Abstract
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<0.001. The CCS class was improved by at least 1 class in 78% of the patients and by at least 2 classes in 38%. This was sustained in 74% of the patients during follow‐up.
Thirty‐six percent of the patients had CCS II or less angina, which was better than pre‐EECP state without a major adverse cardiovascular event during follow‐up. More severe baseline angina and a history of heart failure or diabetes were independent predictors of unfavorable outcome.
Conclusion
An EECP improves angina and quality of life immediately after a course of treatment. For most of the patients, these beneficial effects are sustained for 3 years. Copyright © 2008 Wiley Periodicals, Inc.
Keywords: external counterpulsation, angina pectoris, refractory pain, coronary artery disease, ischemic heart disease
Full Text
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References
- 1. Mannheimer C, Camici P, Chester MR, Collins A, DeJongste M, et al.: The problem of chronic refractory angina: report from the ESC joint study group on the treatment of refractory angina. Eur Heart J 2002; 23: 355–370. [DOI] [PubMed] [Google Scholar]
- 2. Michaels AD, Accad M, Ports TA, Grossman W: Left ventricular systolic unloading and augmentation of intracoronary pressure and doppler flow during enhanced external counterpulsation. Circulation 2002; 106: 1237–1242. [DOI] [PubMed] [Google Scholar]
- 3. Taguchi I, Ogawa K, Oida A, Abe S, Kaneko N, et al.: Comparison of hemodynamic effects of enhanced external counterpulsation and intra‐aortic balloon pumping in patients with acute myocardial infarction. Am J Cardiol 2000; 86: 1139–1141. [DOI] [PubMed] [Google Scholar]
- 4. Arora RR, Chou TM, Jain D, Fleishman B, Crawford L, et al.: The Multicenter Study of Enhanced External Counterpulsation (MUST‐EECP): effect of EECP on exercise‐induced myocardial ischemia and anginal episodes. J Am Coll Cardiol 1999; 33: 1833–1840. [DOI] [PubMed] [Google Scholar]
- 5. Arora RR, Chou TM, Jain D, Fleishman B, Crawford L, et al.: 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 Invest Med 2002; 50: 25–32. [DOI] [PubMed] [Google Scholar]
- 6. Bagger JP, Hall RJ, Koutroulis G, Nihoyannopoulos P: Effect of enhanced external counterpulsation on dobutamine‐induced left ventricular wall motion abnormalities in severe chronic angina pectoris. Am J Cardiol 2004; 93: 465–467. [DOI] [PubMed] [Google Scholar]
- 7. Urano H, Ikeda H, Ueno T, Matsumoto T, Murohara T, et al.: Enhanced external counterpulsation improves exercise tolerance, reduces exercise‐induced myocardial ischemia and improves left ventricular diastolic filling in patients with coronary artery disease. J Am Coll Cardiol 2001; 37: 93–99. [DOI] [PubMed] [Google Scholar]
- 8. Loh PH, Louis AA, Windram J, Rigby AS, Cook J, et al.: The immediate and long‐term outcome of enhanced external counterpulsation in treatment of chronic stable refractory angina. J Intern Med 2006; 259: 276–284. [DOI] [PubMed] [Google Scholar]
- 9. Barsness G, Feldman AM, Holmes DR, Holubkov R, Kelsey SF, et al.: The International EECP Patient Registry (IEPR): design, methods, baseline characteristic, and acute results. Clin Cardiol 2001; 24: 435–442. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10. Lawson WE, Hui JC, Zheng ZS, Oster Z, Katz JP, et al.: Three‐year sustained benefit from enhanced external counterpulsation in chronic angina pectoris. Am J Cardiol 1995; 75: 840–841. [DOI] [PubMed] [Google Scholar]
- 11. Bonetti PO, Barsness GW, Keelan PC, Schnell TI, Pumper GM, et al.: Enhanced external counterpulsation improves endothelial function in patients with symptomatic coronary artery disease. J Am Coll Cardiol 2003; 41: 1761–1768. [DOI] [PubMed] [Google Scholar]
- 12. Masuda D, Nohara R, Hirai T, Kataoka K, Chen LG, et al.: Enhanced external counterpulsation improved myocardial perfusion and coronary flow reserve in patients with chronic stable angina; evaluation by(13)N‐ammonia positron emission tomography. Eur Heart J 2001; 22: 1451–1458. [DOI] [PubMed] [Google Scholar]
- 13. Masuda D, Fujita M, Nohara R, Matsumori A, Sasayama S: Improvement of oxygen metabolism in ischemic myocardium as a result of enhanced external counterpulsation with heparin pretreatment for patients with stable angina. Heart Vessels 2004; 19: 59–62. [DOI] [PubMed] [Google Scholar]
- 14. Bonetti PO, Holmes DR, Lerman A, Barsness GW Jr: Enhanced external counterpulsation for ischemic heart disease: what's behind the curtain? J Am Coll Cardiol 2003; 41: 1918–1925. [DOI] [PubMed] [Google Scholar]
- 15. Michaels AD, Raisinghani A, Soran O, de Lame PA, Lemaire ML, et al.: The effects of enhanced external counterpulsation on myocardial perfusion in patients with stable angina: a multicenter radionuclide study. Am Heart J 2005; 150: 1066–1073. [DOI] [PubMed] [Google Scholar]
- 16. Lawson WE, Hui JC, Kennard ED, Barsness G, Kelsey SF: Predictors of benefit in angina patients one year after completing enhanced external counterpulsation: initial responders to treatment versus nonresponders. Cardiology 2005; 103: 201–206. [DOI] [PubMed] [Google Scholar]
- 17. Soran O, Kennard ED, Kfoury AG, Kelsey SF: Two‐year clinical outcomes after Enhanced External Counterpulsation (EECP) therapy in patients with refractory angina pectoris and left ventricular dysfunction (report from The International EECP Patient Registry). Am J Cardiol 2006; 97: 17–20. [DOI] [PubMed] [Google Scholar]
- 18. Feldman AM, Silver MA, Francis GS, Abbottsmith CW, Fleishman BL, et al.: Enhanced external counterpulsation improves exercise tolerance in patients with chronic heart failure. J Am Coll Cardiol 2006; 48: 1198–1205. [DOI] [PubMed] [Google Scholar]
- 19. Ma H, Zheng ZS, Zhang MQ, Du HJ, Cai NS, et al.: The multicenter research of enhanced external counterpulsation (EECP): One‐year follow‐up in patients with coronary heart disease. Presented at the first international external counterpulsation symposium. Guangzhou, China. May 2006.
- 20. Allen KB, Dowling RD, Angell WW, Gangahar DM, Fudge TL, et al.: Transmyocardial revascularization: 5‐year follow‐up of a prospective, randomized multicenter trial. Ann Thorac Surg 2004; 77: 1228–1234. [DOI] [PubMed] [Google Scholar]
- 21. 21 Andrell P, Ekre O, Eliasson T, Blomstrand C, Borjesson M, et al.: Cost‐effectiveness of spinal cord stimulation versus coronary artery bypass grafting in patients with severe angina pectoris–long‐term results from the ESBY study. Cardiology 2003; 99: 20–24. [DOI] [PubMed] [Google Scholar]