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Enhanced External Counter-Pulsation (EECP)

Enhanced External Counter-Pulsation or EECP is a procedure performed on individuals with Ischemic Cardiomyopathy in order to diminish the symptoms of their cardiac ischemia. In various studies, EECP has been shown to relieve angina, improve exercise tolerance, and decrease the degree of ischemia in a cardiac stress test. EECP is the "last resort" treatment for individuals with Ischemic Cardiomyopathy who are not amenable to Coronary Angioplasty or Bypass surgery. It is performed on individuals who continue to have symptoms while on the maximum tolerated doses of cardiac medications. In addition, individuals with advanced heart failure due to an ischemic etiology may benefit from EECP. This is the object of the PEECH trial, a large multi-center currently ongoing study. EECP works by the inflation of cuffs tied around different levels of the lower limb during cardiac diastole (when the aortic valve is closed) thereby increasing blood flow to the myocardium (the muscle of the heart). This is because, unlike the tissues of the rest of the body, the myocardium receives the majority of its blood during diastole. The increased flow during diastole caused by EECP promotes the formation of collateral arteries in the coronary circulation. Presumably, it is these newly opened collateral arteries that produced the sustained benefit that EECP provides to individuals after the EECP sessions are complete.Another theory is that EECP exposes the coronary circulation to increased shear stress, and that this results in the production of a cascade of growth factors that result in angiogenesis. EECP increases cardiac output by a combination of the increased preload and the decreased afterload during the EECP session. Inflation of the cuffs during diastole compresses the venous system in the legs, causing increased venous return to the heart, thereby increasing left ventricular preload. This increased filling of the heart increases cardiac output. Deflation of the cuffs in systole decrease afterload (the pressure the left ventricle has to overcome in order to eject blood), also increasing the cardiac output. There are long term hemodynamic effects of EECP, which are presumably due to the decreased ischemic burden noted in individuals after completing an EECP regimen. These include a decrease in the left ventricular end diastolic pressure (LVEDP), and subsequently a decrease in brain natriuretic peptide (BNP) levels, and improved diastolic performance of the left ventricle.
 Comment
    "Enhanced External Counter-Pulsation or EECP is a procedure to diminish the symptoms of cardiac ischemia in individuals with Ischemic Cardiomyopathy who are not amenable to Coronary revascularisation and in individuals with advanced heart failure due to an ischemic etiology."

Dr Ajayakumar MD DM FIC
Consultant In Diabetes, Medicine