease-Associated Erectile Dysfunction. Part I: Effects of Risk Factors

Recently it has been demonstrated that enhanced external counterpulsation (EECP) could improve erectile dysfunction (ED) in patients with refractory ischemic heart disease (IHD). To assess the effect of risk factors on the efficacy and the satisfaction rate of EECP in patients with coronary artery disease (CAD)-associated ED. To assess the effect of risk factors on EECP efficacy and satisfaction rate, we compared the pre- and post-EECP responses to erectile function domain, Q3, and Q4 in patients with and without risk factors. Overall satisfaction and global efficacy question (GEQ) were also assessed. A total of 44 male consecutive patients with intractable angina caused by coronary insufficiency which cannot be controlled by conventional therapy were enrolled in this study. Patients were screened and followed up for ED using erectile function domain of the International Index for Erectile Function. A thorough sexual, medical, and psychosocial history was taken from all patients. All patients had severe diffuse triple vessels disease. They all had class III or IV angina. They were receiving the maximal antianginal pharmacotherapy. The mean age +/- SD was 57.1 +/- 5.6 years. Of the patients, 63.9% were below 60 years, and 86.4% were current or ex-smokers. There were significant differences between pre- and post-EECP regarding erectile function domain, Q3, and Q4. The sociodemographic variables were not significantly different among the studies groups and had not affected the GEQ or overall satisfaction. Overall satisfaction and GEQ were negatively influenced by smoking and presence of more than two risk factors. However, diabetes, hypertension, dyslipidemia, myocardial infraction, and obesity have not had such effects. The efficacy and satisfaction rate of EECP in patients with CAD-associated ED were negatively influenced by presence of risk factors; however, the global efficacy and the overall patients' satisfaction were encouraging.

Enhanced External Counterpulsation Improves Exercise Duration and Peak Oxygen Consumption in Older Patients With Heart Failure: A Subgroup Analysis of the PEECH Trial

The Prospective Evaluation of Enhanced External Counterpulsation in Congestive Heart Failure (PEECH) trial demonstrated that enhanced external counterpulsation (EECP) therapy increased exercise duration and improved functional status and quality of life without affecting peak oxygen consumption. The authors present data from a prespecified subgroup of elderly patients (65 years or older) enrolled in the PEECH trial. The 2 co-primary end points were the percentage of subjects with a >60-second increase in exercise duration and the percentage of subjects with a >1.25-mL/kg/min increase in peak volume of oxygen consumption. At 6-month follow-up, the exercise responder rate was significantly higher in EECP patients compared with controls (P=.008). Further, in contrast to the overall PEECH study, the EECP group demonstrated a significantly higher responder rate for peak oxygen consumption (P=.017). The authors conclude that an older subgroup of PEECH subjects confirms the beneficial effect of EECP in patients with chronic, stable, mild-to-moderate heart failure.

Treating Heart Failure With Enhanced External Counterpulsation (EECP): Design of the Prospective Evaluation of EECP in Heart Failure (PEECH) Trial

Background Enhanced external counterpulsation (EECP) treatment can improve exercise tolerance in patients with ischemic heart disease; however, the possible benefits of EECP in patients with stable heart failure (HF) and left ventricular dysfunction (LVD) are unclear. An open pilot study showed significant increases in exercise tolerance in HF patients undergoing EECP. Thus a larger, controlled study of EECP in patients with stable HF (New York Heart Association [NYHA] classes II and III) and LVD was undertaken. Methods and Results The PEECH trial is a controlled, randomized, single-blind, parallel-group, multicenter study of 187 patients with symptomatic but stable HF (NYHA classes II and III) and an LV ejection fraction ≤35% was designed to assess the efficiency of EECP in patients with stable HF. Medical therapy is optimized in all patients based on the recommendations of the Heart Failure Society of America (“Usual Care”), and then randomized between 2 treatment groups; UC or EECP (35 hours over 7 weeks). Conclusion Efficacy measures include standard exercise tolerance tests on a treadmill (modified Naughton protocol), with measurements of peak oxygen uptake and exercise duration time; quality of life questionnaires; NYHA classification; and neurohormonal markers of HF.

Enhanced external counterpulsation improves endothelial function in patients with symptomatic coronary artery disease

ObjectivesThe goal of this study was to examine the effect of enhanced external counterpulsation (EECP) on endothelial function. BackgroundEnhanced external counterpulsation improves symptoms and exercise tolerance in patients with symptomatic coronary artery disease (CAD). However, the exact mechanisms by which this technique exerts its clinical benefit are unclear. MethodsReactive hyperemia-peripheral arterial tonometry (RH-PAT), a noninvasive method to assess peripheral endothelial function by measuring reactive hyperemic response in the finger, was performed in 23 patients with refractory angina undergoing a 35-h course of EECP. In each patient RH-PAT measurements were performed before and after the first, at midcourse, and the last EECP session. In addition, RH-PAT response was assessed one month after completion of EECP therapy; RH-PAT index, a measure of reactive hyperemia, was calculated as the ratio of the digital pulse volume during reactive hyperemia divided by that at rest. ResultsEnhanced external counterpulsation led to symptomatic improvement (≥1 Canadian Cardiovascular Society class) in 17 (74%) patients; EECP was associated with a significant immediate increase in average RH-PAT index after each treatment (p < 0.05). In addition, average RH-PAT index at one-month follow-up was significantly higher than that before EECP therapy (p < 0.05). When patients were divided by their clinical response, RH-PAT index at one-month follow-up increased only in those patients who experienced clinical benefit. ConclusionsEnhanced external counterpulsation enhances peripheral endothelial function with beneficial effects persisting at one-month follow-up in patients with a positive clinical response. This suggests that improvement in endothelial function may contribute to the clinical benefit of EECP in patients with symptomatic CAD.

A review of enhanced external counterpulsation clinical trials.

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.

Ongoing and planned studies of enhanced external counterpulsation.

There is strong, continued interest in enhanced external counterpulsation (EECP) as evidenced by current, ongoing clinical trials. Many of these have been designed to support the current indications of EECP, mainly its application in the treatment of symptomatic coronary artery disease. An exciting area in this regard ishow EECP may help control blood glucose in patients with angina and diabetes mellitus. A variety of planned or ongoing exploratory studies are also helping to explain the mechanism of action behind EECP. Two clinical trials are now investigating a new indication for EECP in patients with congestive heart failure, including the important randomized Prospective Evaluation of EECP in Congestive Heart failure (PEECH) trial.

Enhanced External Counterpulsation as a New Treatment Modality for Patients with Erectile Dysfunction

Enhanced external counterpulsation (EECP) is a noninvasive treatment modality which can increase arterial blood flow in peripheral and coronary arterial disease. Several studies have demonstrated an increase in the flow of the internal iliacal artery and in carotid and renal perfusion during EECP treatment. We investigated the effect of EECP in patients with erectile dysfunction (ED). Thirteen patients were treated with EECP for 20 days, 1 h per day. Patients reported a significant improvement of penile rigidity after completion of the EECP treatment and a significant improvement of penile peak systolic flow was measured by Doppler sonography. No adverse effects were observed. In conclusion, EECP seems to be an effective treatment modality in patients with ED.