EECP (Enhanced External Counterpulsation) and its Uses

A treatment to reduce symptoms of angina

By Richard N. Fogoros, MD 

 Medically reviewed by Yasmine S. Ali, MD, MSCI

 Fact checked by Nick Blackmer

Enhanced external counterpulsation (EECP) therapy is a non-invasive mechanical treatment that can help reduce the symptoms of angina, or chest pain. EECP uses inflatable cuffs on the lower limbs to create pressure and encourage better blood flow.

Clinical studies have shown that EECP treatment can help decrease symptoms of angina in people with coronary artery disease (CAD) who, due to underlying health issues, are not good candidates for surgery. Major medical organizations suggest considering EECP treatment for those with angina who are not helped by other options.1

This article explains how EECP therapy works, its effectiveness, and its risks. It also covers when healthcare providers recommend it.

Dan Dalton / Getty Images

How Does EECP Therapy Work?

With EECP, long, inflatable cuffs are wrapped around both legs and inflated/deflated in tandem with each heartbeat to encourage better blood flow.

This mechanical procedure is done sequentially, from the lower part of the legs to the upper, so that the blood in the legs is “milked” upward toward the heart.

The inflation and deflation are controlled by a computer that receives data from an electrocardiogram (ECG)—a machine that records the electrical activity of your heart. Inflation of the cuffs is triggered early in diastole (when the heart relaxes and is filled with blood). Deflation occurs just as systole (heart contraction) begins.

How Long Does EECP Therapy Take?

EECP involves a series of outpatient treatments. You’ll receive five one-hour sessions per week for seven weeks. The 35 total sessions are aimed at provoking long-lasting beneficial changes in the circulatory system.2

EECP Therapy Benefits

EECP is approved by the Food and Drug Administration (FDA). It has at least two potentially beneficial actions on the heart:

• First, the milking action of the leg cuffs increases the blood flow to the coronary arteries during diastole. (Unlike other arteries, coronary arteries receive their blood flow in between heartbeats, not during them.)

• Second, by deflating just as the heart begins to beat, EECP creates something like a sudden vacuum in the arteries. This reduces resistance in the blood vessels of the legs so that blood can be pumped more easily from your heart, and may also help reduce endothelial dysfunction.3

In addition, there is some evidence that EECP may:

• Help induce the formation of collateral (small) blood vessels in the coronary artery system

• Stimulate the release of key chemicals within endothelium tissue, which lines the coronary arteries4

• Act as a form of “passive” exercise, leading to the same sorts of lasting beneficial health changes that are seen with real exercise5

• Improve peripheral arterial function, which serves to reduce the oxygen demand on heart muscle6

EECP is safe and well tolerated. It is supported by available evidence (albeit imperfect) that strongly suggests the treatment is quite effective in many cases.

In addition, those being treated can tell pretty definitively whether it substantially reduces angina symptoms.

EECP and COVID-19

Roughly 50% of people diagnosed with COVID-19 still have lingering symptoms six months after recovery from the initial infection. For some, this “long COVID” related to blood vessel damage has serious impacts. Some reports, including a study of 50 people with long COVID, suggest EECP can offer benefits to improve health, recovery, and quality of life.7

How Long Do the Benefits of EECP Therapy Last?

Many people report an improvement in symptoms by the fifth or sixth week of treatment. Most people say symptoms begin to improve by the last couple of weeks of the seven-week treatment.

Studies suggest that EECP therapy can be quite effective in treating chronic stable angina.8 Some have shown that improvement in symptoms seems to persist for up to five years, though some patients may require another course of EECP to maintain this.9

About 20% of those who get EECP will need repeat treatment. This is more common in people who didn’t complete the full seven weeks.

 Risks of EECP Therapy

EECP therapy does not usually cause significant side effects. When people do have side effects, they tend to be mild and may include:

• Fatigue

• Muscle aches

• Bruises

• Edema (swelling)

• Numbness or tingling

• Blisters or skin irritation

Rarely, some people will experience shortness of breath. This side effect may require medical intervention, including hospitalization.

What Conditions Can EECP Therapy Treat?

Some of the conditions that EECP is used for include:

• Chronic stable angina

• Kidney failure

• Cerebrovascular disease

• Left ventricular dysfunction

• Lung disease

• Peripheral artery disease

The effects of EECP also are being studied for treating other conditions, such as diabetes.4 and heart failure.

One review of 823 cases included in eight different studies found that EECP can improve physical exercise tolerance and certain heart functions in people living with heart failure, but more study is recommended.10

When EECP Is Recommended

EECP therapy may be considered for anyone who still has angina despite maximal medical therapy, and in whom stents or bypass surgery are deemed unsuitable options.

In 2014, several professional organizations finally agreed in a focused update that EECP treatment ought to be considered for patients with angina that’s not helped by other treatments. These organizations are:1

• American College of Cardiology

• American Heart Association

• American Association for Thoracic Surgery

• Preventive Cardiovascular Nurses Association

• Society for Cardiovascular Angiography and Interventions

• Society of Thoracic Surgeons

EECP isn’t for everyone, but you may want to consider it if you are diagnosed with angina and your cardiologist’s assessment for treatment does not include surgery.

You also may want to ask a healthcare provider about its emerging uses for other conditions, such as long COVID care.

Who Should Not Get EECP Therapy?

EECP can be somewhat uncomfortable but is generally not painful. In studies, the large majority of patients have tolerated the procedure quite well.

However, not everyone can have EECP therapy. You probably should not have EECP if you have:9

• Aortic insufficiency

• History of deep venous thrombosis

• Recent cardiac catheterization

• Irregular heart rhythm such as atrial fibrillation

• Severe hypertension (high blood pressure)

• Peripheral artery disease

• A congenital heart defect2

• Hypertrophic cardiomyopathy

• Valvular disease

• Enlarged heart

• A pacemaker

• Pulmonary hypertension

• Heart rate over 120 beats per minute6

Why Isn’t EECP Used More Often?

Your cardiologist may not have offered EECP treatment to you for several reasons, including your underlying health history and specific treatment plan. It’s not considered a first-line treatment for angina, even though it can decrease the need for common medications like nitroglycerin.9

Treatment availability also may be a factor, because not all communities have accessible EECP equipment. Patient travel time can be a barrier to keeping appointments and completing the necessary full course of EECP treatment.

EECP has become more common in the United States, though, and about 1,200 machines are now in operation across the country.2

What Does EECP Treatment Cost?

The cost of EECP treatment will vary, depending on factors such as where you live and the type of insurance coverage you have. It’s about $4,880 for a full treatment when billed to Medicare* and is now covered under many private healthcare plans.9

Medicare has approved coverage for EECP for patients with angina who have exhausted all other treatment options.

Summary

Enhanced external counterpulsation (EECP) therapy is a safe and effective alternative to surgery when treating angina (chest pain) in people with coronary artery disease. It may have uses for other conditions that remain under study, including heart failure, diabetes, and long COVID.

EECP works by using inflatable cuffs to apply pressure to your lower legs. The pressure is synchronized to your heartbeat to improve blood flow and heart function.

While EECP is not an option for everyone, such as those with a pacemaker, it is increasingly available in the United States. It’s also a comparatively affordable treatment. Talk to your healthcare provider to learn more about whether EECP treatment is an option for you.

Sources

Fihn SD, Blankenship JC, Alexander KP, et al. 2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Thorac Cardiovasc Surg. 2015;149(3):e5-e23. doi:10.1016/j.jtcvs.2014.11.002

University of Michigan Frankel Cardiovascular Center. EECP treatment.

Beck DT, Martin JS, Casey DP, Avery JC, Sardina PD, Braith RW. Enhanced external counterpulsation improves endothelial function and exercise capacity in patients with ischaemic left ventricular dysfunction. Clin Exp Pharmacol Physiol. 2014;41(9):628-636. doi:10.1111/1440-1681.12263

Adams JA, Uryash A, Lopez JR, Sackner MA. The Endothelium as a Therapeutic Target in Diabetes: A Narrative Review and Perspective. Front Physiol. 2021 Feb 23;12:638491. doi:10.3389/fphys.2021.638491.

Zhang X, Zhang Y. Frequency-Domain Characteristics Response to Passive Exercise in Patients With Coronary Artery Disease. Front Cardiovasc Med. 2021 Dec 14;8:760320. doi:10.3389/fcvm.2021.760320. 

Raza A, Steinberg K, Tartaglia J, Frishman WH, Gupta T. Enhanced external counterpulsation therapy: past, present, and future. Cardiol Rev. 2017;25(2):59-67. doi:10.1097/CRD.0000000000000122.

American College of Cardiology. Enhanced External Counterpulsation offers potential treatment option for Long COVID patients.

Zhang C, Liu X, Wang X, Wang Q, Zhang Y, Ge Z. Efficacy of enhanced external counterpulsation in patients with chronic refractory angina on Canadian Cardiovascular Society (CCS) angina class: an updated meta-analysis. Medicine (Baltimore). 2015;94(47):e2002. doi:10.1097/MD.0000000000002002

Caceres J, Atal P, Arora R, Yee D. Enhanced external counterpulsation: a unique treatment for the "no-option" refractory angina patient. J Clin Pharm Ther. 2021;46(2):295-303. doi:10.1111/jcpt.13330

Zhou ZF, Wang DJ, Li XM, Zhang CL, Wu CY. Effects of enhanced external counterpulsation on exercise capacity and quality of life in patients with chronic heart failure: A meta-analysis. Medicine (Baltimore). 2021 Jul 9;100(27):e26536. doi:10.1097/MD.0000000000026536.

By Richard N. Fogoros, MD
Richard N. Fogoros, MD, is a retired professor of medicine and board-certified in internal medicine, clinical cardiology, and clinical electrophysiology.