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STATE-OF-THE-ART PAPER

Enhanced External Counterpulsation and Future Directions

Step Beyond Medical Management for Patients With Angina and Heart Failure

Aarush Manchanda, MD^_* and Ozlem Soran, MD, MPH, FACC, FESC^,_*

^_* Department of Internal Medicine, The George Washington University, Washington, DC
Cardiovascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania

Manuscript received April 2, 2007; revised manuscript received May 25, 2007, accepted July 17, 2007.

^_* Reprint requests and correspondence: Dr. Ozlem Soran, University of Pittsburgh Cardiovascular Institute, 200 Lothrop Street, UPMC, Presbyterian Hospital, F-748, Pittsburgh, Pennsylvania 15213. (Email: soranzo{at}upmc.edu).

Between 25,000 and 75,000 new cases of angina refractory to maximal medical therapy and standard coronary revascularization procedures are diagnosed each year. In addition, heart failure also places an enormous burden on the U.S. health care system, with an estimated economic impact ranging from $20 billion to more than $50 billion per year. The technique of counterpulsation, studied for almost one-half century now, is considered a safe, highly beneficial, low-cost, noninvasive treatment for these angina patients, and now for heart failure patients as well. Recent evidence suggests that enhanced external counterpulsation (EECP) therapy may improve symptoms and decrease long-term morbidity via more than 1 mechanism, including improvement in endothelial function, promotion of collateralization, enhancement of ventricular function, improvement in oxygen consumption (VO ₂), regression of atherosclerosis, and peripheral training effects similar to exercise. Numerous clinical trials in the last 2 decades have shown EECP therapy to be safe and effective for patients with refractory angina with a clinical response rate averaging 70% to 80%, which is sustained up to 5 years. It is not only safe in patients with coexisting heart failure, but also is shown to improve quality of life and exercise capacity and to improve left ventricular function long-term. Interestingly, EECP therapy has been studied for various potential uses other than heart disease, such as restless leg syndrome, sudden deafness, hepatorenal syndrome, erectile dysfunction, and so on. This review summarizes the current evidence for its use in stable angina and heart failure and its future directions.

Abbreviations and Acronyms   CAD = coronary artery disease   cGMP = cyclic guanosine monophosphate   EECP = enhanced external counterpulsation   EF = ejection fraction   HF = heart failure   LVD = left ventricular dysfunction   NYHA = New York Heart Association   RAP = refractory angina pectoris