Chronic Refractory Angina

External Enhanced Counterpulsation Therapy (EECP)

Introduction

External Enhanced Counter Pulsation (EECP) is a safe, non-invasive and reversible therapy that has been shown to produce long-term benefits to patients suffering the debilitating symptoms associated with stable refractory angina. Presently EECP is not widely available outside the US.

In 1997, Aurora et al published results of The Multicentre Study of Enhanced External Counterpulsation (Must – EECP). One hundred and thirty nine patients were randomised to EECP or sham EECP. This study showed clear benefits to those patients in the treatment arm of the study. These benefits were consistent with previous observational studies in the alleviation of symptoms, and more importantly, demonstrated improvements in follow up quality of life measurements. Follow up review studies show beneficial effects can last for 4–7 years post treatment.

EECP seems to be most effective in trials with patients with prior revascularisation, who have single or double vessel disease and least effective in patients with generalised triple vessel disease.

What does EECP involve?

At the National Refractory Angina Centre we recommend that EECP, like other therapies for stable angina, should be offered alongside a comprehensive cognitive behavioural rehabilitation programme. Repeated visits over several weeks provide an excellent opportunity to ensure that patients fully understand their condition and the most effective ways to improve and maintain fitness. Set backs are inevitable and proper patient education should ensure that patients and carers recognise the difference between heart attacks and angina and how to respond.

The main problem is the fact that effective therapy requires thirty-five hours of outpatient treatment. Generally patients can only tolerate one hour at a time and this means that a course of therapy may involve daily visits for an hour of EECP for seven weeks. In the UK and Europe the scarcity of EECP centred means that patients may need to travel large distances each day or find local accommodation. In this situation some EECP centres undertake 2 sessions per day. Gaps of two days between sessions appear to be permissible but longer gaps impair effectiveness. It is usually necessary for patients to start over if therapy is interrupted for a week or more.

Patients are advised not to eat within one hour before treatment and are also asked to void just prior to treatment. The patient is changed into leggings to prevent abrasions and reduce friction. Compression cuffs (like enormous blood pressure cuffs) are wrapped around the patient’s calves thighs and buttocks and the patient lies on a padded bed. The cuffs are inflated when the heart is relaxing and deflate when the heart contracts. The result is that the patient experiences a sudden pressure round the legs and buttocks every beat of their heart for an hour.

It is essential that careful attention is paid to patient selection and that recommended guidelines are followed..

Most patients tolerate EECP and the commonest complaint is that the room can be hot and noisy. Air conditioning and headphones care essential for comfort. Skin abrasions can be a problem especially in elderly and diabetic patients.

Safety

Clinical trails and studies conducted in the United States and China have demonstrated the safety and tolerability of EECP. No major morbidity or mortality has been reported as a result of treatment in clinical centres for patients undergoing EECP. Individual response to treatment varies and some patients begin to experience clinical benefits from the first day others only improve towards the end of the treatment.

Contra-indications and patient selection

The nature of the treatment regimen excludes various patient groups from EECP. Patients with:

- Arrhythmias, abnormal rhythms may interfere with the gating of EECP to the ECG.
- Uncontrolled hypertension, as EECP could produce unacceptable diastolic pressure.
- Aortic regurgitation or insufficiency can prevent diastolic augmentation.
- Significant valvular heart disease.
- Recent Cardiac catheterisation.
- Anticoagulation or bleeding diatheses.
- Symptomatic peripheral vascular disease, DVT or ulcer.
- Permanent Pacemakers or indwelling defibrillator.
- Caution should be taken in patients with a recent CVA.
Note patients with bad backs may find the repeated jolting from the buttock inflations uncomfortable.

Conclusion

The majority of revascularisation procedures for stable angina are palliative and do not prevent myocardial infarction, nor do they reduce mortality from coronary artery disease. Medical management aimed at symptomatic relief, coupled with low cost, non-invasive treatment programmes including therapeutic options such as EECP, should be considered for all patients with ischaemic coronary heart disease for whom the risks of revascularisation are unacceptable to the patient and their carers. In our experience patients opt for EECP in preference to more invasive therapies in the programme. The inconvenience of daily visits is a major problem for patients travelling large distances.

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