Sunday, April 20, 2008
EECP for travellers and medical tourists
As the result of a comment on this blog I thought it would be helpful to other cardiovascular disese sufferers to put down some guidelines for people who were seeking EECP treatment in foreign countries, especially where the climate was more pleasant during a Northern winter - medical tourists. India is an obvious example where EECP provision has been both well developed and adverised on the web.
My qualifications for doing this, besides being a CVD sufferer who has gained tremendous benefit from EECP, is that during my professional career I travelled and worked in many parts of the world. I have no experience in the Indian sub-continent and my EECP sessions have been in the UK (1) and the US (2). Nevertheless I hope that the following paragraphs, being a meld of my travel and EECP experiences, might be of help to others.
These guidelines are only a first draft and would benefit a lot from input from others with complementary experience and more knowledge than mine. So please feel free to add your comments and see if we can't make these better
Introduction
This document is intended as a guide to medical tourists seeking EECP treatment in countries such as India. If you are seeking EECP treatment, the inference is that you are suffering from cardiovascular disease and worse, that you are feeling unwell, perhaps in pain and less able to cope with the daily ups and downs of life. The advice is based on experience of having EECP treatment in various places, not in India particularly.
EECP does not work for everybody and it has been mainly used for patients with chronic stable cardiovascular disease (CVD) where the cardiologists have run the gamut of conventional treatments. It is thus concentrated in cases of advanced CVD with significant levels of angina and impairment. From personal experience I gained great benefit from its use much earlier in the disease cycle – an enlightened cardiologist was the key in my case. Make sure at least that your cardiologist is aware of your intentions and has the opportunity to express his opinion and monitor your decision to proceed.
General
1) Check carefully how far your travel insurance provides you with cover; what happens if, heaven forbid, you suffer a major emergency? Is the clinic you are attending equipped for coronary emergencies? Also check the length of time you can stay outside your home country – many insurances only provide 31 days in any one trip – which you will blow if you have a full 35 session course once a day.
2) Be aware that your legal rights to redress if something goes wrong will be governed by the laws of the country where you get treatment. EECP is a procedure with a small inherent risk of harm and so the overall risk is low. Therefore liability considerations should be a minor part of your decision to proceed, but do not expect these clinics to carry what you may regard as significant levels of liability insurance.
3) Make sure that your vaccinations are up to date for the country you are visiting.
4) The English and Americans are notoriously bad at speaking and understanding foreign languages - a great generalisation! Nevertheless good communication is important, especially when you're not feeling well or something is going wrong. Make sure therefore that you can communicate easily with the clinic and the people working there. If you need an interpreter, will they be available at short notice and at awkward times?
Travel & Accommodation
1) Get hold of a good guidebook for general background, e.g. Rough Guide
2) Be a lot more patient with the transport system, ideas of timing and punctuality can be very different.
3) If you can, agree prices for taxis and other transport before you get into them, unless they have official meters; be prepared to haggle!
4) Make a friend of the hotel manager and/or head porter; they can be immensely helpful avoiding local pitfalls. Be careful initially of local guides who try to sell their services to you; obtain independent verification if you can if they are any good.
5) Make very sure that your hotel room is comfortable and as quiet as possible; because of your condition and the treatment you may need a lot of rest. Having a room next to a busy road or with noisy neighbours is not a good idea!
6) Find out the local phone numbers of your country's consular service in the country you are visiting. They can usually provide information and help in emergencies, eg lost passports or visa problems. Also check the website of your home country's Foreign Service for travellers' advisories about the country you intend to visit.
Food
You will find EECP difficult or impossible if you suffer diarrhoea and/or other types of food poisoning. There are lots of guides on Westerners being careful in hot countries - they seem to have more delicate constitutions! - but some general points may help.
1) Never drink water from a jug or tap, always bottled, unless vouched for by the hotel – and then still be careful! This also means no ice in drinks. Keep well hydrated but take advice if you are on a diuretic blood pressure medication. Beer is OK providing it is a good brand so it has been sterilized properly – but check that the bottle caps are clean. Draft beer from stainless steel barrels should similarly be OK if the glassware is clean. Be wary of fruit juice, milk, etc. unless it comes in Tetrapak-type packaging.
2) Hot drinks should use boiled water, hence tea and coffee OK. If caffeine is a blood pressure stimulant for you, perhaps take a supply of decaf teabags.
3) No salads, no fruit unless it can be peeled properly, e.g. bananas, oranges
4) Cooked meals only where you are reasonably happy with the conditions of preparation.
5) Be careful with bread, cakes, sweetmeats, Anything with exposed sugars or syrups is difficult.
6) Spiced dishes often disguise high salt loads – if you are sensitive to salt, then ask. The same is true of bread and baguettes, often these are made with up to 12 grams/kilo of salt. The European standard is 6 grams/day max.
EECP treatment
The clinic will want to give you a fairly thorough medical examination before starting, if only to familiarize themselves with your case. It is immensely helpful for them to take as much information as your doctor and cardiologist will let you have. Ideally this should include:-
- Copy of prescription
- CD of last angiography
- X-rays of chest
- Ultrasound data
- Stress test history
- Recent blood test results (do you know your total cholesterol, triglycerides, HDL,LDL, Total/HDL ratio?)
- Blood pressure history
- Copy of medical notes, if available
The clinic will probably want to do a stress test for themselves to assess your current state, as well as a 12 lead ECG check-up. They should also give you an ultrasound examination, if only to check that there is no danger of an aortic aneurysm from the EECP, happily a rare occurrence. They may also do a new blood test. They may also check your left ventricular ejection fraction (LVEF). If they have a sophisticated set-up, they may also do a nuclear SPECT imaging test to check heart muscle damage and LVEF. The costs of some of these tests may not be included in the price quoted to you and this may be where they increase the profitability of your case. However, all the data above is potentially very helpful.
The EECP sessions themselves are fairly innocuous. You have doubtless seen pictures of the equipment and you will get used to it very quickly. Initially you should have one session per day – it is possible to have 2 per day if your physical state allows you to do so. They should check your blood pressure before and after but this is not essential if you are reacting well. Keep taking your prescribed medication unless they suggest otherwise. Try not to drink too much before a session, you will then want to stop during the session for a pee!
They may start you off at 260mm inflation pressure but, if you do not feel uncomfortable, get it increased to 300mm (0.4MPa) ASAP. You should have a reasonably tight-fitting pair of longjohns without seams. These are to prevent chafing. They should be of cotton with a small amount of Lycra to make them expand over your skin. Unless they have specifically agreed to supply them, don't assume you can get hold of these locally, a sports shop at home may be best. You may suffer some abrasion chafing in any event, some talcum or zinc oxide cream usually helps but the clinic should be fairly expert at knowing what to do to alleviate the problem. Be suspicious of sheep wool pads and the like, they will certainly help to alleviate chafing problem but at the expense of absorbing a lot of the pneumatic energy you want to transfer into your leg arteries.
The objective of the treatment, is to enhance the flow into the coronary arteries and this is measured indirectly by a finger plethysmograph. They should check your readings every 15 minutes or so and adjust the inflation and deflation timing to optimize the peak and area under the curve. You should take a great interest in these results but do not be disappointed if you do not get a significant effect for the first 10 sessions or so; there may be some significant arterial and heart muscle stiffness to overcome. However, towards the end of the sessions you should be seeing ratio figures over 1.5 if you are lucky.
Make a friend of the operator, he/she will have some very useful background information. Also, if you are dissatisfied or otherwise feel you need to see the supervising cardiologist because you are unwell or making insufficient progress, then be insistent on seeing him quickly. Try and relax during the sessions by reading, listening to music or watching TV. They may even have CNN or BBC World Service!
A simple point is to check whether the EECP room itself is well ventilated. EECP systems are fitted with a fair size blower unit that itself generates considerable heat. The room can get very warm if the heat is not properly dissipated, making the patient feel uncomfortable.
You will certainly feel tired both with the sessions and the heat; however, you should aim to get into a good exercise regime every day, the extent of which will depend on your physical condition. If you can walk reasonably well then this is excellent exercise. The ideal would be an average of 8-10000 steps per day (if you do not have a pedometer, buy one and check your progress. The only decent reliable one in my experience is the Omron Walking Style II (HJ-113), the rest stop working after a few months for one reason or another. If a swimming pool is available then a gentle session is very good. Fatigue is a real enemy, however, and it is a difficult balancing act between being well enough for the EECP session and getting a good level of exercise. Therefore, give in to your tiredness and rest as far as possible.
At the end of the treatment course the clinic may well give you an equivalent set of tests and hopefully you will get some really encouraging results. ¶ 7:10 am
My qualifications for doing this, besides being a CVD sufferer who has gained tremendous benefit from EECP, is that during my professional career I travelled and worked in many parts of the world. I have no experience in the Indian sub-continent and my EECP sessions have been in the UK (1) and the US (2). Nevertheless I hope that the following paragraphs, being a meld of my travel and EECP experiences, might be of help to others.
These guidelines are only a first draft and would benefit a lot from input from others with complementary experience and more knowledge than mine. So please feel free to add your comments and see if we can't make these better
Introduction
This document is intended as a guide to medical tourists seeking EECP treatment in countries such as India. If you are seeking EECP treatment, the inference is that you are suffering from cardiovascular disease and worse, that you are feeling unwell, perhaps in pain and less able to cope with the daily ups and downs of life. The advice is based on experience of having EECP treatment in various places, not in India particularly.
EECP does not work for everybody and it has been mainly used for patients with chronic stable cardiovascular disease (CVD) where the cardiologists have run the gamut of conventional treatments. It is thus concentrated in cases of advanced CVD with significant levels of angina and impairment. From personal experience I gained great benefit from its use much earlier in the disease cycle – an enlightened cardiologist was the key in my case. Make sure at least that your cardiologist is aware of your intentions and has the opportunity to express his opinion and monitor your decision to proceed.
General
1) Check carefully how far your travel insurance provides you with cover; what happens if, heaven forbid, you suffer a major emergency? Is the clinic you are attending equipped for coronary emergencies? Also check the length of time you can stay outside your home country – many insurances only provide 31 days in any one trip – which you will blow if you have a full 35 session course once a day.
2) Be aware that your legal rights to redress if something goes wrong will be governed by the laws of the country where you get treatment. EECP is a procedure with a small inherent risk of harm and so the overall risk is low. Therefore liability considerations should be a minor part of your decision to proceed, but do not expect these clinics to carry what you may regard as significant levels of liability insurance.
3) Make sure that your vaccinations are up to date for the country you are visiting.
4) The English and Americans are notoriously bad at speaking and understanding foreign languages - a great generalisation! Nevertheless good communication is important, especially when you're not feeling well or something is going wrong. Make sure therefore that you can communicate easily with the clinic and the people working there. If you need an interpreter, will they be available at short notice and at awkward times?
Travel & Accommodation
1) Get hold of a good guidebook for general background, e.g. Rough Guide
2) Be a lot more patient with the transport system, ideas of timing and punctuality can be very different.
3) If you can, agree prices for taxis and other transport before you get into them, unless they have official meters; be prepared to haggle!
4) Make a friend of the hotel manager and/or head porter; they can be immensely helpful avoiding local pitfalls. Be careful initially of local guides who try to sell their services to you; obtain independent verification if you can if they are any good.
5) Make very sure that your hotel room is comfortable and as quiet as possible; because of your condition and the treatment you may need a lot of rest. Having a room next to a busy road or with noisy neighbours is not a good idea!
6) Find out the local phone numbers of your country's consular service in the country you are visiting. They can usually provide information and help in emergencies, eg lost passports or visa problems. Also check the website of your home country's Foreign Service for travellers' advisories about the country you intend to visit.
Food
You will find EECP difficult or impossible if you suffer diarrhoea and/or other types of food poisoning. There are lots of guides on Westerners being careful in hot countries - they seem to have more delicate constitutions! - but some general points may help.
1) Never drink water from a jug or tap, always bottled, unless vouched for by the hotel – and then still be careful! This also means no ice in drinks. Keep well hydrated but take advice if you are on a diuretic blood pressure medication. Beer is OK providing it is a good brand so it has been sterilized properly – but check that the bottle caps are clean. Draft beer from stainless steel barrels should similarly be OK if the glassware is clean. Be wary of fruit juice, milk, etc. unless it comes in Tetrapak-type packaging.
2) Hot drinks should use boiled water, hence tea and coffee OK. If caffeine is a blood pressure stimulant for you, perhaps take a supply of decaf teabags.
3) No salads, no fruit unless it can be peeled properly, e.g. bananas, oranges
4) Cooked meals only where you are reasonably happy with the conditions of preparation.
5) Be careful with bread, cakes, sweetmeats, Anything with exposed sugars or syrups is difficult.
6) Spiced dishes often disguise high salt loads – if you are sensitive to salt, then ask. The same is true of bread and baguettes, often these are made with up to 12 grams/kilo of salt. The European standard is 6 grams/day max.
EECP treatment
The clinic will want to give you a fairly thorough medical examination before starting, if only to familiarize themselves with your case. It is immensely helpful for them to take as much information as your doctor and cardiologist will let you have. Ideally this should include:-
- Copy of prescription
- CD of last angiography
- X-rays of chest
- Ultrasound data
- Stress test history
- Recent blood test results (do you know your total cholesterol, triglycerides, HDL,LDL, Total/HDL ratio?)
- Blood pressure history
- Copy of medical notes, if available
The clinic will probably want to do a stress test for themselves to assess your current state, as well as a 12 lead ECG check-up. They should also give you an ultrasound examination, if only to check that there is no danger of an aortic aneurysm from the EECP, happily a rare occurrence. They may also do a new blood test. They may also check your left ventricular ejection fraction (LVEF). If they have a sophisticated set-up, they may also do a nuclear SPECT imaging test to check heart muscle damage and LVEF. The costs of some of these tests may not be included in the price quoted to you and this may be where they increase the profitability of your case. However, all the data above is potentially very helpful.
The EECP sessions themselves are fairly innocuous. You have doubtless seen pictures of the equipment and you will get used to it very quickly. Initially you should have one session per day – it is possible to have 2 per day if your physical state allows you to do so. They should check your blood pressure before and after but this is not essential if you are reacting well. Keep taking your prescribed medication unless they suggest otherwise. Try not to drink too much before a session, you will then want to stop during the session for a pee!
They may start you off at 260mm inflation pressure but, if you do not feel uncomfortable, get it increased to 300mm (0.4MPa) ASAP. You should have a reasonably tight-fitting pair of longjohns without seams. These are to prevent chafing. They should be of cotton with a small amount of Lycra to make them expand over your skin. Unless they have specifically agreed to supply them, don't assume you can get hold of these locally, a sports shop at home may be best. You may suffer some abrasion chafing in any event, some talcum or zinc oxide cream usually helps but the clinic should be fairly expert at knowing what to do to alleviate the problem. Be suspicious of sheep wool pads and the like, they will certainly help to alleviate chafing problem but at the expense of absorbing a lot of the pneumatic energy you want to transfer into your leg arteries.
The objective of the treatment, is to enhance the flow into the coronary arteries and this is measured indirectly by a finger plethysmograph. They should check your readings every 15 minutes or so and adjust the inflation and deflation timing to optimize the peak and area under the curve. You should take a great interest in these results but do not be disappointed if you do not get a significant effect for the first 10 sessions or so; there may be some significant arterial and heart muscle stiffness to overcome. However, towards the end of the sessions you should be seeing ratio figures over 1.5 if you are lucky.
Make a friend of the operator, he/she will have some very useful background information. Also, if you are dissatisfied or otherwise feel you need to see the supervising cardiologist because you are unwell or making insufficient progress, then be insistent on seeing him quickly. Try and relax during the sessions by reading, listening to music or watching TV. They may even have CNN or BBC World Service!
A simple point is to check whether the EECP room itself is well ventilated. EECP systems are fitted with a fair size blower unit that itself generates considerable heat. The room can get very warm if the heat is not properly dissipated, making the patient feel uncomfortable.
You will certainly feel tired both with the sessions and the heat; however, you should aim to get into a good exercise regime every day, the extent of which will depend on your physical condition. If you can walk reasonably well then this is excellent exercise. The ideal would be an average of 8-10000 steps per day (if you do not have a pedometer, buy one and check your progress. The only decent reliable one in my experience is the Omron Walking Style II (HJ-113), the rest stop working after a few months for one reason or another. If a swimming pool is available then a gentle session is very good. Fatigue is a real enemy, however, and it is a difficult balancing act between being well enough for the EECP session and getting a good level of exercise. Therefore, give in to your tiredness and rest as far as possible.
At the end of the treatment course the clinic may well give you an equivalent set of tests and hopefully you will get some really encouraging results. ¶ 7:10 am
