Abstract
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.
Keywords: angina pectoris, refractory angina, enhanced external counterpulsation
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References
- 1. Wu Hu Jian: Probe to the indications, contraindications, course and therapeutic effects of ECP treatment. Chinese ECP J 1993; 5: 1–8 [Google Scholar]
- 2. Xu Y, Zheng ZS: External counterpulsation. Chinese Med J 1990; 103: 768–771 [PubMed] [Google Scholar]
- 3. Zheng ZS: Sequential external counterpulsation (SECP) in China. Trans Am Soc Artif Intern Organs 1983; 29: 699–703 [PubMed] [Google Scholar]
- 4. Taguchi I, Ogawa K, Oida A, Abe S, Kaneko N, Sakio H: 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]
- 5. Arora RR, Lopez S, Saric M: Enhanced external counterpulsation improves systolic function in patients with coronary artery disease. Heart Lung (in press, 2005) [DOI] [PubMed]
- 6. Arora RR, Carlucci ML, Malona AM, Baron NV: Acute and chronic hemodynamic effects of enhanced external counterpulsation in patients with angina pectoris. J Invest Med 2001; 49: 500–504 [PubMed] [Google Scholar]
- 7. 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]
- 8. Michaels AD, Kennard ED, Kelsey SE, Holubkov R, Soran O, Spence S, Chou TM: Does higher diastolic augmentation predict clinical benefit from enhanced external counterpulsation? Data from the International EECP Patient Registry (IEPR). Clin Cardiol 2001; 24: 453–458 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9. Lakshmi MV, Kennard ED, Kelsey SF, Holubkov R, Michaels AD: Relation of the pattern of diastolic augmentation during a course of enhanced external counterpulsation (EECP) to clinical benefit (from the International EECP Patient Registry [IEPR]). Am J Cardiol 2002; 89: 1303–1305 [DOI] [PubMed] [Google Scholar]
- 10. 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]
- 11. Cai D, Wu R, Shao Y: Experimental study of the effect of external counter‐pulsation on blood circulation in the lower extremities. Clin Invest Med 2000; 23: 239–247 [PubMed] [Google Scholar]
- 12. Bonetti PO, Barsness GW, Keelan PC, Schnell TI, Pumper GM, Kuvin JT, Schnall RP, Holmes DR, Higano ST, Lerman A: 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]
- 13. Shechter M, Matetzky S, Feinberg MS, Chouraqui P, Rotstein Z, Hod H: External counterpulsation therapy improves endothelial function in patients with refractory angina pectoris. J Am Coll Cardiol 2003; 42: 2090–2095 [DOI] [PubMed] [Google Scholar]
- 14. Masuda D, Nohara R, Hirai T, Kataoka K, Chen LG, Hosokawa R, Inubushi M, Tadamura E, Fujita M, Sasayama S: 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]
- 15. Bonetti PO, Gadasalli SN, Lerman A, Barsness GW: Successful treatment of symptomatic coronary endothelial dysfunction with enhanced external counterpulsation. Mayo Clin Proc 2004; 79: 690–692 [DOI] [PubMed] [Google Scholar]
- 16. Kern MJ, Aguirre F, Bach R, Donohue T, Siegel R, Segal J: Augmentation of coronary blood flow by intra‐aortic balloon pumping in patients after coronary angioplasty. Circulation 1993; 87: 500–511 [DOI] [PubMed] [Google Scholar]
- 17. Corson MA, James NL, Latta SE, Nerem RM, Berk BC, Harrison DG: Phosphorylation of endothelial nitric oxide synthase in response to fluid shear stress. Circ Res 1996; 79: 984–991 [DOI] [PubMed] [Google Scholar]
- 18. Dimmeler S, Fleming I, Fisslthaler B, Hermann C, Busse R, Zeiher AM: Activation of nitric oxide synthase in endothelial cells by Akt‐dependent phosphorylation. Nature 1999; 399: 601–605 [DOI] [PubMed] [Google Scholar]
- 19. Barsness GW: Enhanced external counterpulsation in unrevascularizable patients. Curr Interv Cardiol Rep 2001; 3: 37–43 [PubMed] [Google Scholar]
- 20. Hasdai MD, Holmes DR Jr, Garratt KN, Edwards WD, Lerman A: Mechanical pressure and stretch release endothelin‐1 from human atherosclerotic coronary arteries in vivo. Circulation 1997; 95: 357–362 [DOI] [PubMed] [Google Scholar]
- 21. Kuchan MJ, Frangos JA: Shear stress regulates endothelin‐1 release via protein kinase C and cGMP in cultured endothelial cells. Am J Physiol 1993; 264: H150–156 [DOI] [PubMed] [Google Scholar]
- 22. Tseng H, Peterson TE, Berk BC: Fluid shear stress stimulates mitogen‐activated protein kinase in endothelial cells. Circ Res 1995; 77: 869–878 [DOI] [PubMed] [Google Scholar]
- 23. Masuda D, Nohara K, Kataoka K, Hosokawa R, Kanbara N, Fujita M: Enhanced external counterpulsation promotes angiogenesis factors in patients with chronic stable angina (abstr). Circulation 2001; 104 (suppl 2): II445 [Google Scholar]
- 24. Arora RR, Chou TM, Jain D, Fleishman B, Crawford L, McKiernan T, Nesto RW: 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]
- 25. Arora RR, Chou TM, Jain D, Fleishman B, Crawford L, McKiernan T, Nesto R, Ferrans CE, Keller S: 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]
- 26. Michaels AD, Linnemeier G, Soran O, Kelsey SF, Kennard ED: Two‐year outcomes after enhanced external counterpulsation for stable angina pectoris (from the International EECP Patient Registry [IEPR]). Am J Cardiol 2004; 93: 461–464 [DOI] [PubMed] [Google Scholar]
- 27. Linnemeier G, Rutter MK, Barsness G, Kennard ED, Nesto RW, IEPR Investigators : Enhanced external counterpulsation for the relief of angina in patients with diabetes: Safety, efficacy and 1‐year clinical outcomes. Am Heart 2003; 146: 453–458 [DOI] [PubMed] [Google Scholar]
- 28. Lawson WE, Hui JC, Zheng ZS: Can angiographic findings predict which coronary patients will benefit from enhanced external counterpulsation? Am J Cardiol 1996; 77: 1107–1109 [DOI] [PubMed] [Google Scholar]
- 29. Stys TP, Lawson WE, Hui JC: Effects of enhanced external counterpulsation on stress radionuclide coronary perfusion and exercise capacity in chronic stable angina pectoris. Am J Cardiol 2002; 89: 822–824 [DOI] [PubMed] [Google Scholar]
- 30. Tartaglia J, Stenerson J Jr, Charney R: Exercise capability and myocardial perfusion in chronic angina patients treated with enhanced external counterpulsation. Clin Cardiol 2003; 26: 287–290 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31. Holubkov R, Kennard ED, Foris JM: Comparison of patients undergoing enhanced external counterpulsation and percutaneous coronary intervention for stable angina pectoris. Am J Cardiol 2002; 89: 1182–1186 [DOI] [PubMed] [Google Scholar]
- 32. Soran O, DeMarco T, Crawford LE, Schneider V, de Lame PA, Grossman W, Feldman AM: Efficacy and safety of enhanced external counterpulsation in mild to moderate heart failure: A preliminary report (abstr). J Cardiac Fail 1999; 5 (3 suppl 1): 53(#195) [Google Scholar]
- 33. Soran O, Fleishman B, Demarco T: Enhanced external counterpulsation in patients with heart failure: A multicenter feasibility study. Congest Heart Fail 2002; 8: 204–208, 227 [DOI] [PubMed] [Google Scholar]
- 34. Gorscan IIIJ, Crawford L, Soran O, Wang H, Severyn D, de Lame PA, Schneider V, Feldman AM: Improvement in left ventricular performance by enhanced external counterpulsation in patients with heart failure. J Am Coll Cardiol 2000; 35: 230A,# 901–905 10636285 [Google Scholar]
- 35. Segers P, Tchana‐Sato V, Leather HA: Determinants of left ventricular preload‐adjusted maximal power. Am J Physiol Heart Circ Physiol 2003; 284: H2295–301 [DOI] [PubMed] [Google Scholar]
- 36. Soran O, Kennard ED, Kelsey SF, Holubkov R, Strobeck J, Feldman AM: 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 2002; 8: 297–302 [DOI] [PubMed] [Google Scholar]