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Primer: practical approach to the selection of patients for and application of EECP

Nature Clinical Practice Cardiovascular Medicine volume 3, pages 623–632 (2006)Cite this article

Abstract

Over the past decade, the frequency of use of enhanced external counterpulsation (EECP®) has increased in patients with angina, irrespective of medical therapy and coronary revascularization status. Many patients referred for EECP® have one or more comorbidities that could affect this treatment's efficacy, safety, or both. By use of data from more than 8,000 patients enrolled in the International EECP® Patient Registry, we provide practical guidelines for the selection and treatment of patients. We have focused on considerations for patients who have one or more of the following characteristics: age older than 75 years, diabetes, obesity, heart failure, and peripheral vascular disease. We have also reviewed outcomes and treatment recommendations for individuals with poor diastolic augmentation during treatment, for those with atrial fibrillation or pacemakers, and for those receiving anticoagulation therapy. Lastly, we examined relevant data regarding extended courses of EECP®, repeat therapy, or both. While clinical studies have demonstrated the usefulness of EECP® in selected patients, these guidelines permit recommendations for the extended application of this important treatment to subsets of patients excluded from clinical trials.

Key Points

  • An extended course of enhanced external counterpulsation (EECP®) yields a sustained reduction in angina severity and improved quality of life in most patients treated for refractory angina

  • EECP® is safe and effective in elderly patients and those with diabetes, compensated heart failure, atrial fibrillation, and pacemakers if precautions are taken before and during therapy

  • For patients with inadequate angina reduction after 35 h of treatment, an extension of therapy by 10–12 h is associated with further reductions

  • Repeated courses of EECP® for patients with recurrent symptoms are effective

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Figure 1: Mean Canadian Cardiovascular Society angina class among patients undergoing a course of EECP® therapy.

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References

  1. Thom T et al. (2006) Heart disease and stroke statistics—2006 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 113: e85–e151

    PubMed  Google Scholar 

  2. Arora RR et al. (1999) The multicenter study of enhanced external counterpulsation (MUST-EECP): effect of EECP on exercise-induced myocardial ischemia and anginal episodes. J Am Coll Cardiol 33: 1833–1840

    Article  CAS  Google Scholar 

  3. Arora RR et al. (2002) 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. J Investig Med 50: 25–32

    Article  Google Scholar 

  4. Michaels AD et al. (2004) Two-year outcomes after enhanced external counterpulsation for stable angina pectoris (from the International EECP Patient Registry [IEPR]). Am J Cardiol 93: 461–464

    Article  Google Scholar 

  5. Barsness G et al. (2001) The international EECP patient registry (IEPR): design, methods, baseline characteristics, and acute results. Clin Cardiol 24: 435–442

    Article  CAS  Google Scholar 

  6. Lawson WE et al.; International Enhanced External Counterpulsation Patient Registry Investigators (2006) Two-year outcomes of patients with mild angina treated with enhanced external counterpulsation. Clin Cardiol 29: 69–73

    Article  Google Scholar 

  7. Feldman AM et al. (2005) Enhanced external counterpulsation improves exercise tolerance in patients with chronic heart failure. J Am Coll Cardiol 48: 1198–1205

    Article  Google Scholar 

  8. Wenger NK et al. (online 13 April 2005) Evidence-based management of coronary artery disease in the elderly—current perspectives [http://www.medscape.com/viewarticle/501751] (accessed 13 July 2006)

  9. Kaiser C et al.; TIME Investigators (2004) Risks and benefits of optimised medical and revascularisation therapy in elderly patients with angina—on-treatment analysis of the TIME trial. Eur Heart J 25: 1036–1042

    Article  Google Scholar 

  10. Cheitlin MD et al. (2001) Do existing databases answer clinical questions about geriatric cardiovascular disease and stroke? Am J Geriatr Cardiol 10: 207–223

    Article  CAS  Google Scholar 

  11. Peterson ED et al.; American Heart Association Chronic CAD Working Group (2004) Multicenter experience in revascularization of very elderly patients. Am Heart J 148: 486–492

    Article  Google Scholar 

  12. Linnemeier G et al. (2003) Enhanced external counterpulsation in the management of angina in the elderly. Am J Geriatr Cardiol 12: 90–94

    Article  Google Scholar 

  13. Gregg EW et al. (2005) Secular trends in cardiovascular disease risk factors according to body mass index in US adults. JAMA 293: 1868–1874

    Article  CAS  Google Scholar 

  14. Flaherty JD and Davidson CJ (2005) Diabetes and coronary revascularization. JAMA 293: 1501–1508

    Article  CAS  Google Scholar 

  15. Marwick TH (2006) Diabetic heart disease. Heart 92: 296–300

    CAS  PubMed  Google Scholar 

  16. Linnemeier GC et al.; IEPR Investigators (2003) Enhanced external counterpulsation for the relief of angina in patients with diabetes: safety, efficacy and 1-year clinical outcomes. Am Heart J 146: 453–458

    Article  Google Scholar 

  17. Michaels AD et al. (2001) Does higher diastolic augmentation predict clinical benefit from enhanced external counterpulsation (EECP)? Data from the International Enhanced External Counterpulsation Patient Registry. Clin Cardiol 24: 453–458

    Article  CAS  Google Scholar 

  18. McCullough PA et al. (2006) Impact of body mass index on outcomes of enhanced external counterpulsation therapy. Am Heart J 151: 139.e9–139.e13

    Article  Google Scholar 

  19. Lawson WE et al. (2001) Benefit and safety of enhanced external counterpulsation in treating coronary artery disease patients with a history of congestive heart failure. Cardiology 96: 78–84

    Article  CAS  Google Scholar 

  20. Soran O (2004) A new treatment modality in heart failure: enhanced external counterpulsation (EECP). Cardiol Rev 12: 15–20

    Article  Google Scholar 

  21. Soran O et al. (2002) Enhanced external counterpulsation (EECP) in patients with heart failure: a multi-center feasibility study. Congest Heart Fail 8: 204–208

    Article  Google Scholar 

  22. Soran O et al. (2002) Enhanced external counterpulsation as treatment for chronic angina in patients with left ventricular dysfunction: a report from the International EECP Patient Registry (IEPR). Congest Heart Fail 8: 297–302

    Article  Google Scholar 

  23. Hirsch AT et al. (2006) ACC/AHA 2005 Practice guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. Circulation 113: e463–e654

    Article  Google Scholar 

  24. Suresh K et al. (1998) Maximizing the hemodynamic benefit of enhanced external counterpulsation. Clin Cardiol 21: 649–653

    Article  CAS  Google Scholar 

  25. Michaels AD et al.; International EECP Patient Registry Investigators (2005) Frequency and efficacy of repeat enhanced external counterpulsation for stable angina pectoris (from the International EECP Patient Registry). Am J Cardiol 95: 394–39755

    Article  Google Scholar 

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Acknowledgements

The International EECP® Patient Registry is sponsored by Vasomedical, Inc., Westbury, NY.

Author information

Authors and Affiliations

  1. Director of the Cardiac Catheterization Laboratory at the University of Utah, Salt Lake City, UT, USA

    Andrew D Michaels

  2. Chief of the Division of Preventive Medicine at the William Beaumont Hospital, Royal Oak, MI, USA

    Peter A McCullough

  3. Director of the EECP® Research Laboratory at the University of Pittsburgh Medical Center Cardiovascular Institute, Pittsburgh, PA, USA

    Ozlem Z Soran

  4. Director of Invasive and Preventive Cardiology at Stony Brook University Medical Center, Stony Brook, NY, USA

    William E Lawson

  5. GW Barsness is an assistant professor of medicine at Mayo Clinic, Rochester, MN, USA

    Gregory W Barsness

  6. Director of Clinical Research at Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, MN, USA

    Timothy D Henry

  7. a physician at St Vincent's Hospital, Indiannapolis, IN, USA

    Georgiann Linnemeier

  8. a staff physician at the Wright-Patterson Medical Center, Dayton, OH, USA

    Anthony Ochoa

  9. Professor of Epidemiology and ED Kennard is a research associate at the University of Pittsburgh, Pittsburgh, PA, USA

    Sheryl F Kelsey & Elizabeth D Kennard

Authors
  1. Andrew D Michaels
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  2. Peter A McCullough
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  3. Ozlem Z Soran
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  4. William E Lawson
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  5. Gregory W Barsness
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  6. Timothy D Henry
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  7. Georgiann Linnemeier
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  8. Anthony Ochoa
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  9. Sheryl F Kelsey
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  10. Elizabeth D Kennard
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Corresponding author

Correspondence to Andrew D Michaels.

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The other authors declared they have no competing interests.

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Michaels, A., McCullough, P., Soran, O. et al. Primer: practical approach to the selection of patients for and application of EECP. Nat Rev Cardiol 3, 623–632 (2006). https://doi.org/10.1038/ncpcardio0691

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