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Published on: May 11, 2015
Practicability and limitations of enhanced external counterpulsation as an additional treatment for angina
Dierk Werner1, Joachim Kropp, Sebastian Schellong
1Department of Cardiology, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany. Dierk.Werner@nexgo.de
Insights
Enhanced external counterpulsation (EECP) therapy effectively reduces angina and improves work capacity in eligible patients. However, many candidates are excluded due to contraindications, and some treated patients find the therapy too time-consuming.
Area of Science:
- Cardiology
- Cardiovascular Medicine
Background:
- Enhanced external counterpulsation (EECP) therapy shows promise in reducing angina and myocardial ischemia.
- However, contraindications and treatment duration limit its widespread application and practicality.
Purpose of the Study:
- To systematically evaluate eligibility and practicality issues of EECP therapy in patients with drug-refractory angina.
- To assess the efficacy and patient-reported outcomes of EECP in a real-world clinical setting.
Main Methods:
- A prospective study evaluated consecutive angina patients for EECP candidacy over 18 months.
- Treated patients underwent exercise tests and perfusion imaging pre- and post-EECP.
- Patient-reported outcomes on angina frequency, nitroglycerin use, and therapy satisfaction were collected.
Main Results:
- Of 48 candidates, 24 were excluded due to medical contraindications (e.g., poor ejection fraction, PAD, anticoagulation, atrial fibrillation).
- Eight patients declined due to time constraints, and 3 dropped out due to side effects.
- The 13 patients completing EECP showed significant reductions in angina (48%) and nitroglycerin use (51%), and improved work capacity (22%).
- However, 31% of treated patients found EECP too time-consuming one year later.
Conclusions:
- EECP therapy effectively reduces angina and improves exercise capacity in selected patients.
- Established contraindications exclude a significant proportion of potential candidates.
- The time commitment of EECP remains a practical barrier for some patients.
Background:
An increasing number of clinical studies indicates reduction of angina and myocardial ischemia by enhanced external counterpulsation (EECP) therapy. However, given the wide range of contraindications and the long duration of treatment, eligibility and practicality issues have not been addressed systematically.
Hypothesis:
Of all candidates for EECP (patients with drug-refractory angina without possibility of revascularization), the majority either have contraindications or have practical problems complying with the time demands that this therapy imposes. In the rest, EECP leads to satisfactory results.
Methods:
During 18 months, every consecutive patient with angina despite medical and interventional therapy was evaluated for EECP at one center. Treated patients underwent a bicycle exercise test and perfusion imaging before and after the standard course of 35 h of EECP. In addition, patients were asked about frequency of angina and nitroglycerin usage before and after EECP, and all patients filled out a final questionnaire 1 year after the end of therapy.
Results:
Overall, 48 patients were considered candidates for EECP. Of these, 24 were excluded for medical reasons: poor ejection fraction (4), peripheral artery disease (4), anticoagulation (4), and atrial fibrillation (3). Eight further patients declined EECP for lack of time or accommodation. Another 3 of the 16 remaining patients dropped out because of side effects. In the 13 patients who finished the treatment course, weekly anginal episodes were reduced by 48% (p < 0.05), on-demand nitroglycerin puffs were reduced by 51% (p < 0.05), work capacity was improved by 22% (p < 0.05), and the number of reversible perfusion defects in perfusion scans decreased nonsignificantly (-28%). However, 4 of 13 treated patients determined 1 year later that the detriment of loss of time exceeded the benefits of EECP.
Conclusion:
Similar to previous reports, our study confirms the reduction of angina and improvement of work capacity after EECP. However, using established contraindications, approximately two-thirds of patients considered to be candidates had to be excluded, and one-third of the treated patients regarded EECP therapy retrospectively as too time consuming.
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