Heart Disease & EECP in Europe

Additional Complications due to Aging!

2010-08-26T07:58:00.003+01:00

I was 70 a couple of months ago - a wry milestone. Glad you've got there and a notice that you're getting older and that things are gradually not working as well as they did. About 4 weeks ago I had a 'big' operation to correct a slipped disc in the lumbar (Lower) section of my back.

I had seriously damaged the Achilles tendon in my left leg about a year ago - running for a bus! This took 6 months to repair and wasn't helped by my active part in building our new house - fortunately now finished - mostly. About the turn of the year I started to notice shooting pains in both legs when I walked and naturally put this down to side effects from the Achilles tendon repair - until the physiotherapist treating me said no - something else is happening - spinal stenosis. This is progressive compression of the spinal cord due to pressure from a slipped disc. He passed me on to a back specialist surgeon who confirmed the diagnosis and gave me the usual options - live with it and use painkillers, local injections or surgery, the last of which I chose. My judgment was that I was probably fit enough to withstand the operation with a reasonable chance of success - the surgeon gave me the odds as 85:15 on a successful outcome based on experience with what is now a 150 year old procedure.

This duly took place towards the end of July and I knew within 24 hours that it had been well done - the pains had gone and everything still appeared to work. The surgeon also told me the damage had nothing to do with the Achilles tendon problem - I was the unwitting victim of 20-30 years of self-inflicted damage of which I knew nothing. If you have no symptoms you just assume you can go on doing these things.

4 weeks later I hardly know that anything has even happened - except for the rather vigorous regime of daily exercises prescribed by the physio whom I see every couple of weeks (I should be doing them now). I no longer stumble and my daily walking is up to over 9000 paces again.

And what of the heart and blood pressure during all this? Not a tremor or whisper of a problem. My BP was 110/68 at the pre-assessment and got up as far as 137/80 immediately after the operation. The anaesthetist said he noticed nothing.

Indeed, over the last 6 months my BP has steadily declined, the average resting BP taken last thing in the evening (so, very benign but consistent conditions) has been 116/70 over the last 3 months. Indeed I wonder if my drug regime - still a full spectrum hypertension package - needs revision. A discussion with the GP next month.

In summary, hooray for EECP and the long-lasting effects of such a good treatment. I am a very lucky man, both with EECP and a well executed back surgery. Let's hope the luck persists

Update - February 2010

2010-02-14T20:55:00.001Z

Just a short entry to report that everything is stable - no real changes. I am indeed very fortunate but EECP is still highly recommended

Update - July 2009

2009-07-22T20:33:00.002+01:00

I was recently upbraided for not keeping my blog up to date, a stricture which I accept. However, there has been very little change since December 2008 - a very fortunate circumstance and a reinforcement of the powerful combination of EECP treatment, diet and exercise. My blood pressure is still recorded twice a day and the results stay in the 110-128 region, depending on what excesses I get up to.

Currently I am project manager on a house-build and this can get quite exciting at times and fatigue can play a real part - the more tired you are the more you are affected by adverse events. I have done a couple of foolish things such as carrying 25kg toilet bowls up the stairs 5 times in succession - this caused a minor flare-up of heartburn/angina which dispersed after a couple of hours. Other than that - nothing! I still keep up the drug regime with a change from Tarka to Olmesartan(an ARB) about 3 months ago, the result being a depression in systolic of 3-5mm.

One effect that is definitely becoming worse is that of short term memory. Whether that is the effect of advancing age (I am 69) or of the 20mg of statins (Lipitor) I take daily, is a moot point. Memory impairment is widely reported in the literature so I will have to monitor this. I have always had a good memory so the decay can be quiye upsetting at times. Reminds me once again of the Barry Cryer joke that Stannah (leading European manufacturer) have recently introduced a high speed stair lift to get you upstairs before you forget why you're going there. See www.spacedoc.net/board/viewtopic.php?t=830&postdays=0&postorder=asc&start=0 for a discussion of memory and other effects. The Spacedoc.net website has some excellent material showing how the conventional frontiers of medicine may not always be tackling medical issues in the right way.

A large scale study recently reports on the positive effects of statin use. The results are summarised very well in a video by Professor Paul Ridker of Harvard University talking about the development of new lipid guidelines leading up to the forthcoming issue of the ATP IV set of guidelines. Check out www.theheart.org/article/961439.do - you may have to sign up to get access. The key point is that you have to not only control lipid levels but also inflammation, the level of C reactive protein (CRP) is very important. Prof Ridker also makes a very powerful case for the importance of regular exercise in the regime for control of cardiovascular disease. So I keep on with the statin treatment and level of exercise until I next see my cardiologist in September for a check-up.

Another factor that is being highlighted these days is the effect of proper levels of Vitamin D3. Most northern dwellers have abysmally low levels of D3 which is really a hormone rather than a vitamin and appears to play a vital role in many essential physiological processes. This has recently been discussed by Dr John Briffa in his excellent medical blog (www.drbriffa.com) and repays some study, especially as it may be a key intermediate in the transport of lipids in the bloodstream.

December 2008 Update

2008-12-21T20:09:00.003Z

I am still in the very fortunate position of confirming this is a continuing success story - the data I recorded in June 2008 (below) is still essentially the same. No angina, a continuing improvement in stamina and resistance to fatigue and unexpected events. EECP has been, at least for me, a miracle.

I have to observe some disciplines, however, coming down to diet and exercise. Taking the exercise first, I try and walk an average of 8-9000 steps a day, but if I have a long day with up to 16000 steps, there is no effect except some aching muscles - and I feel a little well-used the day after. I am convinced that this regime has a major effect. I follow a moderate mediterranean syle diet, keeping the caffeine intake low. A caffeine shot does make a difference but it soon wears off. My weight varies little less than a kilo over the whole period.

I still follow a complete broad spectrum drug regime, ARB, CCB, beta blocker, statin, anti-coagulant, Omega 3 supplement. There have been no changes in this for the last 2 years and I am fortunate that I have no significant side effects.

I am quite frustrated, however, that the take-up of EECP in the National Health Service is still so slow. The pioneering work at Bradford is showing very good results and this needs publicising across the National Health Service as a cost-effective method of keeping a large population of CVD patients in a much better state than relying just on PCI, CABG and drug regime. Coupled with the essential lifestyle modifications, the economic benefits to the CVD population are potentially very large.

A new UK website (http://www.eecp.co.uk/) sets out the modern knowledge on EECP in a much better fashion than I have done in earlier entries in this blog, and I commend this to anyone wanting to follow up on the background to EECP, especially policy analysts in UK Primary Care Trusts - EECP will make a real difference to your budgets!

2008-06-16T10:35:00.003+01:00

June 2008 Update - Something has happened!

The last post was at the end of February and the improvement noted there has continued, in fact to the stage where I am probably in a better state than I have been for several years. The graphic above shows the relationship between exercise amount - basically steps per day shown in light blue - and blood pressure (BP) tendency over the last 12 months. The red trace is the maximum daily systolic pressure and the dark blue trace is the average systolic pressure. All figures are averaged over a continuous 20 day moving period to iron out daily fluctuations and the BP difference is calculated by subtracting the average pressures for the whole of 2006.

Note the very large, and so far permanent, dip since the beginning of March, combined with the steady exercise regime since that time. Nothing like this has happened in a long while.

Having finished the EECP session in California at the beginning of February as noted before the BP did not really settle down although I felt considerably better. I decided about a week later to give up even decaffeinated drinks and bang! - within 2 weeks the BP had dropped by about 10mm. Since then there has been a steady although slow improvement in stamina and strength, effectively a slow healing process. This cannot be due just to EECP but possibly a virtuous circle effect of diet, exercise, medication and EECP all working together. It is still quite difficult to believe but it has been confirmed by a recent Bruce protocol stress test by my cardiologist who has booked me for another one in 6 months' time to see whether it keeps up.

The question is then - what is the secret? I suspect that there was a really persistent area of inflammation somewhere that has declined. In other words the chronic endothelial dysfunction that plagues me - and millions of others - has reduced a few percent and allowed the other improvements. Too early to say definitively but I live in hopes.

Endothelial dysfunction seems to be getting a lot more attention from the medics recently. It appears to be a pincer movement from several angles, not just conventional drug and intervention regimes:-

EECP trials and results being more widely known
Fundamental work to understand the physical and biochemical processes at play in the endothelium
Effects of hormones and cholesterol transport mechanisms, in particular reverse cholesterol transport
Flow mechanics studies
Conventional intervention costs and their escalation
Development of new and cheaper devices to measure endothelial funcion, e.g. Cardiatect

I believe a new paradigm approach is beginning to evolve in early detection and treatment of cardiovascular disease, of which EECP will be one of the constituents.

Finally, I commend the Yahoo EECP Group as a good source of new information on some of these trends.

Mike Slavin
Rye Harbour - UK

EECP for travellers and medical tourists

2008-04-20T07:10:00.003+01:00

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.

February 2008 Update - Effects of Decaffeinated Drinks

2008-02-29T21:00:00.003Z

I should note (see previous post)that I have not drunk any significant amount of caffeinated drinks in the last couple of years and stuck to decaffeinated coffee and tea. I began to get a little bit concerned that EECP was producing the results after the course was completed - and so I cut out any decaffeinated drinks as well.

This graphic (up to 25th February) shows what has happened since the end of the EECP course and eliminating any decaffeinated drinks. The course finished on 5th February and the blue line shows that average SBP was still running about 140. A week later I gave up the decaffeinated drinks - and the blue line marched from 140 to near 120 in a week. This effect has persisted right up to date - long may it continue! At the same time I have been able to increase the amount I can walk each day - so hopefully improving the overall level of fitness.

The ship's doctor's strictures about eating and drinking too much have also worked out well - I came back to the UK a couple of weeks ago 300 grammes lighter than when we departed in December. I still drink only a couple of glasses of wine a day and, if anything, I drank less on the ship.

There is a definite relationship between the amount of exercise - too much probably causes some aggravation of inflammatory patches - and blood pressure in my case. I would dearly like some better insight into how these relationships work. Excessive salt and decaffeinated drinks may also play some part but I am sure that other factors have effects that, at present, I do not understand.

Data update for Nov2007 - Feb 2008

2008-02-29T19:45:00.008Z

I hope this graphic is not too confusing. It is a time series plot of my systolic (SBP) and diastolic blood pressures (DBP) for the period Nov 2007 to the end of January 2008. These are measured using a Microlife recording unit that takes 3 readings and then averages them. Readings are normally twice a day in the morning and evening and are taken sitting up with legs horizontal after 2 - 3 minutes rest.

The vivid purple line is the daily pedometer reading, an attempt to measure the daily physical effort. The red line is the maximum SBP on any one day and the blue line is a running average of the previous 5 days' figures - to get some idea of the trends.

you can see that all through November there has been a steady increase in SBP even though the physical effort is reducing - that is until we started our holiday at the beginning of december, boarding a cruise liner in Barcelona and then taking 10 days to sail to Boston. I was feeling pretty good at the beginning of the voyage and spent quite lot of time walking on the exercise deck, a 610 metre circuit. This effort is reflected in the pedometer readings, followed a couple of days later with a real jump in maximum SBP, making me feel much worse - to the extent of eventually checking in with the ship's doctor. He did a quick examination and said the basic pump was OK and the variations were due probably to:-

Change of food and eating too much
Possible increased salt and/or spices load hidden in exotic dishes
Changed emotional state
Drinking more

Also I was getting older (nearly 68) and not so resilient as before. I was more worried about aggravating plaques, increased inflammatory patches, etc., but of course he could not answer that, not having the right equipment on board.

We landed and then flew to California to stay with some friends, but the increase in average SBP was still a worry - I didn't feel brilliant. I found a local practice in California that had an EECP unit and, having been checked out by their cardiologist, started in on a course of EECP on 10th January, the third in 20 months. This was organised for 2 sessions a day with an interval over lunch of about 2 hours during which I spent some time in coffee bars, etc. You will note that the average SBP did not reduce, even though I felt better and was able to do a lot more walking.

Feb 2008 Update

2008-02-24T19:15:00.002Z

Since the last post in sept 2007, my blood pressure profile has deteriorated - my impression has been that I have been too active, thus causing inflammation. In December 2007 I went on a Transatlantic voyage and, instead of an improvement, it actually got worse - to the point that I checked in with the ship's doctor - he pronounced me OK but came up with a new wrinkle. This was that travel is disruptive, new food, new surroundings, more emotional stress - and I am a very experienced traveller! Was there a mechanical explanation for this variability, I wondered, plaques breasking down, aggravation of existing inflammatory patches, etc? He said it was his common experience to listen to tales like mine and his prime culprits were:-

Eating too much
Hidden salt loads in meals cooked by others

The upshot was that I ended up in January in California undertaking another course of EECP. This has gradually settled things down but it happened that I went for 2 sessions a day with a break in between that used to spend in places like coffee bars, etc., drinking decaffeinated coffee and tea. The blood pressure did not properly settle down until the end of the 35 sessions and until I had an insight that the decaffeinated regime might be part of the problem. I have so far avoided both salt and decaffeinated products for a total of just over 2 weeks. The result is quite significant, the systolic BP is down by about 12-15 mm and stable. Long may it continue! And so the regime that works for me appears to be:-

Not eating too much
Avoiding high salt loads
Avoiding both caffeinated and decaffeinated drinks
Fairly regular EECP maintenance

There is no guarantee that exactly the same will work for others because their physiology will be different, but the basic approach may help. On the eating problem, after 10 weeks away from the UK I ended up 200 grammes lighter than when I left - so eating was not the real problem, it was probably salt and caffeine or caffeine solvents left in the drinks.

I will publish the BP data soon, together with a commentary on how various clinics conduct EECP. To be most effective, the patient should take part in the treatment regime and be ready to signal shortfalls in the clinic's procedures

Stress Test Update

2007-09-18T09:18:00.000+01:00

Yesterday (17th September) I had an ECG stress test. This came up very well - no negative signs - the BP was 173/67 at the end of the stress test, reducing to 132/78 after 2 minutes rest. The traces were all good so my cardiologist's opinion was that EECP had produced some long term positive effects - it was not simply a short term blip.

I have had some BP excursions and occasional angina in the last 3 months but this is always because I have been pushing the exercise envelope too far - over 11000 steps a day or 40 minutes a day aerobic walking (105 paces a minute or faster). The advice is therefore - to live within my limits!

Update - June 2007

2007-06-16T11:06:00.000+01:00

Since the posts last year I have been through quite a stressful time personally - moving house in October 2006, a process involving a lot of physical work. My condition worsened and attacks of angina resumed - in retrospect induced by the excessive physical effort involved in the move ( lifting a lot of 15-20kg banana boxes filled with household bits and pieces is not the best treatment for heart disease!).

The opportunity came up to do another course of EECP in very congenial surroundings - Miami Beach, Florida - in the middle of winter December 2006- January 2007. This worked very well and a nuclear imaging scan at the end of the second course showed a near normal heart muscle, Deo gratias! Since then I have had a progressive improvement, the main problem being fatigue rather than recurrences of angina.

Recently I have started a course of D-ribose (10g/day) and this is having a salutary effect on the fatigue front. I am very well , far better than I deserve to be and am therefore a very strong advocate still for the benefits of EECP. I have been keeping up the daily measurements of BP and hope to publish graphical summaries of the data in the near future with a more detailed explanation of the ups and downs.

I hope that this will encourage others to undergo similar treatment. Because of the way that EECP operates in improving blood flow in and around the heart, the earlier you start, the better the results. Unfortunately most EECP treatments seem to given to people who already have very advanced cardiovascular disease (Canadian Classifications III and IV) where cardiologists are rather defeated by the combination of symptoms presenting to them. I have been very lucky to have been caught at an earlier stage.

HP Masher

EECP - What might be happening in the blood vessels?

2006-10-01T21:48:00.000+01:00

Flow changes

The ideas discussed in previous posts are quite difficult to envision but it helps to check the diagrams produced by the plethysmograph. Remember that the instrument measures the blood flow through a finger during the cycle of a heartbeat. Recall that the therapist uses these traces to adjust the EECP unit for best results with each individual. The data on the chart are taken from one of the author’s sessions; they have been re-traced to a common timebase and there are minor errors in the graphs due to time and zero differences. The flow differences are, however, quite striking through the cycle.The blue trace shows the flow pattern when the body is at rest and the orange trace while undergoing EECP.

Heartbeat cycle

Detailed accounts of the heart’s operation can be found in many sources so what follows only covers those aspects to help understand EECP. If you are a heart patient you will doubtless have heard the terms systolic and diastolic blood pressures. These are the maximum and minimum pressures in the measured artery during the heartbeat cycle. The words are derived from ‘systole’ and ‘diastole’ – of Greek origin meaning ‘contraction’ and ‘expansion’ respectively. They refer to the pumping and relaxation phases of the cycle.

Referring to the chart, we start with the heart being fully relaxed, the lower chambers (atria) being full of blood (marked EDP – End Diastolic Pressure). In the systolic phase the heart muscle is compressing, increasing the pressure and squeezing the blood out of the left and right upper chambers of the heart, the ventricles. The left ventricle blood goes through the open aortic valve to the aorta, generating the maximum (systolic) pressure (marked S – Systole) As the left ventricle empties so the contraction phase finishes, the pressure drops around the valve and it shuts. On the blue curve the pressure then reduces fairly evenly until the next systolic phase begins.

Enhanced flow

With EECP, however, the system is looking for the closure of the aortic valve by interpreting the ECG waveform produced by the heart. It does not have to do this exactly because the therapist can control in detail the start point of leg cuff inflation to obtain the best results. The start of inflation is called the Transition (T) and, on the orange trace, the increase in flow after that point is obvious.

The process of inflation itself is a bit more subtle; the reason that there are three sets of cuffs is that the inflation time for each cuff can be sequenced, the lowest cuff being inflated first, followed by the two upper ones in sequence, each about 50 msec (1/20 second) after the other. In effect the blood is chased back to the heart rather like an extremely rapid squeeze along a toothpaste tube. This process drains the leg of blood and so, as the air pressure is then released simultaneously, the leg tissues expand elastically allowing the blood to flow back with less pumping effort from the heart muscle. The result is that the end diastolic pressure (EDP) is typically lower than in normal operation. The same elastic rebound effect is true at systole, leading to an overall lower load on the heart muscle during EECP.

The therapist and the patient are both interested in the shape of the enhanced diastolic flow curve, the patient in the hope of getting the best from the EECP procedure and the therapist in achieving that goal. The enhancement is typically measured by both the peak value (P) – the maximum flow in comparison with normal operation – and the total area under the curve (A). The area represents the total increase in flow of blood caused by EECP. The greater this is, the more oxygenated arterial blood flows through the coronary arteries.

EECP Effects on the body

One of the most interesting aspects of EECP is that the blood flow effects occur not only in the finger with the plesymograph sensor and in the coronary arteries, but in practically every blood vessel in the body. Thus any disease or condition of the body ‘/affected by impaired blood flow may potentially be improved by a course of EECP. In the author’s case a nagging arthritic joint of the right big toe that had been troublesome for at least 5 years has miraculously improved so that there is now no pain. The present state of knowledge is such that the medical profession cannot make a firm promise of such benefits and thus one should regard them as a real bonus, should they occur.

Effects on the Heart

Heart disease is not simply a question of blockages in certain identifiable locations. If you have a blockage in one or more of your coronary arteries, what do you suppose is the state of the capillaries joined to those arteries? In other words one must expect partial or complete blockage of the blood supply system. Bluntly, the difference between the living and the dead is that the living still have enough open pathways for the heart to function. Heart disease is therefore a system problem. The hopeful part of this for EECP patients is that the healing factors should work on all parts of the blood distribution system, not just the identifiable coronary arteries. Atheroma in the capillaries (the microvascular circulation) can equally cause angina because of the shortage of oxygen supplied to that area of the muscle. The prospective EECP patient should, almost literally, take heart from the prospect that the treatment will improve the whole system, not just the areas of damage identified by your consultant.

Surface and flow effects

A good part of this section is informed speculation as to what happens in the coronary artery circulation and the possible effects that occur. Also this is written by an engineer, rather than a medic, so some of the understanding may be suspect and open to review by wiser and more knowledgeable types!

As already noted in this thread, engineers get very interested when pressure waves occur in tubes because of the sometimes unexpected effects. However, they are normally used to tubes that are the same diameter along their length and do not move about very much. A blood vessel is a very different proposition. Not only does it change in diameter while flow is occurring but it can move substantially in space, bending and flexing as the diameter is changing. To add more complication, blood itself is not a normal fluid, its viscosity – the readiness to flow - lessens the faster it flows. It is called a non-Newtonian fluid, named after you-know-who. So, to analyse in detail how the flow varies during a heartbeat cycle becomes a very complicated exercise. One way of understanding the interplay of these factors is to develop a model, usually as a computer program, where the physical laws governing the flow and the geometric shape of the artery are used to calculate the effects of various disturbances including progressive atheromas. While this work has been under way for a few years it does not yet appear to be advanced enough to provide real guidance to clinicians.

To add to the complication blood vessels possess a very special surface and wall. The surface or inner lining is called the endothelium. Backing up the endothelium and giving strength to the wall is a layer of smooth muscle. The endothelium possesses almost mystical properties that have a fundamental effect on the operation of the blood vessel, in particular the expression and absorption of certain chemical substances that regulate the operation of the smooth muscle. If the endothelium does not work properly then the blood vessel can be badly affected. Atheroma tends to block the vessel by accumulating a hard fatty deposit (plaque) under the surface, expanding into the vessel and, in the worst case , erupting into the vessel and causing a complete blockage further downstream.

The chemical substances of interest to this discussion (there are many others) fall into several categories:-

- Growth Factors

- Vaso-dilators

- Vaso-constrictors

- Inflammatory agents

- Anti inflammatory agents

Vaso-dilators and vaso-constrictors control the diameter of the blood vessel by acting on the smooth muscle underneath. Growth factors control the production of new micro-arteries (angiogenesis) and the bringing back into service of existing arteries (recruitment)that have ceased to function for a variety of reasons including atheroma.

If the balance between these substances goes wrong for any reason then the consequences can be far-reaching. Endothelial dysfunction[i] is the general name for these problems.

[i] Endothelial Functions: Cardiac Events. Lerman & Zeiher. Circulation 2005;111;363-368

Effects of EECP, Systolic Blood Pressure and Physical Effort - Sept 06

2006-09-24T20:58:00.000+01:00

The chart shows graphically the effects of my course of EECP treatment between May and July 2006. It shows the relationship between changes in systolic blood pressure and the amount of physical effort I was capable of before, during and after the course. The red line shows the trend in systolic pressure between July 2005 and September 2006. Rather than show the absolute values I have plotted the average change over any 20 day period compared to the annual average. The reason for this rather convoluted presentation is paradoxically to remove short term day to changes and show the longer term trends. If the slope of the red line is positive (going upward) then the situation is deteriorating; if it is dipping then it is improving. If the line is roughly horizontal then the blood pressure is stable.

The blue line starting in Nov 2005 shows the daily pedometer readings - I started to wear one to check how much exercise I was having. My coronary health deteriorated rapidly between December 2005 and March 2006 - there was a sustained upward trend in blood pressure and a catastrophic loss in physical capacity - 3000 steps a day was a lot. I had an angiogram and IVUS (intra vascular ultrasound) inspection in March where it was determined that the plaques were both bulky and diffuse, one of the right coronary artery branches being at least 80% blocked. A second stent was fitted (the first, also in the right coronary artery, being fitted 24 months before). The improvement after a month was very little - in other words the problem had not been resolved.

My cardiologist then recommended I should undergo an EECP course; I was clearly one of those patients who fell into the refractory category mentioned in an earlier post. The treatment started on 22nd May and continued for 7 weeks. The remarkable effect was that after about 5 treatments I was able to go from 3000 to 8000 steps a day. I had to cope with a lot of side effects of the increased exercise; my body was generally out of condition so I was very tired and joints and muscles were very stiff. As the treatment progressed so the exercise level was sustained, still with a lot of fatigue effects.

The $64,000 question is then - what happened afterward? It is now over 2 months since the treatment was completed and the general level of activity has been sustained, less walking but a lot of other activities (we are planning to move house soon so there is an awful lot to do). I have now started an exercise bike regime - about 25 min/day at a light setting, equivalent to 200kcal and 9km distance. Fatigue effects have gradually lessened as the fitness has increased and - dare I say it - the tone and condition of the heart has improved since July. In particular, if I do too much on any one day I can recover quite quickly whereas 6 months ago I would have been out of action for days, confined to the sofa and forced to watch the world go by. I am once more part of the world!

I hope to post more reports periodically with updates - good, bad or neutral. My experience thus far is - if you have coronary vascular disease and your cardiologist agrees that EECP is a valid treatment - go for it! It will not harm you and you have a 75-80% probability of it doing a lot of good.

HP Masher - 24th September 2006

EECP – A Description

2006-07-21T15:49:00.000+01:00

Background

EECP stands for External Enhanced Counter Pulsation – surely one of the least mellifluous terms in the medical dictionary. No wonder medics lapse into abbreviated jargon so easily – they would be candidates for throat surgery had they to repeat such terms more than once a day. So it is EECP to most people. This note explores some of the background from the layman’s viewpoint and is to help patients in understanding the treatment. The author does not have a medical background and so any mistakes are entirely my responsibility!

What is it?

In short EECP is a non-invasive method of modifying the flow of blood through the heart by applying external pressure through cuffs fitted around the legs. Quite a mouthful to think about but the basic principle is quite simple. If you apply a tourniquet to your arm or leg then very soon you suffer pins and needles because the external pressure has squeezed the arteries, limiting the blood flow to the area. EECP cuffs do the same thing but more gently, the squeeze being timed to modify the blood flow around the heart , rather than cut it off in the leg.

This is easiest to do when the main outlet valve from the heart (the aortic valve) is just closing. You can imagine the main (femoral) artery as part of a continuous column of blood between the leg and the interior of the heart, including the coronary arteries that supply blood and energy to the heart muscle itself. Any external pressure applied on the legs is therefore transmitted to the heart. The aortic valve opens and closes every heartbeat so, since it can’t be seen directly, the closing is detected by measuring the change in the electrical state of the heart. Electrodes are therefore taped to your chest, the output from which produces an ECG waveform, a procedure familiar to every heart patient. These signals are used to trigger a series of pneumatic valves controlling the air pressure in each cuff.

The equipment is in two main parts, firstly a couch fitted with 6 connections to the pressure cuffs - 3 for each leg, secondly a trolley containing an air compressor and control equipment with a console on top for the operator to monitor progress of the procedure. You sit on the couch and the cuffs are wrapped over your legs and buttocks and held in place using Velcro tabs. Each session lasts about an hour and, for best results, a course of 35 sessions is usually recommended. Effectively you are bounced around at your heart rate. If this is 60 beats a minute then you bounce gently on the couch once a second. It is possible to watch TV or read during the session but more intricate activities such as knitting are probably too difficult for most people

During the session the blood flow pattern is checked occasionally by monitoring the flow of blood in the finger using a device called a plethysmograph – a long name for a smart piece of kit. An infrared beam is shone through the finger and a detector monitors how much of the light is absorbed by haemoglobin, the red component of the blood; the greater the blood flow (or volume) the greater the absorption. The therapist uses the display of blood flow through each heart beat to tune the equipment for best results.

Why is it necessary?

EECP is usually recommended for people with heart disease of various types, lumped under the general term of cardiovascular disease (CVD). It is used in various parts of the world to treat other conditions also, but let us concentrate on heart disease. This means there is something wrong with the heart and/or its associated valves, blood vessels or nerves. Each individual patient is only too well aware of the drastic effects such disease can have on their quality of life. In physical terms the regular operation of the heart muscle and associated blood vessels is impeded, whether by fibrillation or blockage of the coronary arteries or malfunction of one or more valves. A common effect is angina, the pain experienced due to lack of oxygen supply to the heart muscle when trying to respond to the body’s demands. Stable angina can be very debilitating and lead to significant loss of quality of life; unstable angina, pain that varies rapidly, can be dangerous and should be reviewed by a medical professional as soon as possible after the onset.

Tremendous advances in medication and intervention procedures have been made over the last 30 years, advances which have corresponded unfortunately with a significant rise in the frequency of CVD in the population. Many heart patients would not be alive now without having benefited from these advances. Cardiologists are, however, not miracle men – they are not able to control and reverse all forms of CVD in every patient. While many patients have derived great benefit from procedures such as catheter ablation, coronary bypass operations or the fitting of arterial stents, there still remain a significant group (up to 15% of the total) who derive only limited or no benefit from such interventions.

EECP was devised as one way of helping this refractory group. One of its great attractions is that it is non-invasive – there is no need to carve holes in the body to gain access! Another great benefit is that it is remarkably safe – any side effects, eg skin chafing, are minor. The procedure has been a long time in development – over 30 years – and there has clearly been a long learning curve in design, test and introduction of the procedure to the cardiology community. The early work was done in China while more recent work has been done in the United States where it is now widely used as one of the battery of procedures available in the battle against CVD. Acceptance in Europe is much slower, partly explained by the different organisation of health care in each country and psychological factors - NIH (not invented here) !

EECP is not a universal panacea – some patients will have a combination of advanced symptoms that preclude any benefit; for instance EECP does not help with atrial fibrillation (AF). Large patient groups in the US have benefited from EECP, those benefits lasting several years. These results have been reported in peer-reviewed papers produced by specialists and thus should be taken seriously. Limited experience in the UK with a much smaller patient group over a short period shows similar qualitative improvements, experience confirmed by objective reports from other parts of Europe. One should always retain a degree of scepticism where the equipment is only available from one supplier – who therefore has a vested interest in the widest possible takeup of the procedure. Fortunately there are at least three significant American manufacturers, together with suppliers from other parts of the world. However, the availability of independent peer reviewed results is a safeguard, reinforced by the recent UK and European experience.

How it works

How is it that pressure pulsations in the bloodstream can have so many beneficial effects? It borders on the magical, but to get an insight into what happens one needs to understand something of how the heart itself works. There is the short explanation and the not so short explanation. The reason for two versions is that, while a lot is known about the mechanisms of the heart, there is still a lot to find out. EECP undoubtedly has both very marked effects and very subtle effects on the heart’s operation. How these various effects work together is still the subject of extended research and so, until the research effort comes up with the definitive answers, one has to rely on an educated guess (hypothesis) about what is happening.

The Short Explanation – or Plunge and Sponge

If you have a blockage in your sink outlet then the first line of attack is with a plunger, pressing up and down on the handle. This causes the column of water before the blockage to move, hopefully releasing the blockage. More precisely you are causing a pressure wave in the pipe as you press down on the plunger. The same is happening with the pressure cuffs on your legs; as the air pressure is applied by the cuff outside the leg so a pressure wave is generated inside the artery, the wave travelling up the femoral artery to the aorta, the main outlet artery from the heart.

Where there is a pressure wave there is also an increase in flow; the Plunge analogy with a blocked sink should not be taken too far, however – it is rare for a blood vessel blockage to be cleared in such a crude fashion, indeed it could be dangerous. The maximum air pressure used is chosen to avoid such a drastic effect. The increase in flow is thought to have several beneficial consequences, particularly in stimulating the production of chemicals, causing the artery to increase in diameter (vaso-dilation)and also promoting the growth of new side arteries (angiogenesis) allowing the blood to diffuse into the heart muscle. These new side arteries also help to bypass existing blockages.

The Sponge analogy refers to the heart muscle itself ; it contracts and relaxes every heartbeat. One of the results of heart disease is that the heart muscle becomes less flexible and thus blood cannot diffuse as easily to the cells of the heart muscle, cutting the energy available , the result being a weaker pumping action, starving the blood supply to the rest of the body. Where the disease has progressed further, parts of the heart muscle are put out of action, completely so where a heart attack has occurred.

Anything that therefore improves the action of the heart muscle will tend to reverse the progress of the disease.

When the pressure wave arrives in the coronary artery not only does it encourage the flow of blood along the artery, it increases the pressure pushing the blood through the artery wall and diffusing into the cells of the heart muscle. To understand the effects, put the fingers of one hand together, place them over your mouth and breathe through them. If the fingers are tightly clamped to each other it is difficult to breathe. If they are loose then it is easy to breathe. The harder you blow (increasing the pressure) the more air passes through. So if the heart cells are inflexible and tightly bound to each other then the blood can only diffuse through with difficulty. Increasing the arterial pressure will therefore cause more blood to flow through a stiff muscle. Improved blood flow will help the heart cells themselves to become more flexible, changing the chemical and energy balance of individual cells. The muscular sponge is diffused with more blood and therefore more energy. More energy means the heart can pump more efficiently – more blood pumped around the body. A virtuous circle of improvement.

EECP therefore makes sense – improved blood flow in the heart without invading the body. Great benefits without expensive advanced surgery and intensive nursing.

The Not so Short Explanation

A Potted Physiology of the Heart for non-Medical Types

The heart pump works by regular contraction and relaxation of the heart muscle around 4 chambers through which the blood flows, one way valves at the entrance and exit of each chamber allowing the blood pressure to increase to overcome the resistance of the body’s blood vessels. To do this 40 million times a year the heart needs a very reliable control system and a source of energy.

The cells of the heart muscle are different to a normal muscle, reacting automatically to changes in electrical voltage to contract and relax. The signals causing the contraction and relaxation are themselves generated in a part of the heart called the sino-atrial node. The strategic control (go faster, go slower ) comes from the brain and nervous system, the detail control is within the heart itself.

The energy for the heart to work comes from arterial blood; this is provided primarily through the coronary arteries. These spread out into a network of capillaries and fresh blood for each heart cell diffuses through from the capillaries. If insufficient blood is available, either due to blockages in the coronary arteries or faulty diffusion then the cells go short of energy and cannot operate properly. The result is very often angina or worse, heart attack.

Blockages or restrictions in the coronary arteries can occur because of atheroma, the build-up of fatty deposits. These build up in the walls of the coronary arteries and narrow the diameter of the artery. Narrowing also occurs as part of the body’s own control mechanism; the need for blood supply in the body varies all the time and one of the range of controls is to widen or narrow the blood vessels to cause less or more resistance to flow as required at the time. The body has a range of hormones and enzymes that control the diameter of each blood vessel, release of which is controlled by the nervous system. Clearly these have to operate very rapidly – just think how quickly you blush when embarrassed or excited! These hormones and associated chemicals have their main effect at the surface wall of the blood vessel – the endothelium, causing the cells to relax or contract. Narrowing is controlled by one set of chemicals and expansion by another set, so keeping the balance from second to second is crucial to the heart’s (and your) wellbeing.

If atheroma interferes with the flow of blood, so also will it interfere with the arrival and reaction of the control chemicals at the endothelium, reinforcing the spiral of ill effects. Some of the drugs prescribed for heart problems are designed to help the process of relaxation of the blood vessel, both improving the flow of blood and supplementing the natural reactions near the wall of the vessel. If these methods do not work properly, e.g. because too much fatty tissue interferes with flow even with medication and changes in lifestyle, the cardiologist will try to resolve the problem by either placing a stent in the diseased section or bypassing it completely with a graft. Both these are drastic interventions and EECP has been developed as another procedure to add to the battery of alternatives available, with the advantage of being non-invasive.

Note also that atheroma occurs not only in the large coronary arteries, but also in the much smaller capillary network – the essential interface to the heart muscle cells, again leading to flow restrictions and blockages in that area.

Pressure Waves and Flow in the Coronary Arteries

So how does a pressure pulse supplement the chemical processes occurring at the wall of the blood vessel and the diffusion of blood through the heart muscle? Recall that the leg cuffs are triggered at the point of closure of the aortic valve – the heart muscle has started to relax, which in turn removes the squeeze on the coronary arteries themselves, lowering their resistance to blood flow – the diameter increases. The coronary arteries are connected to the aorta just above the aortic valve so the pressure pulse sweeps into the coronary arteries with very little resistance. Because the aortic valve is closing, it does not affect the inside of the heart chamber (ventricle) in the same way.

This is where medicine and engineering get very close to each other as disciplines. Engineers get very interested when pressure waves occur in tubes because they cause several effects, especially at the surface boundary of the tube. Flow in anything - a tube, the atmosphere, a blood vessel - occurs because of a difference of pressure, the greater the difference - the greater the flow. A rapid change in pressure causes a rapid change in flow and, because of the friction caused by the uneven surface of the tube, these flow changes cause vortices. Vortices effectively stir up the fluid, leading to a speeding up of any chemical process that may be occurring. A good analogy for this effect is that of stirring a cup of tea (a vortex) to get the sugar to dissolve more rapidly. Hence the hypothesis is that an EECP pressure wave causes a significant improvement in the production and balance of the chemicals controlling the dilation and contraction of the coronary arteries – a good thing!

Pressure difference causes flow not just along the blood vessel, but also through the wall of the vessel. At this point of the cycle, the heart muscle is relaxing so the size and shape of the individual cells is increasing, as is the space between the cells, reducing the resistance to flow of blood – diffusion – through the structure of the heart muscle. If the pressure difference is then boosted by the pressure wave in the coronary artery, so the flow will also be increased – another good thing because the flow of oxygen to the cells is improved. There is some evidence also that EECP has a large effect on micro-capillary atheroma by promoting angiogenesis (working around the blockages) and vaso-dilation. This again increases the surface area available for diffusion of blood.

The result is that angina – essentially a signal that the heart muscle does not have enough oxygen to meet the demand upon it – should be reduced or, perhaps, even eliminated.

Experience as a patient

Every patient with coronary disease is unique. Each individual’s problem is made up many factors:- age, sex, genetic background, physiology, extent and degree of coronary and other disease, etc. The combination of these factors means that the individual’s response to treatments available is going to be different. Therefore it is difficult for the health care professional to be certain of the outcome of any individual course of treatment. He/she has to work from a combination of observation and shared experience in recommending any treatment.

This caution is as true with EECP as any other treatment. However, as already noted, it has great benefits from the patient viewpoint. One of the best medical principles is ‘Primum, non Nocere’ – ‘First, Do no Harm’ , and EECP certainly scores highly in this respect. . Because each patient has a unique set of symptoms inevitably, however, there will be a minority who will be disappointed, experiencing no perceived benefit. Clearly practitioners and websites discussing EECP will accentuate the positive aspects; therefore peer-reviewed results in medical papers are vital in evaluating the effectiveness of EECP

The experience of each patient is also an essential input both for the professionals evaluating the procedure and for patients contemplating a course of treatment. The reaction is overwhelmingly positive; there are several blogs and message threads showing these reactions [references TBA]. Most of these were generated during 2002-2004; for some reason more recently treated patients have been more reticent even though the results are still very good. The author – who has recently finished a course of treatment in the UK – has had an amazing outcome, far better than hoped for. No Angina!

It is hoped to develop a discussion, especially in the European context, of EECP, its benefits and background theory, to widen its availability in Europe. There are a lot of severely disabled patients who could benefit very quickly.

The discussion will, I hope , also cover the health economic benefits within the large state- funded medical systems in Europe such as the NHS in the UK

Heart Disease & EECP in Europe

2006-07-21T15:28:00.000+01:00

This blog has been set up for patients to share their experience in the use of EECP - External Enhanced Counterpulsation - to alleviate their symptoms of heart disease, especially angina. EECP in the United States has been extensively covered on the Internet, both professionally and for patient experience. It has also been used as a procedure in other parts of the world - indeed much of the early work was done in China.

EECP has been used also in Europe and I felt it would be useful to new and existing patients to relay some background and experience in the European context. European health systems are different to the US and the use of EECP could be vastly expanded with a corresponding increase in the quality of life for many people. I believe also that with the right organisation significant savings in healthcare support budgets for angina and heart failure patients can be made. Hence this blog has been set up . I hope that it will both help potential patients to understand more rapidly what is involved and also attract comment and information from health care professionals on its use.

Much of the information available on EECP has been written for medical professionals and is surrounded by a dense thicket of jargon, making it difficult for most people to follow. I am an engineer who has benefited very much from a course of EECP and I hope to post a description of the procedure that I hope will be easier to understand. I'll try to avoid engineering jargon! - we're just as bad as any other profession.

HP Masher - Rye Harbour UK