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Treatment options for refractory angina pectoris: Enhanced external counterpulsation therapy

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Opinion statement

Refractory angina pectoris, defined as angina refractory to maximal medical therapy and standard coronary revascularization procedures, remains a significant health problem in the United States and the world. Despite a panoply of recent therapeutic advances, patients with refractory angina pectoris are not adequately treated; therefore, scientists have been investigating new technologies to help these patients. The technique of counterpulsation, studied for almost half a century, is considered a safe, highly beneficial, low-cost, noninvasive treatment for these angina patients and now also for those with heart failure. Recent evidence suggests that enhanced external counterpulsation (EECP) therapy may improve symptoms and decrease long-term morbidity via several mechanisms, including improvement in endothelial function, promotion of collateralization, enhancement of ventricular function, improvement in oxygen consumption (VO2), regression of atherosclerosis, and peripheral “training effects” similar to exercise. Numerous clinical trials in the past two 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. This review summarizes the current evidence to support EECP’s use in treating refractory angina pectoris.

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References and Recommended Reading

  1. American Stroke Association, American Heart Association: Heart Disease and Stroke Statistics—2005 Update. Available at http://www.americanheart.org/downloadable/heart/1105390918119HDSStats2005Update.pdf. Accessed October 2008.

  2. Kim MC, Kini A, Sharma SK: Refractory angina pectoris: mechanism and therapeutic options. J Am Coll Cardiol 2002, 39:923–934.

    Article  PubMed  Google Scholar 

  3. Manchanda A, Soran O: Enhanced external counterpulsation and future directions: step beyond medical management for patients with angina and heart failure. J Am Coll Cardiol 2007, 50:1523–1531.

    Article  PubMed  Google Scholar 

  4. Urano H, Ikedah H, Ueno T, et al.: Enhanced external counter pulsation improves exercise tolerance, reduces exercise-induced myocardial ischemia and improves left ventricular diastolic filling in patients with coronary artery disease. J Am Coll Cardiol 2001, 37:93–99.

    Article  PubMed  CAS  Google Scholar 

  5. Gorcsan J, Crawford L, Soran OZ, et al.: Improvement in left ventricular performance by enhanced external counterpulsation in patients with heart failure [abstract 901–5]. J Am Coll Cardiol 2000, 35:230A.

    Article  Google Scholar 

  6. Lawson WE, Silver MA, Hui JC, et al.: Angina patients with diastolic versus systolic heart failure demonstrate comparable immediate and one-year benefit from enhanced external counterpulsation. J Card Fail 2005, 11:61–66.

    Article  PubMed  Google Scholar 

  7. Kantrowitz A, Kantrowitz A: Experimental augmentation of coronary flow by retardation of coronary artery pressure pulse. Surgery 1953, 34:678–687.

    PubMed  CAS  Google Scholar 

  8. Birtwell WC, Ruiz U, Soroff HS, et al.: Technical consideration in the design of a clinical system for external left ventricular assist. Trans Am Soc Artif Intern Organs 1968, 14:304–310.

    PubMed  CAS  Google Scholar 

  9. Lawson WE, Hui JC, Zheng ZS, et al.: Improved exercise tolerance following enhanced external counterpulsation: cardiac or peripheral effect? Cardiology 1996, 87:271–275.

    Article  PubMed  CAS  Google Scholar 

  10. Lawson WE, Hui JCK, Soroff HS, et al.: Efficacy of enhanced external counterpulsation in the treatment of angina pectoris. Am J Cardiol 1992, 70:859–862.

    Article  PubMed  CAS  Google Scholar 

  11. Lawson WE, Hui JCK, Zheng ZS, et al.: Can angiographic findings predict which coronary patients will benefit from enhanced external counterpulsation? Am J Cardiol 1996, 77:1107–1109.

    Article  PubMed  CAS  Google Scholar 

  12. Lawson WE, Hui JCK, Zheng ZS et al.: Improved exercise tolerance following enhanced external counterpulsation: cardiac or peripheral effect? Cardiology 1996, 87:271–275.

    Article  PubMed  CAS  Google Scholar 

  13. Lawson WE, Hui JCK, Guo T, et al.: Prior revascularization increases the effectiveness of enhanced external counterpulsation. Clin Cardiol 1998, 21:841–844.

    PubMed  CAS  Google Scholar 

  14. Arora RR, Chou TM, Jain D et al.: The Multicenter Study of Enhanced External Counterpulsation (MUST-EECP): effect of EECP on exercise-induced myocardial ischemia and anginal episodes. J Am Coll Cardiol 1999, 33:1833–1840.

    Article  PubMed  CAS  Google Scholar 

  15. Soran O, Kennard ED, Kfoury AG, et al.: 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). Am J Cardiol 2006, 97:17–20.

    Article  PubMed  Google Scholar 

  16. Masuda D, Nohara R, Hirai T, et al.: Enhanced external counterpulsation improved myocardial perfusion and coronary flow reserve in patients with chronic stable angina. Eur Heart J 2001, 22:1451–1458.

    Article  PubMed  CAS  Google Scholar 

  17. Stys T, Lawson WE, Hui JCK, et al.: Acute hemodynamic effects and angina improvement with enhanced external counterpulsation. Angiology 2001, 52:653–658.

    Article  PubMed  CAS  Google Scholar 

  18. Stys TP, Lawson WE, Hui JCK, et al.: Effects of enhanced external counterpulsation on stress radionuclide coronary perfusion and exercise capacity in chronic stable angina pectoris. Am J Cardiol 2002, 89:822–882.

    Article  PubMed  Google Scholar 

  19. Lawson WE, Hui JC, Kennard ED, et al.: Two-year outcomes in patients with mild refractory angina treated with enhanced external counterpulsation. Clin Cardiol 2006, 29:69–73.

    Article  PubMed  Google Scholar 

  20. Pettersson T, Bondesson S, Cojocaru D, et al.: One year follow-up of patients with refractory angina pectoris treated with enhanced external counterpulsation. BMC Cardiovasc Disord 2006, 6:28.

    Article  PubMed  Google Scholar 

  21. Arora RR, Chou TM, Jain D, et al.: Effects of enhanced external counterpulsation on health-related quality of life continue 12 months after treatment: a substudy of the multicenter study of enhanced external counterpulsation. J Investig Med 2002, 50:25–32.

    Article  PubMed  Google Scholar 

  22. Michaels AD, Linnemeier G, Soran O, et al.: Two-year outcomes after enhanced external counterpulsation for stable angina pectoris (from the International EECP Patient Registry [IEPR]). Am J Cardiol 2004, 93:461–464.

    Article  PubMed  Google Scholar 

  23. Fitzgerald CP, Lawson WE, Hui JC, et al.: Enhanced external counterpulsation as initial revascularization treatment for angina refractory to medical therapy. Cardiology 2003, 100:129–135.

    Article  PubMed  CAS  Google Scholar 

  24. Lawson WE, Hui JCK, Lang G: Treatment benefit in the enhanced external counterpulsation consortium. Cardiology 2000, 94:31–35.

    Article  PubMed  CAS  Google Scholar 

  25. Lawson WE, Hui JCK, Cohn PF: Long-term prognosis of patients with angina treated with enhanced external counterpulsation: five-year follow-up study. Clin Cardiol 2000, 23:254–258.

    Article  PubMed  CAS  Google Scholar 

  26. Loh PH, Cleland JG, Louis AA, et al.: Enhanced external counterpulsation in the treatment of chronic refractory angina: a long-term follow-up outcome from the International Enhanced External Counterpulsation Patient Registry. Clin Cardiol 2008, 31:159–164.

    Article  PubMed  Google Scholar 

  27. Soran O, Kennard ED, Kelsey SF, et al.: Enhanced external counterpulsation as treatment for chronic angina in patients with left ventricular dysfunction: a report from the International EECP Patient Registry (IEPR). Congest Heart Fail 2002, 8:297–302.

    Article  PubMed  Google Scholar 

  28. Lawson WE, Pandey K, Hui JCK, et al.: Benefit of enhanced external counterpulsation in coronary patients with left ventricular dysfunction: cardiac or peripheral effect? J Card Fail 2002, 8(Suppl 41):146.

    Google Scholar 

  29. Soran O, Kennard ED, Bart BA, et al.: Impact of external counterpulsation treatment on emergency department visits and hospitalizations in refractory angina patients with left ventricular dysfunction. Congest Heart Fail 2007, 13:36–40.

    Article  PubMed  Google Scholar 

  30. Taguchi I, Ogawa K, Oida A, et al.: Comparison of hemodynamic effects of enhanced external counterpulsation and intra-aortic balloon pumping in patients with acute myocardial infarction. Am J Cardiol 2000, 86:1139–1141.

    Article  PubMed  CAS  Google Scholar 

  31. Michaels MD, Accad M, Ports TA, et al.: Left ventricular systolic unloading and augmentation of intracoronary pressure and Doppler flow during enhanced external counterpulsation. Circulation 2002, 106:1237–1242.

    Article  PubMed  Google Scholar 

  32. Masuda D, Nohara R, Kataoka K: Enhanced external counterpulsation promotes angiogenesis factors in patients with chronic stable angina. Circulation 2001, 104:II445.

    Google Scholar 

  33. Wu GF, Qiang SZ, Zheng ZS: A neurohormonal mechanism for the effectiveness of the enhanced external counterpulsation. Circulation 1999, 100:I832.

    Google Scholar 

  34. Qian X, Wu W, Zheng ZS: Effect of enhanced external counterpulsation on nitric oxide production in coronary disease. J Heart Disease 1999, 1:193.

    Google Scholar 

  35. Casey DP, Conti CR, Nichols WW, et al.: Effect of enhanced external counterpulsation on inflammatory cytokines and adhesion molecules in patients with angina pectoris and angiographic coronary artery disease. Am J Cardiol 2008, 101:300–302.

    Article  PubMed  CAS  Google Scholar 

  36. Froschermaier SE, Werner D, Leike S, et al.: Enhanced external counterpulsation as a new treatment modality for patients with erectile dysfunction. Urol Int 1998, 61:168–171.

    Article  PubMed  CAS  Google Scholar 

  37. Lawson WE, Hui JC, Kennard ED, et al.: Effect of enhanced external counterpulsation on medically refractory angina patients with erectile dysfunction. Int J Clin Pract 2007, 61:757–762.

    Article  PubMed  CAS  Google Scholar 

  38. El-Sakka AI, Morsy AM, Fagih BI, et al.: Enhanced external counterpulsation in patients with coronary artery disease-associated erectile dysfunction. Part II: impact of disease duration and treatment courses. J Sex Med 2007, 4:1448–1453.

    Article  PubMed  Google Scholar 

  39. Werner D, Tragner P, Wawer A, et al.: Enhanced external counterpulsation: a new technique to augment renal function in liver cirrhosis. Nephrol Dial Transplant 2005, 20:920–926.

    Article  PubMed  Google Scholar 

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  1. University of Pittsburgh Cardiovascular Institute, 200 Lothrop Street, UPMC, Presbyterian Hospital, F-748, Pittsburgh, PA, 15213, USA

    Ozlem Soran

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  1. Ozlem Soran
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Soran, O. Treatment options for refractory angina pectoris: Enhanced external counterpulsation therapy. Curr Treat Options Cardio Med 11, 54–60 (2009). https://doi.org/10.1007/s11936-009-0006-8

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