Enhanced external counterpulsation (EECP) improves biomarkers of glycemic control in patients with non-insulin-dependent type II diabetes mellitus for up to 3 months following treatment

Impact of Enhanced External Counter-pulsation Therapy on Glycaemic Control in People With Prediabetes and Type 2 Diabetes Mellitus: A Systematic Review and Meta-analysis

Background: Enhanced external counter-pulsation (EECP) therapy is approved for refractory angina in coronary artery disease (CAD). EECP is being explored as a treatment modality in type 2 diabetes mellitus (T2DM). Methods: The Embase, Web of Science, Cochrane Library, MEDLINE (PubMed), ClinicaltTrials. gov, CNKI database, Clinical Trials Registry-india (CTRI), and Google Scholar databases were searched for randomized controlled trials (RCTs) involving patients receiving EECP therapy in the intervention arm. The primary outcome was the changes in glycated haemoglobin (HbA1c). The secondary outcomes were the changes in blood glucose parameters, inflammatory markers and any adverse events. Results: Data from 3 RCTs involving 71 people with T2DM/prediabetes was analysed to find out the impact of EECP therapy compared with placebo. As compared with placebo, patients receiving EECP had significantly lower HbA1C immediately after completion of therapy (mean difference [MD] -0.70%, 95% confidence interval (CI) -0.95. -0.45;p<0.00001), at 2-4 weeks post completion of therapy (MD -1.04%, 95%CI -1.32. -0.77; p<0.00001) and 7-12 weeks after therapy completion (MD -0.98%, 95% CI -1.22, -0.74; p<0.00001). EECP therapy was well tolerated without any increased side effects (risk ratio 2.36, 95% CI 0.11-52.41; p=0.59. Conclusion: EECP therapy is effective in blood glucose and pressure lowering over at least 7-12 weeks of therapy completion. Blood glucose and pressure should be monitored with suitable modulation of drug doses to prevent hypoglycaemia and hypotension in patients with angina undergoing EECP therapy. The PROSPERO registration number is CRD42023434533.

Efficacy of two doses of external counterpulsation (ECP) on glycemic control in people with type 2 diabetes mellitus: A randomized SHAM-controlled trial

AIMS

To determine the efficacy of two doses of external counterpulsation (ECP) on glycemic control in people with type 2 diabetes mellitus (T2D), and any persistent benefits 7 weeks following treatment.

METHODS

50 participants with T2D were randomly assigned to either 1) 20x45-minute ECP sessions over 7 weeks (ECP₄₅), 2) 20x30-minute ECP sessions over 7 weeks (ECP₃₀) or 3) SHAM control. Outcomes were assessed at baseline, after 7 weeks of the intervention and 7 weeks after the interventions finished. Efficacy was determined from changes in HbA_1c.

RESULTS

After 7 weeks, there were significant between-group differences, with ECP₄₅ lowering HbA_1c compared to SHAM (mean [95% CI] -0.7 [-0.1 to -1.3] %; -7 [-1 to -15] mmol/mol). Within group changes were; ECP₄₅ (mean±SD -0.8±0.8%; -8±8 mmol/mol), ECP₃₀ (-0.2±0.5%; -2±6 mmol/mol) and SHAM (-0.1±0.9%; -1±10 mmol/mol). HbA_1c in the ECP₄₅ group remained lower 7 weeks after completing the intervention; ECP₄₅ (7.0±1.1%; 53±26 mmol/mol), ECP₃₀ (7.7±1.4%; 60±16 mmol/mol) and SHAM (7.7±1.0%; 60±10 mmol/mol).

CONCLUSIONS

In people with T2D, ECP₄₅ for 7 weeks improved glycemic control when compared to ECP₃₀ and a SHAM control group.

Effects of single and multiple sessions of lower body diastole-synchronized compressions using a pulsating pneumatic suit on endothelium function and metabolic parameters in patients with type 2 diabetes: two controlled cross-over studies

BACKGROUND

Endothelium function is often impaired in patients with type 2 diabetes. We hypothesized that by improving endothelial function using diastole-synchronized compressions/decompressions (DSCD) to the lower body may improve the metabolic profile. The objective of this research was to evaluate the effects of single and multiple DSCD sessions on microcirculation, endothelium function and metabolic parameters of patients with type 2 diabetes.

METHODS

Two monocentric, controlled, randomized cross-over studies (Study 1 and Study 2) were performed. In Study 1, 16 patients received one 20 min DSCD and one simulated (control) session at 2 week intervals; continuous glucose monitoring and cutaneous blood flow were recorded continuously before, during and after DSCD or Control session; other vascular assessments were performed before and after DSCD and control sessions. In Study 2, 38 patients received 60 min DSCD sessions three times/week for three months followed by a 4-6 week washout and 3 month control period (without simulated sessions); vascular, metabolic, body composition, physical activity and quality of life assessments were performed before and after 3 months.

RESULTS

Both studies showed significant, multiplex effects of DSCD sessions. In Study 1, cutaneous blood flow and endothelium function increased, and plasma and interstitial glucose levels after a standard breakfast decreased after DSCD sessions. In Study 2, cutaneous endothelium function improved, LDL-cholesterol and non-HDL cholesterol decreased, extra-cell water decreased and SF-36 Vitality score increased after 3 months of DSCD sessions.

CONCLUSIONS

Our findings support the beneficial effect of DSCD on the endothelium and show concomitant beneficial metabolic and vitality effects. Future clinical trials need to test whether DSCD use translates into a preventive measure against microvascular diabetic complications and its progression. Trial registration ClinicalTrials.gov identifiers: NCT02293135 and NCT02359461.

The Effect of Enhanced External Counterpulsation on the Vascular State, Indicators of Glycemic Control and Quality of Life in Patients with Coronary Artery Disease and Type 2 Diabetes Mellitus

Aim. To study the effect of enhanced external counterpulsation (EECP) on the functional status, quality of life, structural and functional state of the vascular bed, and markers of glycemic control in patients with coronary artery disease (CAD) and type 2 diabetes mellitus (DM).

Material and methods. A pilot prospective randomized study included 30 patients with CAD and DM. Using a random number generator, patients were randomized into 2 groups: EECP (n=15) and a comparison group (n=15). All patients (n=30) received optimal medical therapy (OMT) during 3 months of follow-up. Patients in the EECP group underwent a course of EECP (35 hours, cuff pressure: 220-280 mmHg) during the first 7 weeks of the study. At baseline and after 3 months of follow-up, patients in both groups underwent an assessment of clinical status, quality of life (based on the SF-36 questionnaire), as well as a 6-minute walk test to assess exercise tolerance. The dynamics of fasting glucose, postprandial glucose, insulin resistance index (HOMA-IR) and glycated hemoglobin were assessed. Photoplethysmography and applanation tonometry were performed to assess the state of the vascular bed.

Results. In the EECP group, after 3 months, there was a decrease in the frequency of angina attacks and an improvement in the functional class of angina according to the Canadian Cardiovascular Society (CCS) classification. A significant improvement in exercise tolerance was revealed [an increase in the 6-minute walking distance by 51 (35; 65) m, p<0.05], as well as an improvement in the physical and mental components of health according to the SF-36 questionnaire. A positive dynamics was shown in relation to the indicators of the state of both large vessels and the microvasculature (p>0.05), with the exception of the reflection index and the stiffness index (p<0.05). There was also a significant decrease in the HOMA-IR [-9.9% (-26.5; -4.0) vs 7.7% (-7.9; 13.8), p=0.004], as well as in the levels of fasting glucose [-10.5% (-15.8; -4.0) vs -2.7 (-8.3; 5.9), p=0.012] in the EECP group, compared with the OMT group.

Conclusion. EECP course therapy in addition to OMT has a positive effect on the functional status and quality of life of patients with CAD and DM. After 3 months of observation, there was noted a positive dynamics of the vascular state, as well as markers of glycemic control, and these changes were more pronounced in the EECP group. The results obtained may indicate the effectiveness of EECP as an add-on treatment for this group of patients.

The Endothelium as a Therapeutic Target in Diabetes: A Narrative Review and Perspective

Diabetes has reached worldwide epidemic proportions, and threatens to be a significant economic burden to both patients and healthcare systems, and an important driver of cardiovascular mortality and morbidity. Improvement in lifestyle interventions (which includes increase in physical activity via exercise) can reduce diabetes and cardiovascular disease mortality and morbidity. Encouraging a population to increase physical activity and exercise is not a simple feat particularly in individuals with co-morbidities (obesity, heart disease, stroke, peripheral vascular disease, and those with cognitive and physical limitations). Translation of the physiological benefits of exercise within that vulnerable population would be an important step for improving physical activity goals and a stopgap measure to exercise. In large part many of the beneficial effects of exercise are due to the introduction of pulsatile shear stress (PSS) to the vascular endothelium. PSS is a well-known stimulus for endothelial homeostasis, and induction of a myriad of pathways which include vasoreactivity, paracrine/endocrine function, fibrinolysis, inflammation, barrier function, and vessel growth and formation. The endothelial cell mediates the balance between vasoconstriction and relaxation via the major vasodilator endothelial derived nitric oxide (eNO). eNO is critical for vasorelaxation, increasing blood flow, and an important signaling molecule that downregulates the inflammatory cascade. A salient feature of diabetes, is endothelial dysfunction which is characterized by a reduction of the bioavailability of vasodilators, particularly nitric oxide (NO). Cellular derangements in diabetes are also related to dysregulation in Ca²⁺ handling with increased intracellular Ca²⁺overload, and oxidative stress. PSS increases eNO bioavailability, reduces inflammatory phenotype, decreases intracellular Ca²⁺ overload, and increases antioxidant capacity. This narrative review and perspective will outline four methods to non-invasively increase PSS; Exercise (the prototype for increasing PSS), Enhanced External Counterpulsation (EECP), Whole Body Vibration (WBV), Passive Simulated Jogging and its predicate device Whole Body Periodic Acceleration, and will discuss current knowledge on their use in diabetes.

Therapeutic Approaches for the No-Option Refractory Angina Patient

The combination of an aging population and improved survival rates among patients with coronary artery disease has resulted in an increase in the number of patients with refractory angina or anginal equivalent symptoms despite maximal medical therapy. Patients with refractory angina are often referred to the cardiac catheterization laboratory; however, they have often exhausted conventional revascularization options; thus, this population is often deemed as having "no options." We review the definition, prevalence, outcomes, therapeutic options, and treatment considerations for no-option refractory angina patients and focus on novel therapies for this complex and challenging population. We propose a multidisciplinary team approach for the evaluation and management of patients with refractory angina, ideally in a designated clinic. The severe limitations and symptomatology experienced by these patients highlight the need for additional research into the development of innovative treatments.

Endothelial pulsatile shear stress is a backstop for COVID-19

There has not been any means to inhibit replication of the SARS-CoV-2 virus responsible for the rapid, deadly spread of the COVID-19 pandemic and an effective, safe, tested across diverse populations vaccine still requires extensive investigation. This review deals with the repurpose of a wellness technology initially fabricated for combating physical inactivity by increasing muscular activity. Its action increases pulsatile shear stress (PSS) to the endothelium such that the bioavailability of nitric oxide (NO) and other mediators are increased throughout the body. In vitro evidence indicates that NO inhibits SARS-CoV-2 virus replication but there are no publications of NO delivery to the virus in vivo. It will be shown that increased PSS has potential in vivo to exert anti-viral properties of NO as well as to benefit endothelial manifestations of COVID-19 thereby serving as a safe and effective backstop.

Effects of external counter-pulsation on endothelial function assessed by peripheral artery tonometry, levels of glycaemia and metabolic markers in individuals with type 2 diabetes mellitus

BACKGROUND AND AIMS

External counter-pulsation (ECP) generates sheer stress thereby improving endothelial function and anginal symptoms in coronary artery disease. Endothelial dysfunction is also involved in the pathogenesis of T2DM. The aim of this pilot study was to investigate the use of ECP at different doses in improving endothelial function and glycaemic markers in T2DM.

METHODS

This prospective study involved 46 subjects with T2DM randomly assigned to receive 35 sessions of ECP at different regimens (0.5 h versus 1 h) and duration (7 versus 12 weeks). Endothelial function was evaluated by reactive hyperaemia index (RHI) via peripheral arterial tonometry at the start, midpoint and end of study. Other secondary outcomes included fasting glucose, HOMA-IR, HbA1c, blood pressure, lipid profile, weight and vibration sense.

RESULTS

There was no change in RHI across all 3 regimens of ECP individually or collectively at the end of the study (ΔRHI +0.01%, p = 0.458). Glycaemic markers also remained unchanged at endpoint. Subgroup analysis showed an improvement in RHI (ΔRHI +20.6%, p = 0.0178) in subjects with more severe endothelial dysfunction at baseline.

CONCLUSION

ECP did not show a beneficial effect on endothelial function or glycemic control in this South-East Asian population with T2DM at any of the three regimens. This may partly be explained by less severe endothelial dysfunction and less insulin resistance in our population at baseline.

Expert consensus on the clinical application of enhanced external counterpulsation in elderly people (2019)

Enhanced external counterpulsation (EECP) is a non-invasive assisted circulation technique and a rich pool of evidence has accumulated for its clinical application in the prevention and management of multiple comorbidities in the elderly population, including angina, heart failure, ischemic cerebrovascular diseases, neurodegenerative diseases, sleep disorder, diabetes and its complications, ischemic eye diseases, sudden hearing loss and erectile dysfunction, as well as various psychological and psychiatric conditions. When applying EECP to elderly patients, emphasis should be placed on issues such as safety assessment, risk management and protocol individualization, as well as the monitoring of efficacy during and after treatment.

Individual shear rate therapy (ISRT)-further development of external counterpulsation for decreasing blood pressure in patients with symptomatic coronary artery disease (CAD)

Individual shear rate therapy (ISRT) evolved from external counterpulsation with individual treatment pressures based on Doppler ultrasound measurements. In this study, we assessed the effect of ISRT on blood pressure (BP) in patients with coronary artery disease (CAD). Eighty-four patients with symptomatic CAD were included in the study. Forty-one patients were enrolled for 6 weeks, comprising 30 sessions of ISRT; 43 age- and sex-matched patients represented the control group. The 24-h BP was determined by measuring the pulse transit time before and after 6 weeks of ISRT or the time-matched control. Participants were divided into three groups according to the 24-h BP before treatment: BP1 < 130/80 mmHg (normotensive); BP2 ≥ 130-140/80 mmHg (moderate hypertensive); BP3 > 140/80 mmHg (hypertensive). After 30 sessions of ISRT, the 24-h BP decreased significantly, whereas no changes were observed in the controls. The BP-lowering effect correlated with the 24-h BP before therapy (systolic: r = -0.78; p < 0.001; diastolic: r = -0.76; p < 0.001). In BP1, the systolic BP decreased by 4.3 ± 6.4 mmHg (p = 0.011), and the diastolic BP decreased by 4.8 ± 11.0 mmHg (p = 0.032); in BP2, the systolic BP decreased by 13.3 ± 7.5 mmHg (p < 0.001), and the diastolic BP decreased by 5.0 ± 7.5 mmHg (p = 0.002); and in BP3, the systolic BP decreased by 22.9 ± 11.4 mmHg (p < 0.001), and the diastolic BP decreased by 9.1 ± 9.5 mmHg (p = 0.003). Our findings demonstrate that ISRT reduces BP in patients with CAD. The higher the initial BP the greater the lowering effect.

Effects of External Counterpulsation on Postexercise Recovery in Elite Rugby League Players

PURPOSE

External counterpulsation (ECP) has previously been used to treat cardiac patients via compression of the lower extremities during diastole to increase venous return and coronary perfusion. However, the effects of ECP on exercise performance and markers of recovery in elite athletes are largely unknown.

METHODS

On 2 separate occasions, 48 h apart, 7 elite National Rugby League players performed an identical 60-min field-based conditioning session followed by a 30-min period of either regular ECP treatment or placebo. Power measures during repeated cycle bouts and countermovement jump height and contraction time derivatives were measured at rest and 5 h postexercise. Saliva samples and venous blood samples were taken at rest, postexercise, and 5 h postexercise to assess stress, inflammation, and muscle damage.

RESULTS

After ECP treatment, cycling peak power output (P = .028; 11%) and accumulated peak power (P = .027; 14%) increased compared with the placebo condition. Postexercise plasma interleukin 1 receptor antagonist only increased after ECP (P = .024; 84%), and concentrations of plasma interleukin 1 receptor antagonist tended to be higher (P = .093; 76%) 5 h postexercise. Furthermore, testosterone-to-cortisol ratio was increased above baseline and placebo 5 h postexercise (P = .017-.029; 24-77%). The ratio of postexercise salivary α-amylase to immunoglobulin A decreased after treatment (P = .013; 50%) compared with the placebo control.

CONCLUSIONS

Exercise performance and hormonal indicators of stress were improved and inflammation markers were reduced following acute ECP.

Usefulness of Individual Shear Rate Therapy, New Treatment Option for Patients With Symptomatic Coronary Artery Disease

The aim of this study was to elucidate if patients with coronary artery disease (CAD), who fail to respond to revascularization procedures, can improve from individual shear rate therapy (ISRT). The ISRT is an adaptation of the external counterpulsation with lower individual treatment pressures based on Doppler-ultrasound measurements during counterpulsation. In contrast to the external counterpulsation therapy, the ISRT is based on the detection of the individual intra-arterial shear rate. Here we report about the first clinical trial of 31 patients with CAD who were enrolled for 30 sessions of ISRT. To determine the therapeutic effect of ISRT we measured the exercise capacity, the arterial stiffness, the aortic wave reflection, and the 24-hour blood pressure before and after 30 treatment sessions. After 6 weeks of accomplished ISRT the walking distance during the 6-minute walking test extended by 78 m (p = 0.007). The total exercise duration in the exercise stress electrocardiogram increased by 84 seconds (p = 0.012) but not the stress intensity (p = 0.086). The pulse wave velocity decreased by 1.2 m/s (p = 0.004) and demonstrated a decrease in arterial stiffness. Pulse wave analysis results demonstrated a progressive decrease in central blood pressure by 12 mmHg (p = 0.008), in pulse pressure by 9 mmHg (p = 0.005), and in augmentation pressure by 5.3 mmHg (p = 0.004). The 24-hour blood pressure decreased systolic by 15 mmHg (p <0.001) and diastolic by 8 mmHg (p = 0.033). The patients also benefited subjectively followed by New York Heart Association and Canadian Cardiovascular Society classifications. In conclusion, the ISRT is an effective treatment for patients with CAD to improve cardiac fitness, arterial stiffness, and to reduce blood pressure.

Enhanced external counterpulsation (EECP) decreases advanced glycation end products and proinflammatory cytokines in patients with non-insulin-dependent type II diabetes mellitus for up to 6 months following treatment

AIMS

Enhanced external counterpulsation (EECP) is a noninvasive, non-pharmacologic intervention proven to increase nitric oxide bioavailability in patients with coronary artery disease. The purpose of the present study was to evaluate the potential clinical benefits of EECP on advanced glycation end products (AGEs) and proinflammatory cytokine concentrations in patients with a clinical diagnosis of type II diabetes mellitus (T2DM).

METHODS

Thirty subjects (60.7 ± 1.9 years) with T2DM were randomly assigned (2:1 ratio) to receive either 35 1-h sessions of EECP (n = 20) or time-matched standard care (n = 10). AGEs, receptors for AGEs (RAGEs), soluble vascular cell adhesion molecules-1 (sVCAM-1), and 8-iso-prostaglandin 2α (8-iso-PGF2α) were evaluated before and at 48 h, 2 weeks, 3, and 6 months following EECP treatment or time-matched control.

RESULTS

EECP significantly decreased AGEs and RAGEs at all follow-up measurement time points. AGEs and RAGEs were decreased at 48 h (-75 and -16 %), 2 weeks (-87 and -28 %), 3 months (-89 and -29 %), and 6 months (-92 and -20 %) following EECP treatment, respectively. sVCAM-1 and 8-iso-PGF2α were significantly decreased at 48 h (-30 and -49 %) and 2 weeks (-22 and -27 %) following EECP, respectively. sVCAM-1 (-27 %) remained significantly reduced at 3 months following EECP. Nitrite/nitrate (NOx) was significantly increased at 48 h (+48.4 %) and 2 weeks (+51.9 %) following EECP treatment.

CONCLUSIONS

Our findings provide novel evidence that EECP decreases AGE/RAGE concentrations, inflammation, and oxidative stress in patients with T2DM that persist for up to 6 months following treatment.