ABCs of Modern Management of

Chronic Stable Angina

• A Aspirin(anti platelet), Anti-Angina,ACEI,ARBS
Angioplasty/stent
• B Beta Blockers, Blood Pressure control
• C Cholesterol,Calcium antagonists,Cigarette smoking
cessation,Clopidogrel(PCI),Cord(spinal)
stimulation CABG
• D Diet for weight control,Diabetes control, Depression
• E Education, Exercise, EECP
• F Fattly acid oxidation inhibition(pFox I), Family
• G Glycerol Trinitrate
• H Happiness(antidepressant)
• I Isosorbide Dinitrate
 Enhanced External Counterpulsation (EECP)

EECP is a noninvasive
therapy for patients
with Ischemic heart
disease.

A full course of EECP

is 30-35 hours, 1-2
hour(s) daily for 3-7
weeks.
• During Diastole
– Diastolic Pressure is raised
• Increases Aorto-Coronary
Perfusion Pressure
– Venous Return is Increased
• Increases Cardiac Output by the
Starling Mechanism
• During Systole
– Rapid drop in Diastolic
Pressure
• Unloads the Left Ventricle
• Decreases the work of the
ventricle thus decreasing
Myocardial Oxygen Consumption
Baseline 100mmHg 150mmHg 200mmHg 250mmHg 300mmHg
 Hemodynamic Effects of EECP
Improve Reduce Increase
Diastolic systolic
Systolic Unloading
Filling
Coronary
workload blood flow
Diastolic Augmentation

Increase Diastolic
Cardiac Retrograde
Output Flow
Control EECP
Systole

Intracoronary Ultrasound Coronary Blood

Flow

Control EECP
Andrew Michaels, Circulation 2002;106:1237-1242
 Increase Coronary Artery Blood Flow
Intracoronary Peak Diastolic Intracoronary Diastolic
Doppler Flow Velocity Pressure
Increase 150% Increase 92%

(N=8) (N=9)

Doppler Flow
Velocities obtained
with FloWire in the LAD

Michaels AD, et al. Circulation

2002; 106: 1237-42.
 Summary of basic and clinical effectiveness
 Mechanisms of action demonstrated
 Increase blood flow to all organs during EECP treatment
 Improve endothelial functions

 Clinical evidence on the safety and effectiveness in

treating patients with angina pectoris and heart failure
 Improve exercise capacity
 70%-80% of patients improved their cardiovascular functional
class
 Improve perfusion to ischemic regions of the myocardium
 Improve quality of life by at least 60-70%
 Reduction in nitroglycerin usage
 ANALYSIS OF THE AORTIC PRESSURE WAVE
Measured Wave = Incident Wave + Reflected Wave

Incident
wave
Measured Pressure Wave
Incident wave related
to aortic stiffness

Measured Flow Wave

Reflected Pressure Wave
Reflected wave related
to stiffness of entire arterial
tree

Reflected Flow Wave

 Pulse Wave Velocity and Arterial Stiffness
Travel Time of Reflected Wave Arterial Stiffness
Decreased PWV  Increased  tp/ 2 Arterial Stiffness  Augmentation Index
74 p=0.001 30 p=0.001

Augmentation Index (%)

Travel Time (msec )

72 25

20
70
15 27  10%
68
74  6.6 10 19  10%
66 68  8.0
5
64 0
Pre-EECP Post-EECP Pre-EECP Post-EECP

Ps
Pulse Pressure = ( Pi – Pd )
Pressure Wave

Pi Augmentation Index = (Ps – Pi) / (Ps – Pd)

Aortic pressure
Aortic Pressure
Aortic Pressure Time for pressure wave to travel from aortic root and back = tp
Without
Pressure reflection
without
reflection Wasted LV pressure energy = 2.09 X tp * (Ps – Pi)
LV Workload = Tension Time Index = area under systolic wave

Pd
J Am Coll Cardiol 2006;48:1208-1214
 Effects of EECP
on Arterial Function
• Randomized, sham-controlled study
• 35 hours/sessions of therapy (EECP vs.
SHAM)
• CAD pts. with refractory angina
• Optimal Anti-Hypertensive Medication
• Preliminary Data
30 Subjects
• 20 EECP
• 10 SHAM
Braith et al. NIH HLBI R01-HL077571-01
 Patient Demographics
EECP SHAM
(n=20) (n=10)
Age 63.6  11.1 62.3  9.8
Gender (male/female) 12/8 7/3
BMI 28.8  4.0 33.3  4.8 *
Diabetes 7 (33%) 5 (50%)
Prior MI 8 (40%) 3 (30%)
Multivessel disease
2 - Vessel 10 (50%) 4 (40%)
3 - Vessel 10 (50%) 6 (60%)
Prior PCI 13 (65%) 7 (70%)
Prior CABG 11 (55%) 6 (60%)
Applanation Tonometry

● Central Hemodynamics
 Wave Reflection
Augmentation Index (AIa) Round Trip Travel Time

25 150 *
*
AIa @ 75 bpm (%)

20 140

tp (msec)
15 130
10 120
5 110
0 100
EECP SHAM EECP SHAM

* p ≤ 0.05 vs Baseline
Baseline Midway 35 Sessions
 Wave Reflection
Reflected Aortic Pressure
20
Wasted LV Energy
15

Ag (mmHg)
75 10
EECP
SHAM
60
* 5
msec-mmHg

45 0
30 Baseline Midway 35
Sessions
15 Duration of Reflected Wave
220
0
EECP SHAM 200

Tr (msec)
EECP
Ew = /4(Ag)/(ED-Tr)*1.33322 180
SHAM

160

* p ≤ 0.05 vs Baseline 140

Baseline Midway 35
Sessions
Baseline Midway 35 Sessions
Central Pulse Wave Velocity
Carotid-to-Femoral PWV
15
p  0.05
13
11
*
m/sec

9
7
5
EECP SHAM

Baseline 35 Sessions
Peripheral Pulse Wave Velocity
Carotid-to-Radial Femoral-to-Foot
10
* p  0.07 15
* p  0.06
8 * 13
6 11
*

m/sec
m/sec

4 9
2 7
0 5
EECP SHAM EECP SHAM

Baseline 35 Sessions
 Flow-Mediated Dilation (FMD)
of Brachial and Femoral Arteries

Brachial or ∆ Diameter
Femoral Artery

Tourniquet

Ultrasound Probe
 Brachial FMD

% Change Absolute Dilation (mm)

8
*
0.4
*

change (mm)
6 0.3
% dilation

4 0.2

2 0.1

0 0
EECP SHAM EECP SHAM

Baseline 35 Sessions
Normalized for Shear Rate * p < 0.05
 Femoral FMD
% Change Absolute Dilation (mm)

5 * 0.4
*

change (mm)
4 0.3
% dilation

3
0.2
2
0.1
1
0 0
EECP SHAM EECP SHAM

Baseline 35 Sessions
Normalized for Shear Rate * p < 0.05
Venous Occlusion Plethysmograph

220 mmHg
∆ Circumference 50 mmHg
for 5 seconds

Peak Calf and Forearm Blood Flow

 Limb Blood Flow
Peak Forearm BF Peak Calf BF
25 * 20 *
20

ml/min/100ml
15
ml/min/100ml

15
10
10
5
5
0 0
EECP SHAM EECP SHAM

* p  0.01 vs. baseline

Baseline Midway 35 Sessions
 Anginal Class
C C S C A n g in a l C la s s P<0.001
Improvement
Following EECP
4

0
Baseline 35 Sessions
Canadian Cardiovascular Society Angina Classification
 Conclusions
• EECP improves wave reflection
characteristics, decreases LV afterload
and MVO2.

• EECP reduces central and peripheral

arterial stiffness.

• EECP improves endothelial function in

peripheral conduit and resistance vessels.
 Conclusions
• EECP reduces anginal episodes in
CAD patients.

• EECP improves exercise tolerance,

time to angina, and VO2 peak.

• EECP improves peripheral and

central blood pressures.
• EECP May be Considered Adjunctive
to Conventional Revascularization,
Instead of Being Used After These
Procedures are Performed or Have
Failed
Where are we going?
Enhanced External
Risk Factors Counterpulsation (EECP)

Endothelial dysfunction Increases blood flow / shear stress

Improves Endothelial function

Initiation of
atherosclerotic Prevent Progression of
process Cardiovascular Disease

Progression of
Cardiovascular
Disease
 Symptomatic Coronary Artery
Disease:Treatment Evolution
Current Next step? Eventual?

Aggressive Medical Aggressive Medical Aggressive Medical

Therapy Therapy Therapy

CABG, PCI EECP

EECP CABG,
PCI
EECP/Other CABG, PCI