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{{Chronic stable angina}} | {{Chronic stable angina}} | ||
'''Editor-In-Chief:''' [[C. Michael Gibson, M.S., M.D.]] [mailto:mgibson@perfuse.org] Phone:617-632-7753; '''Associate Editor(s)-In-Chief:''' [[John Fani Srour, M.D.]]; [[WikiDoc Scholars#WikiDoc Scholars with Distinction|Jinhui Wu, M.D.]]; [[Lakshmi Gopalakrishnan, M.B.B.S.]] | |||
Enhanced external counter pulsation (EECP) is another alternative therapy | ==Overview== | ||
Enhanced external counter pulsation ''(EECP)'' is another alternative therapy in the management of refractory angina. Most data are from observational studies, have demonstrated significant improvement in the exercise tolerance and reduction in the frequency of [[Chronic stable angina symptoms|anginal symptoms]] as well as the use of [[Chronic stable angina treatment nitrates|nitroglycerin]] among patients treated with EECP. | |||
EECP has been postulated to decrease myocardial oxygen demand, enhance myocardial collateral flow via increased transmyocardial pressure, and improve endothelial function | ==Mechanisms of Benefit== | ||
*EECP has been postulated to decrease myocardial oxygen demand, enhance myocardial collateral flow via increased transmyocardial pressure, and improve endothelial function. | |||
EECP | *EECP has also shown to decrease peripheral vascular resistance, increases ventricular function, and/or provides placebo effect. Possible placebo effect associated with EECP has not been addressed in many studies, which have not included sham controls. | ||
==Approach== | |||
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 [[chronic stable angina definition|angina]], [[Chronic stable angina assessing the pretest probability of coronary artery disease|documented coronary artery disease]] and [[Chronic stable angina risk assessment in patients with an intermediate or high probability of coronary artery disease|positive exercise treadmill test]] were 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 [[Chronic stable angina treatment nitrates|nitroglycerin]] did not significantly change in both the groups. Thus, the study concluded that enhanced external counterpulsation significantly reduced [[chronic stable angina definition|angina]] and extended the time to exercise-induced ischemia in patients with [[Chronic stable angina symptoms|symptomatic CAD]].<ref name="pmid10362181">Arora RR, Chou TM, Jain D, Fleishman B, Crawford L, McKiernan T et al. (1999) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10362181 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: [http://pubmed.gov/10362181 10362181]</ref> | |||
====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 [[Canadian cardiovascular society classification of angina pectoris|CCS class III or IV angina]] before the start of therapy, 62% used [[Chronic stable angina treatment nitrates|nitroglycerin]], 81% had been previously [[Chronic stable angina revascularization|revascularized]], and 69% were considered unsuited for either [[Chronic stable angina revascularization percutaneous coronary intervention(PCI)|PCI]] or [[Chronic stable angina revascularization coronary artery bypass grafting(CABG)|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.<ref name="pmid11403504">Barsness G, Feldman AM, Holmes DR, Holubkov R, Kelsey SF, Kennard ED et al. (2001) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11403504 The International EECP Patient Registry (IEPR): design, methods, baseline characteristics, and acute results.] ''Clin Cardiol'' 24 (6):435-42. PMID: [http://pubmed.gov/11403504 11403504]</ref> | |||
*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 ([[Canadian cardiovascular society classification of angina pectoris|CCS class II-IV]]), with patients most impaired at baseline demonstrating the greatest improvement ('''39.5%''' of patients in [[Canadian cardiovascular society classification of angina pectoris|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.<ref name="pmid11111142">Lawson WE, Hui JC, Lang G (2000) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11111142 Treatment benefit in the enhanced external counterpulsation consortium.] ''Cardiology'' 94 (1):31-5. PMID: [http://pubmed.gov/11111142 11111142]</ref> | |||
==ACC/AHA Guidelines- Enhanced external counterpulsation (DO NOT EDIT)<ref name="pmid10351980">Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM et al. (1999)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10351980ACC/AHA/ACP-ASIM 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: [http://pubmed.gov/10351980 10351980]</ref><ref name="pmid12515758">Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS et al. (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12515758 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: [http://pubmed.gov/12515758 12515758]</ref>== | |||
{{cquote| | {{cquote| | ||
===Class IIb=== | ===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]=== | ||
'''1.''' [[Enhanced external counterpulsation]] ([[EECP]]). ''(Level of Evidence: B)''}} | '''1.''' [[Enhanced external counterpulsation]] ([[EECP]]). ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''}} | ||
== | ==Vote on and Suggest Revisions to the Current Guidelines== | ||
*[[The Living Guidelines: Chronic Stable Angina Pectoris | The Chronic Stable Angina Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines]] | *[[The Living Guidelines: Chronic Stable Angina Pectoris | The Chronic Stable Angina Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines]] | ||
==Sources== | ==Sources== | ||
*The ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina <ref name="pmid10351980">Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM et al. (1999) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10351980 ACC/AHA/ACP-ASIM 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: [http://pubmed.gov/10351980 10351980]</ref> | *The ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina <ref name="pmid10351980">Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM et al. (1999) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10351980 ACC/AHA/ACP-ASIM 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. [http://circ.ahajournals.org/content/99/21/2829.full.pdf] PMID: [http://pubmed.gov/10351980 10351980]</ref> | ||
*TheACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina <ref name="pmid12515758">Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS et al. (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12515758 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: [http://pubmed.gov/12515758 12515758]</ref> | *TheACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina <ref name="pmid12515758">Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS et al. (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12515758 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.[http://content.onlinejacc.org/cgi/reprint/41/1/159.pdf] PMID: [http://pubmed.gov/12515758 12515758]</ref> | ||
*The 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina <ref name="pmid17998462">Fraker TD, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J et al. (2007) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=17998462 2007 chronic angina focused update of the ACC/AHA 2002 Guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 Guidelines for the management of patients with chronic stable angina.] ''Circulation'' 116 (23):2762-72. [http:// | *Guidelines on the management of stable angina pectoris: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology <ref name="pmid16735367">{{cite journal| author=Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F et al.| title=Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology. | journal=Eur Heart J | year= 2006 | volume= 27 | issue= 11 | pages= 1341-81 | pmid=16735367 | doi=10.1093/eurheartj/ehl001 | pmc= |url=url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16735367 [http://www.escardio.org/guidelines-surveys/esc-guidelines/GuidelinesDocuments/guidelines-angina-FT.pdf]}} </ref> | ||
*The 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina <ref name="pmid17998462">Fraker TD, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J et al. (2007)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=17998462 2007 chronic angina focused update of the ACC/AHA 2002 Guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 Guidelines for the management of patients with chronic stable angina.] ''Circulation'' 116 (23):2762-72.[http://content.onlinejacc.org/cgi/reprint/50/23/2264.pdf] PMID: [http://pubmed.gov/17998462 17998462]</ref> | |||
==References== | ==References== | ||
{{Reflist|2}} | {{Reflist|2}} | ||
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Revision as of 06:46, 4 October 2011
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Chronic stable angina Microchapters | ||
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Classification | ||
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Differentiating Chronic Stable Angina from Acute Coronary Syndromes | ||
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Diagnosis | ||
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Alternative Therapies for Refractory Angina | ||
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Discharge Care | ||
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Guidelines for Asymptomatic Patients | ||
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Case Studies | ||
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [3] Phone:617-632-7753; Associate Editor(s)-In-Chief: John Fani Srour, M.D.; Jinhui Wu, M.D.; Lakshmi Gopalakrishnan, M.B.B.S.
Overview
Enhanced external counter pulsation (EECP) is another alternative therapy in the management of refractory angina. Most data are 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.
Mechanisms of Benefit
- EECP has been postulated to decrease myocardial oxygen demand, enhance myocardial collateral flow via increased transmyocardial pressure, and improve endothelial function.
- EECP has also shown to decrease peripheral vascular resistance, increases ventricular function, and/or provides placebo effect. Possible placebo effect associated with EECP has not been addressed in many studies, which have not included sham controls.
Approach
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 were 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.[1]
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.[2]
- 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.[3]
ACC/AHA Guidelines- Enhanced external counterpulsation (DO NOT EDIT)[4][5]
| “ |
Class IIb1. Enhanced external counterpulsation (EECP). (Level of Evidence: B) |
” |
Vote on and Suggest Revisions to the Current Guidelines
Sources
- The ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina [4]
- TheACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina [5]
- Guidelines on the management of stable angina pectoris: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology [6]
- The 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina [7]
References
- ↑ 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
- ↑ 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
- ↑ Lawson WE, Hui JC, Lang G (2000) Treatment benefit in the enhanced external counterpulsation consortium. Cardiology 94 (1):31-5. PMID: 11111142
- ↑ 4.0 4.1 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
- ↑ 5.0 5.1 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
- ↑ Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F; et al. (2006). [url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16735367 [1] "Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology"] Check
|url=value (help). Eur Heart J. 27 (11): 1341–81. doi:10.1093/eurheartj/ehl001. PMID 16735367. - ↑ Fraker TD, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J et al. (2007)2007 chronic angina focused update of the ACC/AHA 2002 Guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 Guidelines for the management of patients with chronic stable angina. Circulation 116 (23):2762-72.[2] PMID: 17998462