Secret Cardiology (Enhanced External Counter Pulsation)

Dr.S.Ramasamy - International medical Director EECP Therapist Association (IETA) USA

Introduction

It’s common knowledge to most of us that heart disease is the leading killer disease worldwide. World Health organization has projected that India will have 69 million diabetics and 214 million people with hypertension by the year 2025. These are the two main risk factors contributing to the development of future cardio vascular diseases. Their impact will cost the national 237 billion US dollars (as estimated by World Health organization). The key to tackle this problem is to educate the patient about the risk factors of cardio vascular disease and effective preventive program to detect and treat the disease at an early stage.

The key to tackle this problem is to educate the patient about the risk factors of cardio vascular disease and effective preventive program to detect and treat the disease at an early stage.


What is a Cardio Vascular Disease?

The cardio vascular disease is wrongly understood by many patients as a blockage in coronary artery only. In fact, your entire vascular system, such as the blood vessels travelling to all part of the body is susceptible and affected by this disease. The endothelium (cells lining in the inner layer of the blood vessel wall) plays an important role in blockage of the blood vessels. Once dysfunctional it slowly allows the blockage of the vessels. Unless this dysfunction is reversed by diet, controlling the cardiac risk factors, exercise and medication this dysfunction will advance to blockage of vessels.

Expert Opinions

The long-term care of patients with chronic coronary artery disease requires the cardiologist to use aggressive preventive methods and more cost-effective treatments to improve clinical and financial outcomes. EECP treatment is a safe, cost-effective, non-invasive method of restoring myocardial perfusion and reducing symptoms of angina. EECP treatment is the perfect disease management tool for chronic coronary artery disease.

Dr.John E. Strobeck, Interventional Cardiologist, Co-founder of the Heart Failure Society of America Medical Director The Heart & Lung Center Hawthorne, NJ


Cardio Vascular Diseases: Treatment Options

Treatment of cardio vascular disease gradually moves from simple single drug medical management to complex multiple medications.

The treatment for cardio vascular disease mainly follows two basics principles. One is to increase the blood supply to the area of the heart muscle which fails to get enough blood supply due to obstruction in one or more coronary arteries. The second one is to decrease the heart muscle effort to pump the blood in to the circulation.
Cardiac drugs mainly work by decreasing the heart muscle effort to pump the blood in to circulation by making the circulatory system dilate so that it offers less resistance for the heart to pump the blood.

When medical management alone is not able to control the symptoms, Interventional procedures like PTCA (commonly known as Angioplasty) with stent or CABG (commonly known as Bypass Surgery) are suggested.  
Still there are limitations for these treatments; drugs do not always provide adequate relief. These invasive procedures have their own associated risks, such as serious hospital-induced infection, changes in mental status or memory and blood clots in the legs or lungs and in some cases may also lead to stroke or even death.

Moreover, 6-10% of bypass surgeries fail necessitating re-operation, which carries mortality rate of two to three times those of the initial procedure. In angioplasty 20-30% of the patient’s restenosis occurs in the first 6 months following the procedure. Repeat re-operation increases the risk of restenosis as high as 50% has been reported.
 
Bypass Surgery and Angioplasty work by improving the blood flow to the heart muscle by doing mechanical manipulation in the obstructed blood vessels. 

In the seventies, Bypass Surgery was the main line of revascularization procedure in the treatment of cardiovascular disease. In the eighties it was less invasive balloon angioplasty.

As the trend towards less invasive method continues for various diseases, clinicians continuously looked for a better and safer way to treat CVD, this search leads towards a treatment modality which was safe, non-invasive and best of all, did not require any hospitalisation. The treatment is known as Enhanced External Counter Pulsation, or more commonly known as EECP.

Expert Opinions

EECP is very unique because its mode of action is on the smaller vessels in the heart, which are too small for bypass surgery or angioplasty. The treatment works in different area of the blood circulation where Bypass surgery and Angioplasty cannot access. This suits well for Indian patients who are diabetics with smaller vessel diameter diffusely diseased involving multiple vessels which are difficult to bypass or angioplasty.

Dr.S.Ramasamy.( EECP Expert & Consultant)
Frontier Lifeline Hospital (Chennai) International Medical Director (International EECP Therapist Association) USA



EECP: The best kept secret of modern cardiology?

EECP is a USA FDA cleared non-invasive treatment therapy which has evolved as a revolution in the treatment of cardiovascular disease.  

It is a new emerging treatment for patients with chest pain and poor heart pumping function. The treatment needs no hospitalization, is completely Non-Invasive and absolutely painless.

In USA alone, there are more than 1000 EECP treatment centres where the treatment is reimbursed by medical insurance company. The treatment is viewed as effective, safe and cost effective alternative for invasive procedures like bypass surgery and angioplasty in many patients.

In India, the increase in cardio vascular incidence is primarily due to high prevalence of Diabetes and hypertension. Angioplasty and bypass surgery is not available in most parts of Rural India. Still, the new treatment called Enhanced External Counter Pulsation, which is considered as a reasonably alternative procedure for bypass surgery and angioplasty, is largely ignored by many cardiologists. Even in USA where CABG and PTCA are available to every patient only 10% of them undergo these expensive procedure and 90% of them are managed by medical management, Non-invasive therapy, Life style changes and regular exercise.

This article will evaluate whether the ignorance is due to lack of scientific evidence for the treatment or lack of awareness about the existence of the treatment.

Enhanced External Counter Pulsation

(EECP )- How does it work?
The treatment functions as a passive exercise for the heart.  During the treatment blood flow to the heart is increased due to the cuffs inflation.

When the increased blood flow is sustained one hour a day for 35 days continuously, the hearts tiny vessels which lies dormant in the heart starts opening up to accommodate the increase blood flow. There are many clinical evidences that not only dormant vessels are opened but also new vessels are formed around the blocked arteries naturally bypassing the obstructed arteries.

Over all after completion of 35 sessions the patient’s heart now started receiving more blood supply than before reducing or completely eliminating the chest pain and shortness of breath. The patients feel the new lease of life with more energy and improved quality of life. EECP treatment currently is the only treatment which can increase the blood flow to heart muscle as an effective alternative to bypass surgery or Angioplasty. The only point of debate within the clinical circle is whether the improvement is comparable to what been achieved by intervention procedures like bypass surgery and angioplasty. The treatment is not a replacement for bypass surgery or angioplasty but if used widely it can help many patients to avoid interventional procedures.

Incidentally EECP does stimulate the intensive exercise effect and restore the dysfunctional endothelium towards normal.

Effects of EECP

Overall EECP helps cardiac patients by

  • 1. Reducing the work load of heart
  • 2. Increasing blood flow to the heart
  • 3. Stimulate the effect of drugs and exercise and thereby slowing the progress of the cardiovascular disease

Traditionally, all these benefits are provided by Invasive procedure and exercise. Now EECP can achieve them without undergoing the risk of surgery and risk of exercise in patients who have poor exercise tolerance due to cardiac symptoms.

The clinical data supporting EECP therapy are gaining momentum in the past 5 years. There are more than 160 journal articles are published in International reputed journals. Physicians should discuss about EECP to their patients as an option for their disease, but still EECP is seldom mentioned as an option in India unless the patients firmly asked about it.




Expert Opinions

I have seen many of my patients getting better and started doing 30-45 minutes exercise. What’s surprising is they were not even able to walk 3 minutes due to their cardiac symptom before the treatment. I believe EECP had great potential in the management of patient with chronic stable Angina.

Prof. Dr.M.Dhanapal. Consultant cardiologist
Retired Dean Madras Medical College


Role of EECP Treatment in Cardio Vascular disease.

Cardiovascular disease is a chronic illness which cannot be cured but aggressive treatment with medication and other interventional procedures can slow the progress of the disease and provide clinical improvement. The improvement provided by any of the treatment can be sustained for longer period only if the patients pursue an active exercise and healthy life style. If the long term sustained exercise training is not provided to the heart after the treatment the disease may progress and affect the bypass graft done causing graft occlusion, closing the stent causing stent restenosis and fail the medical management causing obstruction in other part of the coronary vessels. 

Many cardiologist and physicians recommend EECP when the graft is occluded and the stent is closed. EECP is recommended during this course of the disease to stimulate the natural mechanism to promote new vessel formation around blocked arteries. So it is called “A NATURAL BYPASS”. Unfortunately by this time the disease is progressed towards the aggressive stage and the patient is termed as inoperable or no option patient with only one option left called EECP. The famous terminology adopted is “EECP IS A OPTION FOR PATIENTS WITH NO OPTION”. It’s been proved even in this stage EECP has shown to benefit the patients immensely. The irony is still doctors don’t want to provide the EECP treatment during the initial phase of the disease or mild form of the disease.  The treatment for the cardiac disease is not only to restore patient’s cardiac health but it should also restore his/her vascular health.

Every patient know blockage in the blood vessels carrying blood to the heart will lead to poor blood supply and in turn leads to heart attack and further complications. What they fail to understand is the cause for the blockage is due to dysfunction of the entire vascular system not merely the vascular supply to the heart alone. Treatment should also focus to restore the entire vascular system health. If patient have a poor vascular health the chance of getting heart attack is high irrespective of how mild or severe the blockages are. That is why interventional treatment like Bypass surgery and Angioplasty which restore cardiac health is always combined with regular exercise, risk factor modification and medication which are all shown to restore the vascular health.

Expert Opinions

Scientific data shows that EECP treatment helps patients with Ischemic Heart Disease by recruitment of collaterals and increase of blood flow to ischemic regions. It also improves endothelial functions and reduces arterial stiffness.|

All the above mechanism of action seem to benefit patients of Chronic Stable angina and heart failure

Dr Ashok H Punjabi.
Director, Krishna Cardiac Care Centre, Mumbai and honorary cardiologist at the Lilavati Hospital


Invasive and Not-Invasive cardiovascular disease Management.

Consider this scenario patients come to hospital with chronic chest pain not able to exercise. The doctor prescribes a battery of tests and finally decided to do an angiogram. If the test reveals the patient have obstruction in the coronary artery supplying blood to heart muscles. He declares patient have cardiovascular disease. The chances are the patient will be offered a Bypass surgery or Angioplasty with aggressive medical management, life style modification and regular exercise after the interventional procedure. The simple equation of the INVASIVE MANAGEMENT doctor feels appropriate for the patient is given below.



What your Physician may not discuss in detail is another option called EECP which is safe, effective, doesn’t involve hospitalization and completely non-invasive. EECP is currently only treatment which is validated by science and approved by scientific community which can restore both vascular and cardiac health. The simple logic would be if EECP works in patient with advance disease (No option patients) then it should work in patient with less advanced disease also.

The simple equation of EECP MANAGEMENT for the patient is given below.



Facts that every cardiac patients should remember about EECP

SAFE:
One of the biggest benefits of EECP is its ability to offer patients something they do not have before, an alternative to more risky and invasive procedure. 

SCIENTIFIC
:
Scientific studies have shown, EECP to be as effective as Bypass or Angioplasty procedures in selected patient group. EECP is USA FDA approved for chest pain and poor heart function and also is a first truly non-invasive outpatient treatment.

DOCUMENTED:
More than 150 research articles are published worldwide supporting EECP. These articles prove EECP relieve chest pain and shortness of breath in cardiac patients. It also decreases the dependence on medication and improves the overall quality of life. The benefit last up to five years.

PROVEN: EECP has been proven to
  • Improve blood flow to the Heart
  • Improve cardiac function
  • Improve vascular health
  • Decrease and sometimes elimination of cardiac symptoms
  • Increase blood flow to other parts of the body

AVAILABLE:
EECP is practised in major hospitals and university worldwide including India

 

The physician is bound to tell the patient all options for managing the patient’s disease, to have an unbiased dialogue with patients. Those who don’t include EECP are definitely withholding information. There is no justification for it. Currently only a fraction of patients who could immensely benefit from the treatment are referred for EECP.  When we have a treatment which has nothing to say negative about it and have shown amazing clinical benefit it’s surprising to note why it’s still sparsely used. 

 

Expert Opinions

The Robust effectiveness of EEP as a Non-Invasive device, together with its relatively low start up and recurrent cost, makes it an attractive consideration for treating patient with milder refractory angina in addition to the patient with severely disabling angina treated in current practise

Dr.William E Lawson
Professor of Medicine
Director, Preventive Cardiology
Director, Interventional Cardiology Fellowship Program
Stony Brook, State University of NY.

 

 

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Mr. Vinod Agarwal, 76 yrs old gentleman, has had anterior and inferior wall myocardial infarction at the age of 60 yrs. He underwent CABG surgery.