Enhanced external counterpulsation (eecp) role in
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Enhanced external counterpulsation (EECP) involves the use of inflatable cuffs wrapped around the lower extremities that are synchronized with the cardiac cycle to improve coronary perfusion. A study investigated EECP in patients with heart failure and found it improved exercise duration but not peak oxygen consumption compared to medical therapy alone. While EECP appears safe, more research is still needed to determine its efficacy in treating heart failure.
Enhanced external counterpulsation (eecp) role in
- 1. Enhanced External Counterpulsation (EECP)-Role in Management of Heart Failure Dr. Moniruzzaman Ahmed Associate Professor, Dept of Medicine MAG Osmani Medical College, Sylhet Email: dr_zaman01217@yahoo.com
- 2. EECP-An overview • EECP stands for Enhanced External Counterpulsation Therapy • Involves the use of three paired inflatable cuffs wrapped around the patient’s lower extremities • The patient is connected to an ECG monitor and a finger plethysmograph • Pressures in the range of 250-275 mmHg applied • Treatment course consists of 35 one-hour sessions
- 3. History of External Counterpulsation 1950’s1950’s: - Kantrowitz Brothers - diastolic augmentation - Sarnoff - LV unloading - Birtwell - combined concepts - Gorlin - defined counterpulsation 1960’s1960’s: - Birtwell & Soroff - Dennis- Osborne - hydraulic external counterpulsation 1970’s1970’s: - Soroff - cardiogenic shock - Banas - stable angina - Amsterdam - acute MI 1980’s1980’s: - Failure to gain acceptance - China; redeveloped technology- pneumatic system - Soroff, Hui, Zheng collaboration at Stony Brook
- 4. Early externalEarly external counterpulsationcounterpulsation devices haddevices had hydraulic pulsatorhydraulic pulsator chambers.chambers.
- 5. • In the early 1980’s, a Chinese group lead byZ.S. Zheng redeveloped technology- pneumatic system • Their positive clinical experience led to the installation of more than 1500 external counterpulsation units in China
- 7. The cuffs are sequentially inflated (calves → lower thighs → upper thighs) during diastole
- 8. The R wave of the ECG is used as the trigger for inflation and deflation
- 10. All pressure is released at the onset of systole • All pressure is released at the onset of systole
- 12. • Retrograde aortic pressure wave • ⇑ diastolic pressure • ⇑ intracoronary perfusion pressure • ⇑ myocardial perfusion • ⇑ venous return • ⇑ preload • ⇑ cardiac output • ⇓ systemic vascular resistance • ⇓ cardiac workload • ⇓ myocardial O2 consumption • ⇓ afterload
- 13. INTRA-AORTIC BALLOON PUMP Systole Diastole Deflation Inflation Standby Counter pulsation Arterial Pressure Increased Venous Return Diastolic Augmentation Systolic Unloading Improve LV Diastolic Filling
- 14. Mechanism of Effect in angina & HF EECP believed to increase the development of collateral circulation resulting in improved myocardial perfusion Chronic exposure to EECP increases shear stress in the coronary circulation –Shear stress results in a cascade of growth factors which stimulate angiogenesis Clin Cardiol 1999;22:173-178
- 15. Potential for increased transmyocardial pressure to open collaterals
- 16. INTRODUCTION Enhanced external counter pulsation (EECP) is a recently approved treatment modality for selected patients with refractory angina and Heart failure.
- 17. INDICATION FOR EECP THERAPY. A. Chronic CAD Primary utilization of EECP to revascularize Anginal Patient refractory to Medical treatment B. Surgery /PTCA not contemplated Patient refused Diffuse distal disease. Target lesion is inaccessible. Co-morbid states create high risk LV dysfunction – High risk CABG. Restenosis after PTCA CABG graft occlusion C. Preparation for Revascularization Severe LV Dysfunction with lot of hibernation to stabilize Heart Function. Waiting due to some other reason. D. Heart Failure Non-Ischemic Cardiomyopathy Ischemic Cardiomyopathy Patient with LV Dysfunction Patient with moderate to severe levels of CHF. E. Cardiac X Syndrome. .
- 18. Efficacy • The first multicenter randomized sham- controlled trial was the MUlticenter STudy of Enhanced External CounterPulsation (MUST-EECP) • MUST-EECP compared full EECP treatment –vs- sham on exercise treadmill scores and subjective angina
- 19. Follow-up analysis of patients in the MUST-EECP trial at 1 yr showed greater improvement in the health- related quality of life measures in the active treatment group
- 20. More Studies…
- 21. A modified course of Enhanced External Counterpulsation improved myocardial perfusion in patients with severe left ventricular dysfunction Pradeep G.Nayar1 , S.Ramasamy1 ,Madhu.N.Sankar1 , K.M.Cherian1 ,William E Lawson2 and John CK Hui2 Presented in American Heart failure society 12th Annual scientific Meeting. Toronto Canada. 1 Frontier Lifeline & Dr.K.M.Cherain Heart Foundation, 2 Cardiology, SUNY at Stony Brook, NY, USA
- 22. One (1) hour per day Six (6) days per week. Six (6) weeks Two (2) hours per day Six (6) days per week. Three (3) weeks One (1) hour per day 10-15 sessions. Seven(7) days per week Standard treatment protocol Modified treatment protocol Short course treatment protocol EECP Therapy Treatment For Angina & Heart Failure
- 23. Summary Short course of EECP in patient with Severe LV Dysfunction prior to CABG improves myocardial perfusion and LV contractility. Short course EECP can reduce post CABG hospitalization and IABP insertion.
- 24. • In January 1998, Phase 1 of the International EECP Patient Registry (IEPR) was established to document patient characteristics, safety, efficacy, and long-term outcomes of EECP therapy • Analysis of long-term outcomes demonstrates that the clinical benefits achieved with EECP are sustained up to at least 24 months
- 25. Two-Year Clinical Outcomes After Enhanced External Counterpulsation (EECP) Therapy in Patients With Refractory Angina Pectoris and Left Ventricular Dysfunction (Report from the International EECP Patient Registry) Ozlem Soran, MD, MPH, Elizabeth D. Kennard, PhD, Abdallah Georges Kfoury, MD, Sheryl F. Kelsey, PhD and IEPR Investigators American Journal of Cardiology Volume 97, Issue 1, Pages 17-20 (January 2006) DOI: 10.1016/j.amjcard.2005.07.122
- 26. Effect of Enhanced External Counterpulsation on Ejection Fraction in Patients with Ischemic Heart Disease • EECP significantly improved LV ejection fraction, stroke volume, cardiac output in patients with ischemic heart disease and – Left ventricular EF > 35% – Left ventricular EF ≤ 35% • The increase in Left Ventricular EF is mediated predominately by a decrease in end-systolic volumes. William E Lawson1 , Himanshu Padh2 , Subramanian Ramasamy3 , John CK Hui1 Journal of American college of cardiology March 11,2008 Volume51 ,No 10 ( Sup A)))_
- 27. Prospective Evaluation of EECP in Congestive Heart Failure (PEECH) Trial PEECH TrialPEECH Trial Presented atPresented at The American College of CardiologyThe American College of Cardiology Scientific Sessions 2005Scientific Sessions 2005 Presented by Dr. Arthur M. FeldmanPresented by Dr. Arthur M. Feldman
- 28. EECP + ACE-Inhibitors or EECP + ARB & beta-blockers, EECP as 35, 1 hour sessions for 7 weeks n=93 EECP + ACE-Inhibitors or EECP + ARB & beta-blockers, EECP as 35, 1 hour sessions for 7 weeks n=93 Primary Endpoint: Percentage of subjects with 1)at least a 60 second increase in exercise duration from baseline to 6 months or 2) at least 1.25 ml/min/kg increase in peak VO2 from baseline to 6 months Secondary Endpoint: Adverse events or changes in exercise duration and peak VO2, NYHA classification, quality of life Primary Endpoint: Percentage of subjects with 1)at least a 60 second increase in exercise duration from baseline to 6 months or 2) at least 1.25 ml/min/kg increase in peak VO2 from baseline to 6 months Secondary Endpoint: Adverse events or changes in exercise duration and peak VO2, NYHA classification, quality of life PEECH Trial Presented at ACC 2005 ACE Inhibitors or ARB & beta-blockers n=94 ACE Inhibitors or ARB & beta-blockers n=94 187 patients with stable heart failure with NYHA class II/III symptoms, Ischemic or non-ischemic etiology, LVEF ≤35%, optimal pharmacologic therapy, ability to exercise ≥3 minutes, limited by SOB or fatigue (not angina) 24% female, mean age 63 years 76% received ACE-inhibitors, 19% ARB, 85% beta-blockers 187 patients with stable heart failure with NYHA class II/III symptoms, Ischemic or non-ischemic etiology, LVEF ≤35%, optimal pharmacologic therapy, ability to exercise ≥3 minutes, limited by SOB or fatigue (not angina) 24% female, mean age 63 years 76% received ACE-inhibitors, 19% ARB, 85% beta-blockers
- 29. PEECH Trial: Primary Endpoint • The primary endpoint of increase in exercise duration by at least 60 seconds occurred more frequently in the EECP group compared with the control group at a 6 month follow-up. • The co-primary endpoint of increase in peak VO2 of at least 1.25 ml/min/kg was the same between the two groups. Primary endpoints of increase in excercise duration at 6 months & increase in peak VO2 Presented at ACC 2005 0% 6% 12% 18% 24% 30% 36% Increase duration Increase VO2 EECP Control p=0.016 p=NS 22.8% 35.4% 25.3% 24.1%
- 30. PEECH Trial: Secondary Endpoint of Change in Exercise Duration 26.4 24.7 -10.0 -9.9 -10 0 10 20 30 1 week 6 months EECP Control Presented at ACC 2005 p=0.01 p=0.01 • The change inThe change in exercise duration wasexercise duration was longer in the EECPlonger in the EECP group versus thegroup versus the control group, whichcontrol group, which actually had aactually had a decrease in exercisedecrease in exercise duration at 1 weekduration at 1 week and 6 months.and 6 months. • The increase in theThe increase in the EECP group’sEECP group’s exercise duration wasexercise duration was maintained at the 6maintained at the 6 month follow-up.month follow-up.
- 31. PEECH Trial: Secondary Endpoint 33.3% 31.3% 30.3% 11.4% 14.3% 29.5% 0% 5% 10% 15% 20% 25% 30% 35% 1 week 6 mos Adverse events EECP Control • There was more improvement in NYHA classification in the EECP group compared to the control group. •The was no significant difference in the occurrence of serious adverse events between groups. Presented at ACC 2005 p<0.001 p<0.001 p=NS %ChangeinNYHAClass%ChangeinNYHAClass
- 32. PEECH Trial: Summary • Among patients with systolic dysfunction, stable heart failure symptoms and treated with optimal pharmacologic therapy, the use of EECP was associated with improvements in exercise duration, NYHA classification and quality of life but no difference in change in peak VO2 compared with optimal pharmacologic therapy alone •The present study demonstrated improvements in exercise duration and quality of life despite optimal medical therapy Presented at ACC 2005
- 33. Evaluation Of EECP in Congestive Heart Failure (PEECH) trial (n=187), four sets of registry data ranging from 127 to 1958 and one case series (n=32) RCTS indicate that EECP may be beneficial in both chronic stable angina & HF Registry data & case series also suggest that EECP may improve patient outcomes such as improved LVEF, NYHA functional class, decreased rate of exacerbation & improved QoL There were numerous methodological limitations to the registry data and case series such as lack of comparison group, conclusions based subjective assessment and lack of completion of the case series study for HF In the studies that investigated EECP for HF ‘ adverse events (AEs) incude major adverse cardiac events (MACEs), death, PCI & incidence of all-cause hospitalisations, and rates ranged from 5% to 72% Health Technology Assessment 2009; Vol. 13: No.24
- 34. EECP for Heart Failure: Is the Juice Worth the Squeeze We need to know much more about EECP in HF before it is used ( and reimbursed ) for HF care Journal Watch Cardiology September 27, 2006
- 37. CONCLUSIONS Enhanced external counterpulsation (EECP) is one of the treatment strategies that is finding a role in the treatment of patients with refractory angina and heart failure RCTS indicate that EECP may be beneficial in both chronic stable angina & HF Registry data & case series also suggest that EECP may improve patientoutcomes such as improved LVEF, NYHA functional class, decreased rate of exacerbation & improved QoL EECP is safe in HF but its efficacy is still uncertain Long-term follow-up trials assessing quality of life from EECP in both refractory stable angina and heart failure are required
Editor's Notes
- #4: In 1974, Soroff and colleagues reported a survival rate 45% higher than the average 15% survival rate for patients treated with standard therapy, in 20 cardiogenic shock patients treated with external counterpulsation. Also in the 1970’s, Banas and coworkers demonstrated in 11 of 18 incapacitating angina patients that effective diastolic augmentation relieved angina symptoms. It was further associated with definite angiographic evidence of increased vascularity in 5 patients, and equivocal evidence in 4 patients, one-to-two months after treatment. In a randomized trial of 258 acute MI patients from 25 centers, Amsterdam and co-workers showed that 3 hours of external counterpulsation starting within 24 hours of the onset of symptoms, reduced mortality significantly in patients over age 46 – 8.3% mortality compared with 17.5 % in the control group. During the 1980’s, early external counterpulsation systems failed to find acceptance in the U.S., partly because of technical problems, and partly owing to increased adoption of bypass surgery and coronary angioplasty. In China, however, the need to treat large numbers of patients at low cost drove the development of a pneumatically-activated cuff system which could reliably alter coronary artery pressure and flow hemodynamics. In 1986, Dr. John Hui, working with Dr. Soroff at SUNY Stony Brook, began a joint research program with Dr. Zheng of the Sun Yat-Sen University of Medical Science in China. This team, together with Drs. Cohn and Lawson, set up collaborative clinical testing and product development. Their joint efforts produced a viable enhanced external counterpulsation delivery system.
- #5: Research in external counterpulsation goes back nearly 50 years, to 1953 when the Kantrowitz brothers at MIT described the concept of increased coronary artery blood flow and perfusion at higher pressure when blood pressure is raised during diastole – this is diastolic augmentation. During the same period, Sarnoff and colleagues showed that left ventricular work and myocardial oxygen consumption are more related to the pressure at which the left ventricle must work, than the volume of blood it pumps. Mechanical left ventricular unloading, therefore, reduces the heart’s energy requirements. Birtwell combined the two principles in a system that increased coronary perfusion pressure in diastole and decreased left ventricular tension during systole. Gorlin named this process “counterpulsation”. By the early 1960’s Birtwell and Soroff, Dennis, and Osborn all independently developed hydraulic external counterpulsation systems. To create counterpulsation, all these devices pumped water in and out of a single chamber enclosing the legs. They were used in all early U.S. clinical studies of external counterpulsation.
- #10: The cuffs inflate sequentially, from the calves, to the lower thighs, to the upper thighs. This inflation sequence creates a retrograde arterial wave that raises coronary perfusion pressure during diastole. The compression sequence also increases venous return, raising cardiac output significantly.