In the United States alone, more than 2.5 million patients with symptomatic coronary heart disease (CHD) are not amenable to percutaneous coronary intervention -angioplasty with stent deployment- or coronary artery bypass grafting (CABG) surgery because of unsuitable coronary anatomy, multipleprevious revascularization attempts, age, additional comorbid conditions, or patient preference.
For these patients with medically refractory angina pectoris, enhanced external counter pulsation (EECP) is the only truly noninvasive and unique treatment for which a reduction of angina symptoms and nitrate usage, increased exercise tolerance, and an improvement in myocardial ischemia.
However, EECP has also been used in conditions other than coronary heart disease; such as:
- Restless legs syndrome
- Erectile dysfunction
- Hepatorenal syndrome
- Ocular ischemic disease
- Diabetes mellitus, etc.
A 60-year-old gentleman with bypass surgery Lawrence is a sixty-year-old Caucasian male with symptomatic hardening of the coronary arteries (CHD) since 2006. He has history of hypertension, diastolic heart failure, and hypercholesterolemia. He underwent coronary artery bypass grafting (CABG) x 4 in May of 2008, more than 11 years ago. He had an abnormal stress echocardiogram after 10 minutes of exercise showing dyskinesis of the anterior and septal left ventricular walls compatible with myocardial ischemia.
He complained of chest discomfort on exertion and other symptoms of equivalent angina pectoris despite optimal medical therapy for angina. He underwent a selective coronary arteriography and visualization of the grafts (see diagram) showing severe obstructive CAD in the 3 vessels with total occlusion of the saphenous vein grafts and only the left internal mammary graft was patent. A repeat CABG surgery was not possible.
Therefore, he received 35 one-hour sessions of EECP as the best treatment for his symptomatic CAD despite previous CABG surgery and optimal medical therapy.
A 64-year-old lady with Restless Leg Syndrome
Joy is a 64-year-old Caucasian lady from Pasadena with restless leg syndrome (RLS) for many years. Her cardiovascular evaluation was unremarkable with no evidence of CHD. She is very active doing bicycling and swimming. She takes two different medications for her severe daily symptoms of RLS. She was aware of the benefits of EECP in patients with RLS and wanted to discontinue taking her medications.
After a couple of EECP trial sessions, she began a formal EECP 35- one-hour sessions for her RLS, aware that Medicare does not cover EECP for this non-cardiac indication.
After the 4 th week of EECP, her symptoms subsided at the point she decreased her RLS medications; and eventually discontinued taking it since her RLS symptoms no longer recurred.
Indeed, clinical studies have shown that EECP improves RLS symptoms significantly and could be considered as an adjunct treatment for patients with RLS. In some cases, the improvement lasts for months after the course of treatment. In this way EECP is unique and unlike pharmacotherapy which requires continuous daily treatment.
An 84-year-old man with Atrial Fibrillation
Jerry is an 84-year-old gentleman with known coronary heart disease, hypertension, chronic atrial fibrillation, hyperlipidemia and recurrent angina pectoris despite optimal medical therapy. He refused to have angioplasty with coronary stents or CABG.
His electrocardiogram (EKG) always have shown atrial fibrillation (AF) – an irregularly irregular arrhythmia of the heart. He completed 35 days of EECP therapy in early May 2019. Few weeks later, during his follow up visit in late May, he was found to be on normal heart rhythm.
It is not a total surprise to see a conversion of chronic atrial fibrillation to normal sinus rhythm in this patient with hypertension and hypertensive heart disease with CHD and normal heart function. The well-known hemodynamic effects of EECP therapy by increasing the cardiac output and lowering blood pressure my have contributed to the AF conversion.
A 67-year-old lady with Cardiac Syndrome X
Lita is a 67-year-old lady with recurrent episodes of typical precordial chest discomfort (angina) on exertion and even at rest sometimes relieved by nitroglycerin sublingual tablets. She has an abnormal EKGs with myocardial ischemia in a stress echocardiogram showing dyskinesis of the anterior and lateral walls of her left ventricle. She underwent a left heart CATH and selective coronary arteriography showing “normal” coronary arteries, except for the presence of bridges in two arteries.
This patient illustrates the Cardias Syndrome X. Indeed, about 50% of women discharged with “normal coronaries” continue to experience atypical chest pain that are often unresponsive to anti-ischemic therapy.
It has been reported that EECP is beneficial in patients with medically refractory angina due to large epicardial vessel disease and those with microvascular coronary artery disease (Cardiac Syndrome X).