Analysis of baseline factors associated with reduction in chest pain in patients with angina pectoris treated by enhanced external counterpulsation

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.

Refractory angina frequencies during 7 weeks treatment by enhanced external counterpulsation in coronary artery disease patients with and without diabetes

Background:

Refractory angina is a clinical diagnosis which implies to chronic pain due to coronary artery insufficiency and it is often resistant to routine cardiac treatment. The present study conducted to compare changes in refractory angina frequencies during 7 weeks treatment by enhanced external counterpulsation (EECP) in coronary artery disease (CAD) patients with and without diabetes.

Methods:

In this retrospective study, 94 CAD patients (30 diabetics vs. 64 nondiabetics) who referred to cardiac rehabilitation department of Imam Ali Hospital of Kermanshah, Iran, during January 2006–2014 were assessed. The interventional method was EECP and medical records and frequencies of self-reported chest pain were research instruments. Data were analyzed through Chi-square test, mixed repeated measures, and Bonferroni test.

Results:

Frequencies of pain in both diabetic and nondiabetic groups during 7 weeks had linear reduction, but this reduction was significant only among nondiabetic patients (P < 0.0005). Furthermore, the significant reduction in frequencies of pain among this group begins after the 5^th week.

Discussion:

Diabetes is one of the obstacles to the successful control of pain frequencies by the EECP in patients with CAD. Future studies may pay attention to the confounding role of diabetes in improving the severity of chest pain.

Enhanced External Counterpulsation Is an Effective Treatment for Depression in Patients With Refractory Angina Pectoris

OBJECTIVE

To examine the effect of enhanced external counterpulsation (EECP) on depression in patients with refractory angina pectoris (Canadian Cardiovascular Society class 2-4).

METHOD

The study was a prospective observational investigation with a 2-month control period preceding the EECP therapy (to minimize a possible effect of the regression-toward-the-mean phenomenon). The patients were examined 2 months before and just before EECP and just after, 3 months after, and 12 months after EECP. Depression was assessed using the Major Depression Inventory and the ICD-10. During EECP, 3 sets of cuffs were fastened around the lower extremities and were inflated sequentially to a pressure of 260 mm Hg in each diastole for 60 minutes 5 days a week for 7 weeks (35 sessions). The study was conducted at a regional hospital in Denmark from May 2006 to January 2011.

RESULTS

Fifty patients with angina pectoris and an abnormal coronary angiography, with no possibility for revascularization, were included (72% men, mean age of 63 years) between May 2006 and January 2011. The prevalence of depression before EECP was 18%, just after was 2%, 3 months after was 2%, and 12 months after was 4% (P = .013). The depressive state was more severe at a lower age (P = .016). No significant predictors of effect of EECP on depression were found (P > .05), and no association was detected between decline in depressive state and chest pain (P > .05).

CONCLUSIONS

The study indicates that EECP is an effective treatment for depression in patients with refractory angina pectoris, that depression is more severe in younger patients, and that the effect of EECP on depression is not related to the effect on chest pain.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01112163.

Enhanced external counterpulsation has no lasting effect on ambulatory blood pressure

BACKGROUND

Enhanced external counterpulsation (EECP) has been reported to reduce blood pressure (BP) using clinic BP readings. The aim of this study was to assess the effect of a course of EECP on BP using ambulatory BP (ABP) measurements.

HYPOTHESIS

EECP has a lasting BP lowering effect.

METHODS

Patients referred for EECP due to refractory angina pectoris were consecutively included in the study. The ABPs were measured for 24 hours using a Spacelabs Ultralite 90217 device at 5 time points during the study period: 2 months before the EECP course, just before the EECP course, just after the EECP course, and at 3 and 12 months after EECP. Antihypertensive medication was held constant during the study period. Changes in BP were tested by repeated measures analysis.

RESULTS

Fifty patients were included in the study. The mean age was 63 years, and 72% were male. The Canadian Cardiovascular Society Angina Grading Scale class improved from a mean of 2.6 to 1.5. The mean daytime ABPs were 114/69, 114/70, 115/71, 114/70, and 116/71 mm Hg and the mean nighttime ABPs were 107/63, 108/63, 106/62, 108/63, and 107/62 mm Hg at 2 months before the EECP course, just before the EECP course, just after the EECP course, and at 3 and 12 months after EECP, respectively (all P > 0.10). Further, when controlling for quartiles of baseline ABP level, no significant change in ABP was found.

CONCLUSIONS

Enhanced external counterpulsation treatment has no lasting effect on ABP.

Enhanced external counter pulsation in treatment of refractory angina pectoris: two year outcome and baseline factors associated with treatment failure

Background

Enhanced external counter pulsation (EECP) is a non-invasive treatment option for patients with refractory angina pectoris ineligible to further traditional treatment. The aim of this study was to evaluate the effect of EECP on patients at a Scandinavian medical centre and to investigate if outcome can be predicted by analysing baseline factors.

Methods

86 consecutive patients (70 male, 16 female) were treated with EECP and followed for two years post treatment. Canadian cardiovascular society (CCS) class was analysed, and medication and adverse clinical events were researched prior to EECP, at the end of the treatment, and at six, 12 and 24 months thereafter. Patients responding to therapy by improving at least one CCS class were compared with those who failed to respond. Any differences in background factors were recorded and analysed.

Results

79% of the patients responded to therapy by improving at least one CCS class. In general, the CCS class improved by one class after EECP treatment (3.05 before versus 2.14 after treatment). A total of 61.5% of the initial responders showed sustained improvement at the 12 month follow-up while 29% presented sustained improvement after 24 months. Treatment was most effective among patients suffering from CCS class III-IV angina pectoris, while patients suffering from CCS class II angina pectoris improved transiently but failed to show sustained improvement after the 12 month follow-up. Diabetes mellitus and calcium channel antagonists were more common among the non-responders (p < 0.05).

Conclusion

This study confirms the safety and efficiency of EECP as a treatment option for patients suffering from refractory angina pectoris. The therapy is most beneficial in patients suffering from severe angina (CCS III-IV) while sustained response to therapy could not be verified among patients suffering from CCS class II angina pectoris.

Passive tobacco exposure may impair symptomatic improvement in patients with chronic angina undergoing enhanced external counterpulsation

Background

The adverse effects of tobacco abuse on cardiovascular outcomes are well-known. However, the impact of passive smoke exposure on angina status and therapeutic response is less well-established. We examined the impact of second-hand smoke (SHS) exposure on symptomatic improvement in patients with chronic ischemic coronary disease undergoing enhanced external counterpulsation (EECP).

Methods

This observational study included 1,026 non-smokers (108 exposed and 918 not-exposed to SHS) from the Second International EECP Patient Registry. We also assessed angina response in 363 current smokers. Patient demographics, symptomatic improvement and quality of life assessment were determined by self-report prior and after EECP treatment.

Results

Non-smoking SHS subjects had a lower prevalence of prior revascularization (85% vs 90%), and had an increased prevalence of stroke (13% vs 7%) and prior smoking (72% vs 61%; all p < 0.05) compared to non-smokers without SHS exposure. Despite comparable degrees of coronary disease, baseline angina class, medical regimens and side effects during EECP, fewer SHS non-smokers completed a full 35-hour treatment course (77% vs 85%, p = 0.020) compared to non-smokers without SHS. Compared to non-smokers without SHS, non-smoking SHS subjects had less angina relief after EECP (angina class decreased ≥ 1 class: 68% vs 79%; p = 0.0082), both higher than that achieved in current smokers (66%). By multivariable logistic regression, SHS exposure was an independent predictor of failure to symptomatic improvement after EECP among non-smokers (OR 1.81, 95% confidence intervals 1.16–2.83).

Conclusion

Non-smokers with SHS exposure had an attenuated improvement in anginal symptoms compared to those without SHS following EECP.

One year follow-up of patients with refractory angina pectoris treated with enhanced external counterpulsation

Background

Enhanced external counterpulsation (EECP) is a non-invasive technique that has been shown to be effective in reducing both angina and myocardial ischemia in patients not responding to medical therapy and without revascularization alternatives. The aim of the present study was to assess the long-term outcome of EECP treatment at a Scandinavian centre, in relieving angina in patients with chronic refractory angina pectoris.

Methods

55 patients were treated with EECP. Canadian cardiovascular society (CCS) class, antianginal medication and adverse clinical events were collected prior to EECP, at the end of the treatment, and at six and 12 months after EECP treatment. Clinical signs and symptoms were recorded.

Results

EECP treatment significantly improved the CCS class in 79 ± 6% of the patients with chronic angina pectoris (p < 0.001). The reduction in CCS angina class was seen in patients with CCS class III and IV and persisted 12 months after EECP treatment. There was no significant relief in angina in patients with CCS class II prior to EECP treatment. 73 ± 7% of the patients with a reduction in CCS class after EECP treatment improved one CCS class, and 22 ± 7% of the patients improved two CCS classes. The improvement of two CCS classes could progress over a six months period and tended to be more prominent in patients with CCS class IV. In accordance with the reduction in CCS classes there was a significant decrease in the weekly nitroglycerin usage (p < 0.05).

Conclusion

The results from the present study show that EECP is a safe treatment for highly symptomatic patients with refractory angina. The beneficial effects were sustained during a 12-months follow-up period.

Management Options for Angina Refractory to Maximal Medical and Surgical Interventions

Despite the seemingly daily advances in the primary, secondary, and tertiary prevention for coronary artery disease, many patients will ultimately experience progression of their disease and experience angina refractory to further active treatment. In these patients, disabling angina occurs at rest or during simple activities of daily living. When this occurs, symptom management, a predominant focus of nursing, becomes the goal of care. Several medical and surgical alternatives are available to patients with refractory angina. Enhanced external counterpulsation and transmyocardial laser revascularization are Food and Drug Administration approved therapies that can be used to attempt to restore the balance of supply and demand. Modulation of sympathetic tone via procedures such as stellate ganglion blocks has also been employed. Other methods to control the pain are techniques that alter pain perception such as spinal opioids, transcutaneous electrical nerve stimulation, and spinal cord stimulation. Too few patients with refractory angina are referred for any of these palliative therapies. Armed with knowledge regarding these therapies, nurses will be better prepared to provide anticipatory guidance to patients and their families and to support the patient's hope for relief as they cope with this devastating condition.

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

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).