All you need to know about Enhanced External Counterpulsation (EECP) therapy

By Dr. Dineshani Hettiarachchi Sirisena

General and interventional cardiologist Dr. Gotabhaya Ranasinghe (MBBS, MD, FCCP, FRCP, FAPSIC, FACC)

Nowadays, diseases of the cardiovascular system (CVD) are the leading cause of illness and death worldwide. CVDs broadly comprise atherosclerosis-related coronary heart disease (CHD), stroke, and peripheral vascular disease. Almost 80% of deaths and disease burden due to CVD is seen in developing countries and its prevalence and mortality rates are expected to double from 1990 to 2020. Over 80% of this increase is estimated to be in developing countries in the South Asian region. According to the Ceylon Medical Journal, the community prevalence of CHD in Sri Lanka is estimated to be 9.3%, and the prevalence of stroke in the Colombo District alone is 1.04%. CHD and stroke together account for 23% of hospital deaths in Sri Lanka. However, with new technological advancements, modern clinical medicine has seen a paradigm shift towards individual, personalised treatment options refining the standards set by evidence‐based guidelines. To educate the public on newer treatment modalities for cardiovascular diseases, we spoke to general and interventional cardiologist Dr. Gotabhaya Ranasinghe (MBBS, MD, FCCP, FRCP, FAPSIC, FACC).

One of the most common symptoms of coronary heart disease (CHD) is angina, more commonly known as chest pain. Angina is defined as the discomfort or pain in the chest due to insufficient amounts of oxygen-rich blood reaching the heart. Chest pain due to angina can radiate to the shoulders, arms, neck, or jaw. These symptoms can be atypical in some patients, particularly in women and in patients with diabetes. In some cases, angina symptoms can include shortness of breath, nausea, or upper abdominal pain.

Although not all chest pain is related to heart disease, angina-type chest pain can be a symptom of an underlying heart condition such as coronary artery disease. In this case, a blockage or narrowing of one or more of the coronary arteries obstructs the blood flow sufficiently to cause these symptoms (chest pain). Sometimes, angina occurs due to coronary microvascular disease (MVD), which affects the smaller coronary arteries in the heart. Angina due to MVD is more prevalent in women. Recognising angina early and seeking treatment can reduce symptoms and avert more serious consequences of untreated heart disease.

What is External Counterpulsation (EECP®/ECP) therapy?

EECP®/ECP therapy is a US FDA cleared, non-invasive medical therapy for the treatment of chronic stable angina that is refractory to optimal antianginal medical therapy without options for revascularisation.

Also, based upon clinical studies published in peer-reviewed medical journals, physicians refer patients to EECP therapy for the relief of symptoms from other ischemic cardiovascular diseases such as left ventricular dysfunction or heart failure, diabetes, cerebrovascular disease, and peripheral vascular disease.

Enhanced External Counterpulsation (ECCP) therapy for angina

EECP is performed as a non-invasive treatment to lower the number and intensity of angina episodes. Treatment that is now available locally. It is administered through three pairs of external inflatable cuffs that are applied around the lower legs, upper legs, and buttocks. These cuffs continuously inflate and deflate between the resting period of the heartbeat and increase blood returned to the heart.

The basic principle of EECP treatment involves increasing the amount of blood returning to the heart, which helps supply more oxygen to its starved areas. With more oxygen available, the heart can function much more efficiently and therefore reduce chest pain.

Patients with refractory angina pectoris (RAP) have frequent chronic ischemic symptoms that are unresponsive to both conventional medical therapy and revascularisation procedures, or they are inoperable or at a high risk of the operative/interventional complications. Refractory angina pectoris is also associated with significant impairment in quality of life. Hence they are ideal candidates for EECP.

How often and for how long?

The treatment schedule includes seven weeks of continuous treatment, which includes daily visits for an hour, Monday through Friday, with the total number of treatment hours at 35 in most cases.

Other treatment options for coronary artery disease (CAD) or cardiac ischemia:

· Medication
· Angioplasty – with or without stenting
· Bypass

Advantages of EECP over traditional methods:

· Non-pharmacologic
· Non-invasive
· Outpatient procedure
· Carried out over 35 one-hour sessions

Benefits to patient

EECP improves anginal symptoms and exercise tolerance, and reduces nitroglycerin use in patients with chronic, stable angina. EECP has also been shown to be safe and beneficial in patients with symptomatic stable congestive heart failure. Overall, EECP is proven to be a safe form of therapy.

Significant improvements for patients with angina were:
· Particularly decreased episodes of angina and the use of nitrates
· Increasing time to get an exercise-induced ST depression, thereby increasing exercise tolerance
· Improved quality of life
· Increased myocardial perfusion
· Other clinically observed benefits

Concept of counter pulsation

This is a technique that synchronises the external pumping of blood with the heart’s cycle to assist the circulation and decrease the work of the heart. Counterpulsation pumps when the heart is resting to increase blood flow and oxygen to the heart. Counterpulsation stops pumping when the heart is working to decrease the heart’s workload and lessen oxygen demand.

There are three concepts used in this type of treatment:

· Sequential cuff inflation, which raises diastolic pressure, also known as diastolic augmentation
· Simultaneous cuff deflation, which results in a decrease in systolic pressure, also known as systolic unloading
· Enhanced venous return, which leads to increased cardiac output
All these effects result in increased blood flow to multiple vascular beds in various organs, including coronary arterial circulation.

Mechanism of action

· The enhanced diastolic flow increases shear stress
· The increased shear stress activates the release of growth factors – vascular endothelial growth factor (VEGF)
· The augmentation of growth factor release and nitric oxide-mediated vasodilatation activates angiogenesis
· This then enhances vascular reactivity
· Improves endothelial function

Advantages of EECP over surgery

· Non-invasive and no risk of infection
· Safe (low risk)
· Outpatient procedure
· No additional medication
· No recuperation time required
· No side effects

EECP®/ECP therapy is a safe and effective treatment for ischemic diseases, supported by strong and compelling scientific and clinical data. Recent studies have shown promising results and verified its mechanism of action. This has led to an enhanced understanding and the acceptance of this treatment modality by specialists globally. Thus, we are fortunate to offer this treatment to Sri Lankan patients locally as well. Due to the rising healthcare costs and the long waiting list for minimally invasive and invasive procedures such as angioplasty and open cardiac surgeries, it is a timely effort to bring this new modality to the general public, especially as we must now look at more revolutionised treatment options for common diseases to make the healthcare system sustainable.

In a nutshell, we need to now top treating the lesion and start treating the progression of the disease. However, this does not take away from the benefits of preventive care and risk factor modification. Finally, EECP®/ECP therapy is a reasonable, affordable, and simple solution to a very complex and dynamic health issue.