Medicine:External counterpulsation

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External counterpulsation
Blausen 0161 Cardiac Enhanced External Counterpulsation.png
Illustration showing cardiac external counterpulsation
Other namesEnhanced external counterpulsation (EECP)

External counterpulsation therapy (ECP) is a procedure that may be performed on individuals with angina, heart failure, or cardiomyopathy.

Medical uses

The FDA approved the CardiAssistTM ECP system for the treatment of angina, acute myocardial infarction and cardiogenic shock under a 510(k) submission in 1980[1] Since then, additional ECP devices have been cleared by the FDA for use in treating stable or unstable angina pectoris, acute myocardial infarction, cardiogenic shock, and congestive heart failure.[2]

Studies have found EECP to be beneficial for patients with erectile dysfunction and some COPD patients. Additionally, improvements in exercise endurance in the non-diseased patient has been found in research studies.[3][4]

Some reviews did not find sufficient evidence that it was useful for either angina or heart failure.[5][6] Other reviews found tentative benefit in those with angina that does not improve with medications.[7][8]

For stroke due to lack of blood flow a 2012 Cochrane review found insufficient evidence to make conclusions.[9]

Significantly improved the exercise endurance of normal adults, low endurance adults, and COPD patients.[3]


While an individual is undergoing ECP, they have pneumatic cuffs on their legs and is connected to telemetry monitors that monitor heart rate and rhythm. The most common type in use involves three cuffs placed on each leg (on the calves, the lower thighs, and the upper thighs (or buttocks)). The cuffs are timed to inflate and deflate based on the individual's electrocardiogram. The cuffs should ideally inflate at the beginning of diastole and deflate at the beginning of systole. During the inflation portion of the cycle, the calf cuffs inflate first, then the lower thigh cuffs, and finally the upper thigh cuffs. Inflation is controlled by a pressure monitor, and the cuffs are inflated to about 200 mmHg.

Of note, therapies are tailored on an individual basis but beginning regimens tend to include daily one-hour treatments that occur 5 days of the week and last 6–8 weeks with an average overall of 35 hours.[10]

Physiological considerations

One theory is that ECP exposes the coronary circulation to increased shear stress, and that this results in the production of a cascade of growth factors that result in new blood vessel formation in the heart (arteriogenesis and angiogenesis).[11][12]

To best understand the pathophysiology of the therapy it is easiest to understand what each step does. To begin with, as the cuffs on each leg inflate, starting at the calf and working up to the upper thighs, blood is propelled back to the heart thereby increasing the venous return or preload. This increase in preload occurs simultaneously with diastole which happens to be the time during the cardiac cycle in which coronary perfusion occurs. So, by increasing the coronary perfusion, you allow more oxygen to perfuse the heart and ultimately generate more collateral circulation without actually increasing the work of the heart. Additionally, cardiac output is increased via the Frank-Starling mechanism secondary to the increased venous return. As the cardiac cycle progresses to systole, the cuffs on the extremities deflate, allowing for the increased cardiac output to adequately perfuse all tissues including the extremities.[13]


  1. "510(k) Premarket Notification". FDA. 
  2. "Decision Memo for External Counterpulsation (ECP) Therapy (CAG-00002R2)". 
  3. 3.0 3.1 "Enhanced External Counterpulsation Efficacy on Exercise Endurance in COPD Patients and Healthy Subjects: A Pilot Randomized Clinical Trial". International Journal of Chronic Obstructive Pulmonary Disease 15: 25–31. 7 January 2020. doi:10.2147/COPD.S225566. PMID 32021141. 
  4. "Enhanced external counterpulsation in rehabilitation of erectile dysfunction: a narrative literature review". Vascular Health and Risk Management 14: 393–399. 3 December 2018. doi:10.2147/VHRM.S181708. PMID 30584313. 
  5. "Enhanced external counterpulsation for the treatment of stable angina and heart failure: a systematic review and economic analysis.". Health Technology Assessment 13 (24): iii-iv, ix-xi, 1–90. April 2009. doi:10.3310/hta13240. PMID 19409154. 
  6. "Enhanced external counterpulsation for chronic angina pectoris.". The Cochrane Database of Systematic Reviews (2): CD007219. 17 February 2010. doi:10.1002/14651858.CD007219.pub2. PMID 20166092. 
  7. "Alternative therapy for medically refractory angina: enhanced external counterpulsation and transmyocardial laser revascularization.". Cardiology Clinics 32 (3): 429–38. August 2014. doi:10.1016/j.ccl.2014.04.009. PMID 25091968. 
  8. "Does Enhanced External Counterpulsation (EECP) Significantly Affect Myocardial Perfusion?: A Systematic Review & Meta-Analysis.". PLOS ONE 11 (4): e0151822. 2016. doi:10.1371/journal.pone.0151822. PMID 27045935. Bibcode2016PLoSO..1151822Q. 
  9. "External counterpulsation for acute ischaemic stroke.". The Cochrane Database of Systematic Reviews 1: CD009264. 18 January 2012. doi:10.1002/14651858.CD009264.pub2. PMID 22259001. 
  10. "Enhanced External Counterpulsation in Patients with Coronary Artery Disease-Associated Erectile Dysfunction. Part I: Effects of Risk Factors". The Journal of Sexual Medicine 4 (3): 771–779. May 2007. doi:10.1111/j.1743-6109.2007.00458.x. PMID 17433083. 
  11. "Enhanced external counterpulsation in the management of patients with cardiovascular disease". Clin Cardiol 22 (3): 173–8. March 1999. doi:10.1002/clc.4960220304. PMID 10084058. 
    "Enhanced external counterpulsation and future directions: step beyond medical management for patients with angina and heart failure". J. Am. Coll. Cardiol. 50 (16): 1523–31. October 2007. doi:10.1016/j.jacc.2007.07.024. PMID 17936150. 
  13. Conti, C. R. (June 1999). "EECP-Enhanced External Counterpulsation*". Journal of the American College of Cardiology 33 (7): 1841–1842. doi:10.1016/s0735-1097(99)00136-9. PMID 10362182. 

USFDA Approved EECP Treatment Center | Dr. Chandandeep Sandhu, MBBS FCGP FIPM FAM PGC (Cardiology) (11 March 2022)