The past，Present and Future of Enhanced External Counterpulsation

John CK Hui, PhD

Cardiology,

State University of New York at Stony Brook, NY, USA

 External counterpulsation (ECP) was developed in the early 1960s as a circulatory assist device to support patients in acute myocardial infarction and cardiogenic shock. In the mid 1970s, Dr. ZS Zheng in China developed a pneumatic sequential counterpulsation system ushering the modern era of Enhanced

ECP (EECP). During the past ten years, most of the research has been concentrated on EECP mechanisms of action including increases in shear stress that improves endothelial function,releases vasoactive factors controlling vascular dilation, promotes angiogenesis enhancing vascular growth and capillary development,activates anti-oxidative, anti-inflammatory cytokines protecting the vasculature, relaxes the vascular wall leading to a decrease

in arterial stiffness, and stimulates the release of progenitor cells potentiating regeneration of impaired vasculature.

Currently in the United States, the Food and Drug Administration (FDA) has cleared EECP for the treatment of refractory angina pectoris as a Class II device, and all other applications including congestive heart failure as class III. The Centers of Medicare and Medicaid Services (CMS)

in the US has approved EECP for national reimbursement coverage for the treatment of refractory angina patients. Consequently, EECP therapy is used mostly in the treatment of refractory angina because of these regulatory limitations. However, EECP therapy has been shown by numerous studies to be effective in the treatment of various ailments.

Since EECP is noninvasive and is effective in generating collateral vessels, improving endothelial function, and arterial stiffness, reducing inflammatory and oxidative stress, the underlying pathophysiology indicates that EECP therapy should be a first line preventive treatment of systemic vascular systems, particularly useful in microvascular impairment and in the control of cardiac risk factors including hypertension, hyperlipidemia, smoking, obesity, diabetes, and physical inactivity to produce a cumulative effect over time to inhibits the atherosclerotic process and prevent progression of vascular disease.

In addition, EECP should be a therapy that provides a chance to integrate the cooperative efforts of the four disciplines of vascular diseases.

·Cardiovascular Disease including ischemic heart disease, heart failure, metabolic syndromes with endothelial dysfunction, cardiac syndrome X and patients suffering from Septic shock

·Cerebrovascular Disease including patients recovering from stroke, patients with vascular dementia or mild cognitive Impairment

·Endovascular Disease including patients with chronic kidney disease, management of control of glucose in diabetes and improve effectiveness of dialysis therapy

· Peripheral Vascular including claudication
EECP will serve as an integrator to bring researchers and clinicians from multiple disciplines together to share their experience, knowledge and treatment approach.
Finally, there is already evidence demonstrating that EECP is a therapy for regeneration medicine. The transition of EECP from an acute circulatory assist device to a therapeutic device relied on the evidence that EECP promotes the release of vascular growth factors, stimulates collateral circulation recruitment and development. All these findings support EECP to be considered a regeneration of blood vessels to delivery much needed oxygenate blood to ischemic regions of organs. EECP also promotes the

regeneration of nerve. It has often been reported from diabetic neuropathy patients that they have regained their feeling of the texture of the ground on which they stood and walked after EECP therapy. This may be an indication of the regeneration of nerve cells in the peripheral. EECP has been shown to generate a significant increase in blood flow through the bone marrow, flushing out progenitor cells and serves as a new supply to replacing damage endothelium and improves endothelial function.

EECP therapy has the potential in regeneration medicine to serve as a therapy for blood vessel and neurological growth.

A good therapy should be based on sound pathophysiological principles, with proven mechanisms of action, easy to use, safe, and reproducible, with effective clinical outcomes and cost effectiveness. EECP has all these favorable features. It will be exciting if we can provide better education, training and understanding to all so that

we can work together to gather more data in the many aspects of EECP therapy and continue to promote this noninvasive effective therapy.