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      Predictors of benefit in angina patients one year after completing enhanced external counterpulsation: initial responders to treatment versus nonresponders.

      Radiology
      Adult, Aged, Aged, 80 and over, Angina Pectoris, classification, surgery, Angioplasty, Balloon, Coronary, Chronic Disease, Cohort Studies, Coronary Artery Bypass, Counterpulsation, methods, Female, Follow-Up Studies, Forecasting, Humans, Male, Middle Aged, Myocardial Infarction, etiology, Nitroglycerin, therapeutic use, Prospective Studies, Quality of Life, Survival Rate, Treatment Outcome, Vasodilator Agents

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          Abstract

          Enhanced external counterpulsation (EECP) has been shown to reduce Canadian Cardiovascular Society angina class. This study examines the factors that affect the reduction at 1 year, especially in patients who do not demonstrate an initial response. The data of 2,007 consecutive patients enrolled in the International EECP Patient Registry were analyzed. After 36.6 +/- 4.9 h of EECP, angina was reduced by at least one class in 82.7%. At 1 year, 35.4% of initial nonresponders and 70.6% of responders remained improved by at least one angina class and free of major adverse cardiovascular events. Multivariate predictors of 1-year benefit are initial response to treatment (odds ratio 4.5, 95% CI 3.5-5.8), baseline angina class compared with class IV (odds ratios: class I 2.1, CI 0.93-4.81; class II 0.62, CI 0.43-0.87; class III 0.80, CI 0.62-1.01) and no history of congestive heart failure (odds ratio 1.41, CI 1.14-1.74). Copyright 2005 S. Karger AG, Basel.

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          The multicenter study of enhanced external counterpulsation (MUST-EECP): effect of EECP on exercise-induced myocardial ischemia and anginal episodes.

          The purpose of this study was to assess safety and efficacy of enhanced external counterpulsation (EECP). Case series have shown that EECP can improve exercise tolerance, symptoms and myocardial perfusion in stable angina pectoris. A multicenter, prospective, randomized, blinded, controlled trial was conducted in seven university hospitals in 139 outpatients with angina, documented coronary artery disease (CAD) and positive exercise treadmill test. Patients were given 35 h of active counterpulsation (active CP) or inactive counterpulsation (inactive CP) over a four- to seven-week period. Outcome measures were exercise duration and time to > or =1-mm ST-segment depression, average daily anginal attack count and nitroglycerin usage. Exercise duration increased in both groups, but the between-group difference was not significant (p > 0.3). Time to > or =1-mm ST-segment depression increased significantly from baseline in active CP compared with inactive CP (p = 0.01). More active-CP patients saw a decrease and fewer experienced an increase in angina episodes as compared with inactive-CP patients (p 0.7). Enhanced external counterpulsation reduces angina and extends time to exercise-induced ischemia in patients with symptomatic CAD. Treatment was relatively well tolerated and free of limiting side effects in most patients.
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            Left ventricular systolic unloading and augmentation of intracoronary pressure and Doppler flow during enhanced external counterpulsation.

            Enhanced external counterpulsation (EECP) is a noninvasive, pneumatic technique that provides beneficial effects for patients with chronic, symptomatic angina pectoris. However, the physiological effects of EECP have not been studied directly. We examined intracoronary and left ventricular hemodynamics in the cardiac catheterization laboratory during EECP. Ten patients referred for diagnostic evaluation underwent left heart catheterization and coronary angiography from the radial artery. At baseline and then during EECP, central aortic pressure, intracoronary pressure, and intracoronary Doppler flow velocity were measured using a coronary catheter, a sensor-tipped high-fidelity pressure guidewire, and a Doppler flow guidewire, respectively. Similar to changes in aortic pressure, EECP resulted in a dramatic increase in diastolic (71+/-10 mm Hg at baseline to 137+/-21 mm Hg during EECP; +93%; P<0.0001) and mean intracoronary pressures (88+/-9 to 102+/-16 mm Hg; +16%; P=0.006) with a decrease in systolic pressure (116+/-20 to 99+/-26 mm Hg; -15%; P=0.002). The intracoronary Doppler measure of average peak velocity increased from 11+/-5 cm/s at baseline to 23+/-5 cm/s during EECP (+109%; P=0.001). The TIMI frame count, a quantitative angiographic measure of coronary flow, showed a 28% increase in coronary flow during EECP compared with baseline (P=0.001). EECP unequivocally and significantly increases diastolic and mean pressures and reduces systolic pressure in the central aorta and the coronary artery. Coronary artery flow, determined by both Doppler and angiographic techniques, is increased during EECP. The combined effects of systolic unloading and increased coronary perfusion pressure provide evidence that EECP may serve as a potential mechanical assist device.
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              Long-term prognosis of patients with angina treated with enhanced external counterpulsation: five-year follow-up study.

              Enhanced external counterpulsation (EECP) is a noninvasive treatment for coronary artery disease (CAD) that has been used successfully in patients not responding to medical and/or surgical therapy. The study was undertaken to evaluate the effect of EECP on long-term prognosis in such patients. Major adverse cardiovascular events (MACE) were tracked in 33 patients with CAD treated with EECP. Patients were subgrouped based on whether or not they demonstrated an early improvement in radionuclide stress perfusion imaging (Responders vs. Nonresponders) and followed for MACE over a mean follow-up of 5 years. Patient population characteristics included 73% with multivessel disease; 45% with prior myocardial infarction(s); and 61% who had undergone either coronary artery bypass grafting (CABG) or percutaneous transluminal coronary angioplasty (PTCA), or both. There were 26 of 33 (79%) Responders, and 7 of 33 (21%) Nonresponders. Subsequent MACE over the 5-year follow-up included four deaths and eight patients with cardiovascular events [acute myocardial infarct (4), new CABG or PTCA (6), valve replacement (1), unstable angina (1)]. Nonresponders had significantly (p < 0.01) more MACE (6/7 or 86%) than Responders (6/26 or 23%). Overall, 21 of the 33 (64%) patients remained alive and without MACE and the need for revascularization 5 years post EECP treatment. This study suggests that, particularly for the majority of patients demonstrating improvement in radionuclide stress perfusion post treatment, EECP may be an effective long-term therapy.
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