Chronic stable angina enhanced external counter pulsation

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: John Fani Srour, M.D.; Jinhui Wu, M.D.; Lakshmi Gopalakrishnan, M.B.B.S.


Enhanced external counter pulsation (EECP) is another alternative therapy in the management of refractory angina. Most data from observational studies have demonstrated significant improvement in the exercise tolerance and reduction in the frequency of anginal symptoms as well as the use of nitroglycerin among patients treated with EECP.[1]

Enhanced External Counter Pulsation

Mechanisms of Benefit

  • EECP has been postulated to decrease myocardial oxygen demand, enhance myocardial collateral flow via increased transmyocardial pressure, and improve endothelial function.
  • Possible placebo effect associated with EECP has not been addressed in many studies, which have not included sham controls.


EECP uses three paired pneumatic cuffs that are applied to the lower extremities. The cuffs are sequentially inflated then deflated.

The therapy is usually administered over 7 weeks consisting of 35-one hour treatments.

Supportive Trial Data

Randomized-Controlled Study

  • A multicenter, prospective, randomized, blinded, controlled trial involving 139 patients with angina, documented coronary artery disease and positive exercise treadmill test randomly assigned to receive either EECP (35 hours of active counterpulsation) or inactive EECP (over a 4- to 7-week period) to determine the safety and efficacy of EECP. The study demonstrated a significant improvement in the time to ST segment depression from baseline in the active EECP group (P=0.01). More active-EECP patients experienced a significant reduction in the frequency of anginal episodes (P=less than 0.05); however, the usage of nitroglycerin did not significantly change in both the groups. Thus, the study concluded that enhanced external counterpulsation significantly reduced angina and extended the time to exercise-induced ischemia in patients with symptomatic CAD.[2]

Registry Studies

  • The International EECP Patient Registry (IEPR) involved 978 patients with refractory angina from 43 clinical centers to evaluate the safety and effectiveness of EECP in the management of chronic stable angina. Of the 978 patients analyzed, 70% had CCS class III or IV angina before the start of therapy, 62% used nitroglycerin, 81% had been previously revascularized, and 69% were considered unsuited for either PCI or CABG at the time of starting EECP. 86% patients completed a full 35-one hour course of EECP, of whom 81% reported a significant improvement of at least one angina class immediately after the last treatment.[3]
  • A cohort study of 2,289 patients with refractory angina, from more than 100 centers, were evaluated to assess the safety and efficacy of EECP in the management of refractory angina. Angina class improved in 74% of patients with limiting angina (CCS class II-IV), with patients most impaired at baseline demonstrating the greatest improvement (39.5% of patients in CCS class III and IV improved 2 or more classes). The treatment was generally well tolerated and effective in patients ranging from 19 to 97 years.[4]

2014 focussed update of 2012 ACC/AHA Guidelines- Enhanced external counterpulsation (DO NOT EDIT)[5][6][7]

Class IIb
"1. Enhanced external counterpulsation (EECP) may be considered for relief of refractory angina in patients with SIHD. (Level of Evidence: B)"


  1. Urano H, Ikeda H, Ueno T, Matsumoto T, Murohara T, Imaizumi T (2001) Enhanced external counterpulsation improves exercise tolerance, reduces exercise-induced myocardial ischemia and improves left ventricular diastolic filling in patients with coronary artery disease. J Am Coll Cardiol 37 (1):93-9. PMID: 11153780
  2. Arora RR, Chou TM, Jain D, Fleishman B, Crawford L, McKiernan T et al. (1999) The multicenter study of enhanced external counterpulsation (MUST-EECP): effect of EECP on exercise-induced myocardial ischemia and anginal episodes. J Am Coll Cardiol 33 (7):1833-40. PMID: 10362181
  3. Barsness G, Feldman AM, Holmes DR, Holubkov R, Kelsey SF, Kennard ED et al. (2001) The International EECP Patient Registry (IEPR): design, methods, baseline characteristics, and acute results. Clin Cardiol 24 (6):435-42. PMID: 11403504
  4. Lawson WE, Hui JC, Lang G (2000) Treatment benefit in the enhanced external counterpulsation consortium. Cardiology 94 (1):31-5. PMID: 11111142
  5. Fihn SD, Blankenship JC, Alexander KP, Bittl JA, Byrne JG, Fletcher BJ; et al. (2014). "2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". J Am Coll Cardiol. 64 (18): 1929–49. doi:10.1016/j.jacc.2014.07.017. PMID 25077860.
  6. Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM et al. (1999)guidelines for the management of patients with chronic stable angina: executive summary and recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Chronic Stable Angina).Circulation 99 (21):2829-48. PMID: 10351980
  7. Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS et al. (2003) ACC/AHA 2002 guideline update for the management of patients with chronic stable angina--summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina). Circulation 107 (1):149-58. PMID: 12515758

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