The only facility for EECP in Collier County is:
Walther R Evenhuis
1351 Pine St
Cardiology, Internal Medicine, Cardiovascular Disease
A G-suit is a special garment and generally takes the form of tightly-fitting trousers, which fit either under or over (depending on the design) the flying suit worn by the aviator or astronaut. The trousers are fitted with inflatable bladders which, when pressurized through a G-sensitive valve in the aircraft or spacecraft, press firmly on the abdomen and legs, thus restricting the draining of blood away from the brain during periods of high acceleration.
Now imagine a “G-Suit for your heart. If you were hooked up to a EKG machine that applied external counter pressure whenever your heart beat it would have the potential to give you a natural by-pass to clogged arteries plus other benefits.
Such treatment is available and is often kept secret from heart patients.
EECP therapy is a safe, non-invasive, outpatient treatment option for patients suffering from ischemic heart diseases such as angina and heart failure. EECP therapy has helped thousands of patients. In fact, clinical studies show, over 75% of patients benefit from EECP therapy and sustain improvement up to three years post- treatment.
Recent data documenting the effectiveness of Enhanced External Counterpulsation (EECP) for the treatment of angina has failed to bring this apparently effective procedure into the mainstream of cardiology practice. In this article, DrRich discusses what EECP is, how it works, and why cardiologists are avoiding this safe, noninvasive treatment like the plague.
What is EECP?
EECP is a mechanical procedure in which long inflatable cuffs (like blood pressure cuffs) are wrapped around both of the patient’s legs. While the patient lies on a bed, the leg cuffs are inflated and deflated with each heartbeat. This is accomplished by means of a computer, which triggers off the patient’s ECG so that the cuffs deflate just as each heartbeat begins, and inflate just as each heartbeat ends. When the cuffs inflate they do so in a sequential fashion, so that the blood in the legs is “milked” upwards, toward the heart.
EECP has two potentially beneficial actions on the heart. First, the milking action of the leg cuffs increases the blood flow to the coronary arteries. (The coronary arteries, unlike other arteries in the body, receive their blood flow after each heartbeat instead of during each heartbeat. EECP, effectively, “pumps” blood into the coronary arteries.) Second, by its deflating action just as the heart begins to beat, EECP creates something like a sudden vacuum in the arteries, which reduces the work of the heart muscle in pumping blood into the arteries. Both of these actions have long been known to reduce cardiac ischemia (the lack of oxygen to the heart muscle) in patients with coronary artery disease. Indeed, an invasive procedure that does the same thing, intra-aortic counterpulsation (IACP, in which a balloon-tipped catheter is positioned in the aorta, which then inflates and deflates in time with the heartbeat), has been in widespread use in intensive care units for decades, and its effectiveness in stabilizing extremely unstable patients is well known.
While a primitive form of external counterpulsation has also been around for a long time, it has not been very effective until recently. Thanks to new computer technology that allows the perfect timing of the inflation and deflation of the cuffs, and produces the milking action, modern EECP has been greatly enhanced.
EECP is administered as a series of outpatient treatments. Patients receive 5 one-hour sessions per week, for 7 weeks (for a total of 35 sessions). The 35 one-hour sessions are aimed at provoking long lasting beneficial changes in the circulatory system.
How effective is it?
EECP now appears to be quite effective in treating chronic stable angina. A randomized trial with EECP, published in the Journal of the American College of Cardiologyin 1999, showed that EECP significantly improved both the symptoms of angina (a subjective measurement) and exercise tolerance (a more objective measurement) in patients with coronary artery disease. EECP also significantly improved “quality of life” measures, as compared to placebo therapy.
More recent data show that this improvement in symptoms following a course of EECP seems to persist for up to five years.
Furthermore, there is also preliminary data suggesting that EECP may be useful for treating unstable angina, as adjunctive therapy after revascularization (i.e., with angioplasty, stent, and/or bypass surgery), and even as first-line (instead of last resort) therapy for more routine forms of angina. (Read about EECP as early therapy for angina here.)
Finally, clinical trials have suggested that EECP may be useful in improving symptoms in patients with heart failure. Read about EECP for heart failure here.
Who is likely to benefit from EECP?
Based on what is already known, EECP should be considered in anybody who still has angina despite maximal medical therapy and prior revascularization. No cardiologist could argue logically against this. And, frankly, if a patient insisted on trying EECP prior to agreeing to purely elective revascularization for chronic stable angina, the cardiologist might not like it, but would be hard pressed to give anything beyond a purely emotional reason as to why this should not be tried.
Why does EECP work?
The mechanism for the sustained benefits seen with EECP still amount to speculation. Everyone can agree that there are good reasons for EECP (just as for IACP) to benefit the heart while the therapy is actually taking place. But as to why the benefit of EECP persists even after the therapy is finished, no one can say for sure.
There are preliminary data suggesting that EECP can help induce the formation of collateral vessels in the coronary artery tree, by stimulating the release of nitric oxide and other growth factors in within the coronary arteries. There is also evidence that EECP may act as a form of “passive” exercise, leading to the same sorts of persistent beneficial changes in the autonomic nervous system that are seen with real exercise.
Can EECP be harmful?
EECP can be somewhat uncomfortable (it is said to be more difficult to watch – what with the patient being noticeably jostled due to the milking action of the inflatable leg cuffs – than it is to actually have it done), but is not painful. In fact, it is apparently very well tolerated by the large majority of patients.
But not everyone can have it. People probably should not have EECP if they have certain types of valvular heart disease (especially aortic insufficiency), or if they have had a recent cardiac catheterization, an irregular heart rhythm, severe hypertension, significant blockages in the leg arteries, or a history of deep venous thrombosis (blood clots in the legs). For anyone else, however, the procedure appears to be quite safe.
Despite its increasingly apparent potential usefulness, EECP is hardly taking the cardiology world by storm. In fact, it seems that for most cardiologists EECP is not even on the list of potential treatments for coronary artery disease. Why is that?
There are several possible reasons. Let us dispense with the most obvious first, namely, that EECP doesn’t pay well. A series of 35 treatments costs $5000 to $6000 dollars. That’s not chicken feed, but keep in mind that we’re talking about 35 hours of therapy over 7 weeks, which involves not only the doctor’s time but also the time of office staff, nursing personnel, etc., etc. Still not a terrible return, but when you consider that a cardiologist can often bill that much by spending a morning in the cath lab, well - - -.
Then there’s the fact that EECP remains somewhat intellectually unsatisfying. To your average cardiologist, there’s no reason at all that anyone should have thought it would work in the first place – that temporarily providing counterpulsation would have lasting effects. And the fact that it apparently does work is merely blind luck, and leaves investigators scrambling ridiculously to explain why it does. This is a less than satisfying way to advance science.
In addition, to most cardiologists, EECP is logistically difficult. To accommodate patients for EECP, they would not only have to purchase expensive equipment, but also would have to radically change the organization of their offices, their office staff, and their space.
Finally, and most importantly, EECP has nothing in common with what cardiologists do. Cardiologists study and treat the heart, for goodness sake. They stress it, image it, measure it, pace it, shock it, stent it, ablate it, revascularize it, and bathe it in drugs. What they do takes years of specialized training and expertise, millions of dollars of high-tech equipment, and tremendous manual dexterity, and it brings them significant prestige, even within the medical community.
Now they’re supposed to drop all that? In order to attach fancy balloons to peoples’ legs, throw a switch, watch them bounce around for an hour, then say, “See you tomorrow?” That’s not cardiology. That’s glorified physical therapy.
This, in DrRich’s estimation, is the real reason the average cardiologist is completely ignoring EECP, as if it doesn’t even exist. They simply can’t believe anyone really expects them to do this.
In any case, you may need to raise your cardiologist’s consciousness. If you have coronary artery disease that has proved difficult to treat, then you need to bring EECP up yourself.
Once enough patients show themselves to be aware of this new therapy and to be expecting it, suddenly EECP will no longer be beneath cardiologists, and they’ll eagerly find a way to incorporate it into their practices.
How can you receive EECP?
If you are a candidate for EECP and wish to pursue it, start with your doctor. If your doctor discourages you from pursuing EECP, make sure he/she gives you a good reason for discouraging it. Good reasons would include: you don’t have the sort of coronary artery disease or angina that would benefit from EECP; your coronary artery disease is of the type that requires revascularization; or you have one of the contraindications (listed above) for having EECP. (Good reasons would not include: it’s unproven; it doesn’t work; it’s voodoo; or I’ve never heard of it.)
There are fewer than 200 places today performing EECP, though the number is growing rapidly. If your doctor can’t think of a place to refer you for EECP, go online. The best place to start online would be EECP.com. This is a website run by Vasomedical, Inc., the company that makes the equipment for EECP, so it is not unbiased. But it does offer an excellent means of finding a place where you can get EECP in your area.
Your insurance carrier should cover EECP, though these fine humanitarians might well deny coverage initially. Medicare has approved EECP for reimbursement, and once Medicare approves a new treatment, insurance companies normally fall in line quite quickly. In the case of EECP, however, many insurance companies are still balking at paying, perhaps because their cardiology consultants are telling them it’s not really a serious therapy. Don’t let this discourage you. If you are turned down for reimbursement, appeal the decision. Most insurance companies count on patients failing to appeal (which is why they so frequently deny therapy that is obviously needed), and with Medicare supporting your contention that EECP ought to be covered, odds are that if you appeal you’ll win.
More than 100 articles and studies on EECP have been published in leading cardiology journals, all supporting the treatment's safety and effectiveness. We hope you find this sampling helpful, and we will continue to update this section as often as possible.
• Predictors of benefit in angina patients one year after completing enhanced external counterpulsation: initial responders to treatment versus nonresponders.
Lawson WE, Hui JC, Kennard ED, Barsness G, Kelsey SF; IEPR investigators.
Cardiology. 2005;103(4):201-6. Epub 2005 Apr 13.
• An update on enhanced external counterpulsation.
Shea ML, Conti CR, Arora RR.
Clinical Cardiology. 2005 Mar;28(3):115-8. Review.
• Enhanced external counterpulsation: a new technique to augment renal function in liver cirrhosis.
Werner D, Tragner P, Wawer A, Porst H, Daniel WG, Gross P.
Nephrology, Dialysis, Transplantation. 2005 May;20(5):920-6. Epub 2005 Mar 23.
• Enhanced External Counterpulsation.
Brosche TA, Middleton SK, Boogaard RG.
Dimensions of Critical Care Nursing. 2005 September/October;23(5):208-214.
• Enhanced external counter pulsation (EECP) as a novel treatment for restless legs syndrome (RLS): a preliminary test of the vascular neurologic hypothesis for RLS.
Rajaram SS, Shanahan J, Ash C, Walters AS, Weisfogel G.
Sleep Medicine. 2005 Mar;6(2):101-6. Epub 2005 Jan 24.
• Angina patients with diastolic versus systolic heart failure demonstrate comparable immediate and one-year benefit from enhanced external counterpulsation.
Lawson WE, Silver MA, Hui JC, Kennard ED, Kelsey SF.
Journal of Cardiac Failure. 2005 Feb;11(1):61-6.
• Frequency and efficacy of repeat enhanced external counterpulsation for stable angina pectoris (from the International EECP Patient Registry).
Michaels AD, Barsness GW, Soran O, Kelsey SF, Kennard ED, Hui JC, Lawson WE; International EECP Patient Registry Investigators.
American Journal of Cardiology. 2005 Feb 1;95(3):394-7.
• Effects of enhanced external counterpulsation on hemodynamics and its mechanism.
Taguchi I, Ogawa K, Kanaya T, Matsuda R, Kuga H, Nakatsugawa M.
Circulation Journal. 2004 Nov;68(11):1030-4.
• Effectiveness of enhanced external counterpulsation in patients with left main disease and angina.
Lawson WE, Hui JC, Barsness GW, Kennard ED, Kelsey SF; IEPR Investigators.
Clinical Cardiology. 2004 Aug;27(8):459-63.
• Accelerated reperfusion of poorly perfused retinal areas in central retinal artery occlusion and branch retinal artery occlusion after a short treatment with enhanced external counterpulsation.
Werner D, Michalk F, Harazny J, Hugo C, Daniel WG, Michelson G.
Retina. 2004 Aug;24(4):541-7.
• Enhanced external counterpulsation improves skin oxygenation and perfusion.
Hilz MJ, Werner D, Marthol H, Flachskampf FA, Daniel WG.
European Journal of Clinical Investigations. 2004 Jun;34(6):385-91.
• Successful treatment of symptomatic coronary endothelial dysfunction with enhanced external counterpulsation.
Bonetti PO, Gadasalli SN, Lerman A, Barsness GW.
Mayo Clinic Proceedings. 2004 May;79(5):690-2.
• Two-year outcomes after enhanced external counterpulsation for stable angina pectoris (from the International EECP Patient Registry [IEPR]).
Michaels AD, Linnemeier G, Soran O, Kelsey SF, Kennard ED.
American Journal of Cardiology. 2004 Feb 15;93(4):461-4.
• A New Treatment Modality in Heart Failure Enhanced External Counterpulsation (EECP)
Cardiology in Review. 2004 Jan-Feb;12(1):15-20.
• Enhanced External Counterpulsation as Initial Revascularization Treatment for Angina Refractory to Medical Therapy
Fitzgerald CP, Lawson WE, Hui JC, Kennard ED; IEPR Investigators.
• Enhanced External Counterpulsation and Functional Improvement in Octogenarians with Symptomatic Ischemic Heart Disease
Braverman D, Wechsler B.
Archives of Physical Medicine and Rehabilitation. 2003 Sept;84(9):A10.
• Enhanced External Counterpulsation in the Management of Angina in the Elderly
Linnemeier G, Michaels AD, Soran O, Kennard ED; International EECP Registry (IEPR) Investigators.
American Journal of Geriatric Cardiology. 2003 Mar-Apr;12(2):90-6.
• Ongoing and Planned Studies of Enhanced External Counterpulsation
Clinical Cardiology. 2002 Dec;25(12 Suppl 2):II26-28.
• Treatment Options for Angina Pectoris and the Future Role of Enhanced External Counterpulsation
Holmes DR Jr.
Clinical Cardiology. 2002 Dec;25(12 Suppl 2):II22-25.
• Current Use of Enhanced External Counterpulsation and Patient Selection
Clinical Cardiology. 2002 Dec;25(12 Suppl 2):II16-21.
• Enhanced External Counterpulsation: Mechanism of Action
Clinical Cardiology. 2002 Dec;25(12 Suppl 2):II11-15.
• A Review of Enhanced External Counterpulsation Clinical Trials
Clinical Cardiology. 2002 Dec;25(12 Suppl 2):II6-10.
• A Historical Overview of Enhanced External Counterpulsation
Clinical Cardiology. 2002 Dec;25(12 Suppl 2):II3-5.
• Enhanced External Counterpulsation as Treatment for Chronic Angina in Patients with Left Ventricular Dysfunction: A Report from the International EECP Patient Registry (IEPR)
Soran O, Kennard ED, Kelsey SF, Holubkov R, Strobeck J, Feldman AM.
Congestive Heart Failure. 2002 Nov-Dec;8(6):297-302.
• Left Ventricular Systolic Unloading and Augmentation of Intracoronary Pressure and Doppler Flow During Enhanced External Counterpulsation
Michaels AD, Accad M, Ports TA, Grossman W.
Circulation. 2002 Sep 3;106(10):1237-1242.
• Enhanced External Counterpulsation in Patients with Heart Failure: A Multicenter Feasibility Study
Soran O, Fleishman B, Demarco T, Grossman W, Schneider VM, Manzo K, de Lame PA, Feldman AM.
Congestive Heart Failure. 2002 Jul-Aug;8(4)204-8, 227.
• Relation of the Pattern of Diastolic Augmentation During a Course of Enhanced External Counterpulsation (EECP) to Clinical Benefit [from the International EECP Patient Registry (IEPR)]
Lakshmi MV, Kennard ED, Kelsey SF, Holubkov R, Michaels AD.
American Journal of Cardiology. 2002 Jun 1;89(11):1303-1305.
• Comparison of Patients Undergoing Enhanced External Counterpulsation and Percutaneous Coronary Intervention for Stable Angina Pectoris
Holubkov R, Kennard ED, Foris JM, Kelsey SF, Soran O, Williams DO, Holmes Jr. DR.
The American Journal of Cardiology. 2002 May 15;89:1182-1186.
• Effects of Enhanced External Counterpulsation on Stress Radionuclide Coronary Perfusion and Exercise Capacity in Chronic Stable Angina Pectoris
Stys TP, Lawson WE, Hui JCK, Fleishman B, Manzo K, Strobeck JE, Tartaglia J, Ramasamy S, Suwita R, Zheng ZS, Liang H, Werner D.
The American Journal of Cardiology. 2002 Apr 1;89(7):822-824.
• 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
Arora RR, Chou TM, Jain D, Fleishman B, Crawford L, McKiernan T, Nesto R, Ferrans CE, Keller S.
Journal of Investigative Medicine. 2002 Jan;50(1):25-32.
• Acute and Chronic Hemodynamic Effects of Enhanced External Counterpulsation in Patients with Angina Pectoris
Arora RR, Carlucci ML, Malone AM, Baron NV.
Journal of Investigative Medicine. 2001 Nov;49(6):500-504.
• Acute Hemodynamic Effects and Angina Improvement with Enhanced External Counterpulsation
Stys T, Lawson WE, Hui JCK, Lang G, Liuzzo J, Cohn PF.
Angiology. 2001 Oct;52(10):653-658.
• A Report from the International Enhanced External Counterpulsation Registry (IEPR)
Holubkov R, Kennard E, Kelsey S, Soran O.
Advances in Coronary Artery Diseases-4th International Congress on Coronary Artery Disease. 2001 Oct 21-24;(Prague, Czech Republic):387-391.
• Benefit and Safety of Enhanced External Counterpulsation in Treating Coronary Artery Disease Patients with a History of Congestive Heart Failure
Lawson WE, Kennard ED, Holubkov R, Kelsey SF, Strobeck JE, Soran O, Feldman AM.
• Enhanced External Counterpulsation Improved Myocardial Perfusion and Coronary Flow Reserve in Patients with Chronic Stable Angina; Evaluation by 13N-Ammonia Positron Emission Tomography
Masuda D, Nohara R, Hirai T, Kataoka K, Chen LG, Hosokawa R, Inubushi M, Tadamura E, Fujita M, Sasayama S.
European Heart Journal. 2001 Aug;22(16):1451-1458.
• Safety and Effectiveness of Enhanced External Counterpulsation in Improving Angioplasty Restenosis
Stys TP, Lawson WE, Hui JCK, Tartaglia JJ, Subramanian R, Du ZM, Zhang MQ.
Proceedings of the 2nd International Congress on Heart Disease – New Trends in Research, Diagnosis and Treatment (International Academy of Cardiology).. 2001 Jul 21-24;(Washington DC, USA):369-372.
• Psychosocial Effects of Enhanced External Counterpulsation in the Angina Patient: A Second Study
Springer S, Fife A, Lawson W, Hui JCK, Jandorf L, Cohn PF, Fricchione G.
Psychosomatics. 2001 Mar-Apr;42(2):124-132.
• Enhanced External Counterpulsation Improves Exercise Tolerance, Reduces Exercise-Induced Myocardial Ischemia and Improves Left Ventricular Diastolic Filling in Patients with Coronary Artery Disease
Urano H, Ikeda H, Ueno T, Matsumoto T, Murohara T, Imaizumi T.
Journal of the American College of Cardiology. 2001 Jan;37(1):93-99.
• Comparison of Hemodynamic Effects of Enhanced External Counterpulsation and Intra-Aortic Balloon Pumping in Patients with Acute Myocardial Infarction
Taguchi I, Ogawa K, Oida A, Abe S, Kaneko N, Sakio H.
The American Journal of Cardiology. 2000 Nov 15;86(10):1139-1141.
• Treatment Benefit in the Enhanced External Counterpulsation Consortium
Lawson WE, Hui JCK, Lang G.
• Noninvasive Revascularization by Enhanced External Counterpulsation: A Case Study and Literature Review
Singh M, Holmes Jr. DR, Tajik AJ, Barsness GW.
Mayo Clinic Proceedings. 2000 Sep;75(9):961-965.
• Long-Term Prognosis of Patients with Angina Treated with Enhanced External Counterpulsation: Five-Year Follow-Up Study
Lawson WE, Hui JCK, Cohn PF.
Clinical Cardiology. 2000 Apr;23(4):254-258.
• Pneumatic External Counterpulsation: A New Noninvasive Method to Improve Organ Perfusion
Werner D, Schneider M, Weise M, Nonnast-Daniel B, Daniel WG.
The American Journal of Cardiology. 1999 Oct 15;84(8):950-952.
• The Multicenter Study of Enhanced External Counterpulsation (MUST-EECP): Effect of EECP on Exercise-Induced Myocardial Ischemia and Anginal Episodes
Arora RR, Chou TM, Jain D, Fleishman B, Crawford L, McKiernan T, Nesto R.
The Journal of the American College of Cardiology. 1999 Jun;33(7):1833-1840.
• Improvement of Regional Myocardial and Coronary Blood Flow Reserve in a Patient Treated with Enhanced External Counterpulsation: Evaluation by Nitrogen-13 Ammonia PET
Masuda D, Nohara R, Inada H, Hirai T, Li-Guang C, Kanda H, Inubushi M, Tadamura E, Fujita M, Sasayama S.
Japanese Circulation Journal. 1999 May;63(5):407-411.
• Enhanced External Counterpulsation as a New Treatment Modality for Patients with Erectile Dysfunction
Froschermaier SE, Werner D, Leike S, Schneider M, Waltenberger J, Daniel WG, Wirth MP.
Urologia Internationalis. 1998;61(3):168-171.
• Prior Revascularization Increases the Effectiveness of Enhanced External Counterpulsation
Lawson WE, Hui JCK, Guo T, Burger L, Cohn PF.
Clinical Cardiology. 1998 Nov;21(11):841-844.
• Three-Year Sustained Benefit from Enhanced External Counterpulsation in Chronic Angina Pectoris
Lawson WE, Hui JCK, Zheng ZS, Oster Z, Katz JP, Diggs P, Burger L, Cohn CD, Soroff HS, Cohn PF.
The American Journal of Cardiology. 1995 Apr 15;75:840-841.