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EECP Therapy Bibliography
Hemodynamic Effects of EECP Therapy
The publications listed below will provide you a great start to learning about the benefits, mechanisms of action, and long-term outcomes of EECP therapy.
Key Mechanisms of Action Hemodynamic Effects of EECP Therapy
Left Ventricular Systolic Unloading and Augmentation of Intracoronary Pressure and Doppler Flow During Enhanced External Counterpulsation
Michaels AD, Accad M, Ports TA, Grossman W. Circulation. 2002 Sep 3;106(10):1237-1242.
Summary: 10 patients underwent left heart catheterization significantly increasing their coronary diastolic pressure (93%), decreasing systolic pressure (15%) and their peak coronary flow velocity increased by 109% as measured by intracoronary Doppler ultrasound during EECP therapy when compared with baseline.
Endothelial Cell Function
Enhanced External Counterpulsation Improves Endothelial Function in Patients with Symptomatic Coronary Artery Disease
Bonetti PO, Barsness GW, Keelan PC, Schnell TI, Pumper GM, Kuvin JT, Schnall RP, Holmes DR, Higano ST, Lerman A.
Journal of the American College of Cardiology. 2003 May 21;41(10):1761-1768.
Summary: 17 (74%) of the 23 patients with refractory angina improved at least 1 symptomatic Canadian Cardiovascular Society class with a significant increase in their endothelial function as measured by reactive hyperemia-peripheral arterial tonometry (RH-PAT) index which occurred after 1 hour of EECP treatment and remained high at 1-month follow-up.
Arterial Stiffness
Enhanced External Counterpulsation Treatment Improves Arterial Wall Properties and Wave Reflection Characteristics in Patients With Refractory Angina
Nichols WW, Estrada JC, Braith RW, Owens K,Conti CR.
Journal of the American College of Cardiology. 2006 Sep 19;48(6):1209-1215. Epub 2006 Aug 25.
Summary: 17 (74%) of the 23 patients with refractory angina improved at least 1 symptomatic Canadian Cardiovascular Society class with a significant increase in their endothelial function as measured by reactive hyperemia-peripheral arterial tonometry (RH-PAT) index which occurred after 1 hour of EECP treatment and remained high at 1-month follow-up.
Inflammatory Markers
Effect of Enhanced External Counterpulsation on Inflammatory Cytokines and Adhesion Molecules in Patients with Angina Pectoris and Angiographic Coronary Artery Disease
Casey DP, Conti CR, Nichols WW, Choi CY, Khuddus MA, Braith RW..
American Journal of Cardiology. 2008 Feb 1;101(3):300-302. Epub 2007 Dec 11.
Summary: 21 patients were randomly assigned to EECP or sham treatment, plasma tumor necrosis factor was reduced by 29% and monocyte chemoattractant protein-1 by 19% after active treatment compared with no significant changes in the sham group. Circulating level of proinflammatory cytokines are predictors of future coronary events.
Endothelial Progenitor Cell Release
The Effect of External Counter Pulsation Therapy on Circulating Endothelial Progenitor Cells in Patients with Angina Pectoris
Barsheshet A, Hod H, Shechter M, Sharabani-Yosef O, Rosenthal E, Barbash IM, Matetzky S, Tal R, Bentancur AG, Sela BA, Nagler A, Leor J.
Cardiology. 2008;110(3):160-6. Epub 2007 Dec 4.
Summary: Circulating endothelial progenitor cells (EPCs) positive for CD34 measured by flow cytometry and kinase insert domain receptor (KDR) measured by the number of colony-forming units in 25 patients with angina pectoris randomized to 35 daily 1-hour EECP treatment sessions (n=15) and control (n=10) were significantly increased in the EECP treated group and not in the control group. Patients in the EECP therapy group also improved their anginal score from 3.0 pre-EECP therapy to 2.0 post EECP therapy (p<0.001). The improvement of angina post EECP treatment is associated with an increased number of colony-forming capacities of circulating EPCs.
Randomized Clinical Trials and Patient Registry Data in the Treatment of Angina Pectoris and Heart Failure
The Multicenter Study of Enhanced External Counterpulsation (MUST-EECP): Effect of EECP on Exercise-Induced Myocardial Ischemia and Anginal Episodes
Arora RR, Chou TM, Jain D, Fleishman B, Crawford L, McKiernan T, Nesto R.
The Journal of the American College of Cardiology. 1999 Jun;33(7):1833-1840.
Summary: A multicenter (7 university hospitals), prospective, randomized, blinded, control trial of 139 angina patients with documented coronary artery disease and positive exercise treadmill tests were treated with either active counterpulsation (applied cuff pressure up to 350 mmHg), and inactive counterpulsation (<75 mmHg). Exercise duration increased in both groups, with time to = 1-mm ST-segment depression increased significantly from baseline in the active group compared with the inactive group (p=0.11), as well as a significant reduction in the number of angina episodes (p<0.05). Nitroglycerin usage decreased in the active group but did not change in the inactive group; the between-group difference was not significant (p>0.7).
Enhanced External Counterpulsation Improves Exercise Tolerance in Patients With Chronic Heart Failure
Feldman AM, Silver MA, Francis GS, Abbottsmith CW, Fleishman BL, Soran O, de Lame PA, Varricchione T for the PEECH Investigators.
Journal of the American College of Cardiology. 2006 Sep 19;48(6):1199-1206. Epub 2006 Aug 25
Summary: 187 subjects with mild-to-moderate symptoms of heart failure were randomized to either EECP treatment with protocol-defined pharmacologic therapy (PT) or PT alone. 35% in the EECP therapy group and 25% in control group increased their exercise time by at least 60 sec (p=0.016) at 6 months. However, there was no between group difference in the percentage of subjects with at least 1.25 ml/kg/min increase in peak volume of oxygen uptake. New York Heart Association (NYHA) functional class improved in the active treatment group at 1-week (p<0.01), 3 months (p<0.02), and 6 months (p<0.01 post treatment). The Minnesota Living with Heart Failure score also improved significantly in the treated group at 1 week (p<0.002) and 3 months (p=0.01) after treatment, versus no significant changes in the control group.
Enhanced External Counterpulsation Improves Exercise Duration and Peak Oxygen Consumption in Older Patients With Heart Failure: A Subgroup Analysis of the PEECH Trial
Abbottsmith CW, Chung ES, Varricchione T, de Lame PA, Silver MA, Francis GS, Feldman AM; Prospective Evaluation of EECP in Congestive Heart Failure (PEECH) Investigators.
Congestive Heart Failure. 2006 Nov-Dec;12(6):307-311.
Summary: This paper reports the results of a pre-specified subgroup analysis of 85 elderly patients (65 years or older) enrolled in the PEECH trial. At 6-months post treatment, the percentage of subjects with >60-second increase in exercise duration was significantly higher in EECP patients compared with the control group (p=0.08). Moreover, in contrast to the overall PEECH study (see above), the older patient group demonstrated a significantly higher percentage of responders with >1.25 ml/kg/min increase in peak volume of oxygen consumption (p=0.017). In addition, the mean changes in exercise duration and peak oxygen consumption from baseline were significantly increased compared with the control group at 1 week, 3 months and 6 months following completion of treatment.
Perfusion to Ischemic Region
Effects of Enhanced External Counterpulsation on Stress Radionuclide Coronary Perfusion and Exercise Capacity in Chronic Stable Angina Pectoris
Stys TP, Lawson WE, Hui JCK, Fleishman B, Manzo K, Strobeck JE, Tartaglia J, Ramasamy S, Suwita R, Zheng ZS, Liang H, Werner D.
The American Journal of Cardiology. 2002 Apr 1;89(7):822-824..
Enhanced External Counterpulsation in the Treatment of Chronic Refractory Angina: A Long-term Follow-up Outcome from the International Enhanced External Counterpulsation Patient Registry
Loh PH, Cleland JG, Louis AA, Kennard ED, Cook JF, Caplin JL, Barsness GW, Lawson WE, Soran OZ, Michaels AD. Clinical Cardiology. 2008 Apr 10;31(4):159-164.
Experimental Studies
Enhanced External Counterpulsation Inhibits Intimal Hyperplasia by Modifying Shear Stress Responsive Gene Expression in Hypercholesterolemic Pigs
Zhang Y, He X, Chen X, Ma H, Liu D, Luo J, Du Z, Jin Y, Xiong Y, He J, Fang D, Wang K, Lawson WE, Hui JC, Zheng Z, Wu G.
Circulation. 2007 Jul 31;116(5):526-534. Epub 2007 Jul 9
Summary: The coronary arteries and aortas of 35 male pigs randomly assigned to control, high-cholesterol diet and high-cholesterol diet +EECP (EECP started at week 9 to 15) were analyzed after 15 weeks. There was significant increase in peak diastolic arterial wall shear stress during EECP with reduction of intima-to-media area ratio by 42% compared with high-cholesterol group. EECP treated group also increased the protein expression of endothelial nitric oxide synthase suppressed the phosphorylation of extracellular signal-regulated kinases ½.
Cost-Effectiveness
Impact of External Counterpulsation Treatment on Emergency Department Visits and Hospitalizations in Refractory Angina Patients with Left Ventricular Dysfunction
Soran O, Kennard ED, Bart BA, Kelsey SF.
Congestive Heart Failure. 2007 Jan-Feb;13(1):36-40.
Review Paper
Enhanced External Counterpulsation and Future Directions: Step Beyond Medical Management for Patients with Angina and Heart Failure
Manchanda A, Soran O.
Journal of the American College of Cardiology. 2007 Oct 16;50(16):1523-1531. Epub 2007 Oct 1
