Enhanced external counterpulsation ameliorates endothelial dysfunction and elevates exercise tolerance in patients with coronary artery disease

Evaluation of Enhanced External Counter Pulsation (EECP) as an Alternative Treatment Modality for Hypertension: A Systematic Review and Meta-Analysis

This systematic review and meta-analysis evaluate the efficacy of enhanced external counterpulsation (EECP) in reducing blood pressure among hypertensive patients. From an initial 323 articles, 37 studies involving 1504 patients met the inclusion criteria, with 11 included in the meta-analysis. EECP therapy durations ranged from 0.75 to 36.5 hours, with the majority around 35 hours. Meta-analysis revealed a significant reduction in systolic blood pressure (SBP) [mean difference (MD), -7.85 mm Hg; 95% CI, -9.59 to -6.11; P < 0.00001; I2 = 0%]. Diastolic blood pressure (DBP) also showed a significant decrease (MD, -3.94 mm Hg; 95% CI, -5.56 to -2.33; P < 0.00001; I2 = 45%). Mean arterial pressure did not significantly change (MD, -3.08 mm Hg; 95% CI, -7.51 to 1.34; P = 0.17; I2 = 77%). Funnel plots and statistical tests indicated no significant publication bias for SBP or DBP changes. EECP therapy significantly reduces both SBP and DBP in hypertensive patients, suggesting its potential as an effective adjunctive treatment for hypertension. However, the effect on mean arterial pressure remains inconclusive. The therapy's noninvasive nature, coupled with its demonstrated efficacy, supports broader clinical application. Further research with larger sample sizes and standardized protocols is necessary to better understand the mechanisms behind EECP and its long-term benefits in hypertension management.

Research focus and theme evolution on enhanced external counterpulsation: A bibliometric analysis

Aims

The study delved into the identification of key research areas and evolving trends within the domain of Enhanced External Counterpulsation, aiming to gain comprehensive insights into the subject matter.

Methods

Utilizing the sophisticated search parameter of 'topic' (TS) on the Web of Science (WoS) database, the necessary information was retrieved. This research employed an array of tools for effective data extraction, analysis, and visualization, which included Microsoft Excel for tabular management, HistCite Pro for citation analysis, GunnMap for geographical mapping, BibExcel for bibliometric assessments, and VOSviewer for network visualization purposes.

Results

From its establishment up until March 31, 2024 a total of 535 entries were recorded in the WoS database, with 491 of these relevant to the specified subject matter. The USA was the most prolific country, and China ranked second. Sun Yat Sen University was the most productive institution, which was from China. And 80 % of the top 10 institutions were from the USA. A keyword co-occurrence analysis was conducted, revealing four distinct research foci. And they were the application of EECP in cardiovascular disease, the main indications of EECP, the mechanism of EECP and the therapeutic effect of EECP, respectively. Researchers paid the most attention to the application of EECP on the cardiac cardiovascular system. Professor Lawson WE, Hui JCK and Kennard ED were the top three prolific authors. Lawson WE, Henry TD, Braith RW and Zheng ZS were identified as the core authors in the author co-citation network analysis.

Conclusion

A comprehensive analysis was conducted on the literature surrounding improved enhanced external counterpulsation in this investigation, which can help researchers understand the theme trend better and grasp the research gap, to carry out further research and promote the progress of the topic.

The effects of enhanced external counter-pulsation on post-acute sequelae of COVID-19: A narrative review

Some of the millions of patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have developed new sequelae after recovering from the initial disease, termed post-acute sequelae of coronavirus disease 2019 (PASC). One symptom is anxiety, which is likely due to three etiologies: brain structural changes, neuroendocrine disruption, and neurotransmitter alterations. This review provides an overview of the current literature on the pathophysiological pathways linking coronavirus disease 2019 to anxiety, as well as the possible mechanisms of action in which an increasingly scrutinized treatment method, enhanced external counter-pulsation (EECP), is able to alleviate anxiety. SARS-CoV-2 triggers increased inflammatory cytokine production, as well as oxidative stress; these processes contribute to the aforementioned three etiologies. The potential treatment approach of EECP, involving sequenced inflation and deflation of specifically-placed airbags, has become of increasing interest, as it has been found to alleviate PASC-associated anxiety by improving patient cardiovascular function. These functional improvements were achieved by EECP stimulating anti-inflammatory and pro-angiogenic processes, as well as improving endothelial cell function and coronary blood flow, partially via counteracting against the negative effects of SARS-CoV-2 infection on the renin-angiotensin-aldosterone system. Therefore, EECP could promote both psychosomatic and cardiac rehabilitation. Further research, though, is still needed to fully determine its benefits and mechanism of action.

Old and new equations for maximal and anaerobic threshold heart rate prediction in coronary heart disease in Chinese population

BACKGROUND

The prediction of maximal heart rate (MHR) and anaerobic threshold heart rate (HRAT) in patients with coronary heart disease (CHD), particularly among the Chinese population, remains a significant challenge. Existing equations for MHR prediction are primarily designed for healthy individuals not on medication for optimized β-blocker (BB) therapy, showing limited efficacy for individuals on various drug regimens. Moreover, the prediction of HRAT lacks established formulas. This study aims to develop equations for MHR and HRAT, assess the accuracy of historical MHR formulas, and examine their correlation with HR measurements at the anaerobic threshold (AT).

METHODS

Among 2021 to 2023, 170 CHD patients were recruited. Patients were categorized into groups based on BB usage. BB dose was transformed into carvedilol dose. Multiple linear stepwise regression analysis was employed to identify predictors of MHR and HRAT, incorporating key patient variables according to prior studies (age, sex, height, weight, carvedilol dose, HRrest). The mean absolute percentage errors (MAPEs) were calculated and compared among abovementioned MHR and HRAT prediction formulas. Besides, the percentages of MHR in predicting HRAT among different formulas were calculated.

RESULTS

For the patients with BB medication, the simplified equations derived for MHR and HRAT were 176 - 1.2*age + 0.7*HRrest - 0.4*weight and 98 - 0.6*age + 0.7*HRrest - 0.3*weight, respectively. For those without BB medication, the derived equations for MHR and HRAT were 200 - 1.1*age and 91 - 0.5*age + 0.5*HRrest, respectively. There are significant differences between the results predicted by the new formula and the prior formulas. The new formulas are helpful for predicting the MHR of patients during exercise more accurately and guiding exercise training more scientifically.

CONCLUSIONS

The new equations for estimating MHR and HRAT in CHD patients enhance the accuracy of prior formulas. Given the BB impact on sympathetic nerve activity, the predictive formulas for MHR and HRAT were significantly improved.

Endothelial dysfunction: molecular mechanisms and clinical implications

Cardiovascular disease (CVD) and its complications are a leading cause of death worldwide. Endothelial dysfunction plays a crucial role in the initiation and progression of CVD, serving as a pivotal factor in the pathogenesis of cardiovascular, metabolic, and other related diseases. The regulation of endothelial dysfunction is influenced by various risk factors and intricate signaling pathways, which vary depending on the specific disease context. Despite numerous research efforts aimed at elucidating the mechanisms underlying endothelial dysfunction, the precise molecular pathways involved remain incompletely understood. This review elucidates recent research findings on the pathophysiological mechanisms involved in endothelial dysfunction, including nitric oxide availability, oxidative stress, and inflammation-mediated pathways. We also discuss the impact of endothelial dysfunction on various pathological conditions, including atherosclerosis, heart failure, diabetes, hypertension, chronic kidney disease, and neurodegenerative diseases. Furthermore, we summarize the traditional and novel potential biomarkers of endothelial dysfunction as well as pharmacological and nonpharmacological therapeutic strategies for endothelial protection and treatment for CVD and related complications. Consequently, this review is to improve understanding of emerging biomarkers and therapeutic approaches aimed at reducing the risk of developing CVD and associated complications, as well as mitigating endothelial dysfunction.

Hemodynamics of ventricular-arterial coupling under enhanced external counterpulsation: An optimized dual-source lumped parameter model

BACKGROUND AND OBJECTIVE

Enhanced external counterpulsation (EECP) is a mechanically assisted circulation technique widely used in the rehabilitation and management of ischemic cardiovascular diseases. It contributes to cardiovascular functions by regulating the afterload of ventricle to improve hemodynamic effects, including increased diastolic blood pressure at aortic root, increased cardiac output and enhanced blood perfusion to multiple organs including coronary circulation. However, the effects of EECP on the coupling of the ventricle and the arterial system, termed ventricular-arterial coupling (VAC), remain elusive. We aimed to investigate the acute effect of EECP on the dynamic interaction between the left ventricle and its afterload of the arterial system from the perspective of ventricular output work.

METHODS

A neural network assisted optimization algorithm was proposed to identify the ordinary differential equation (ODE) relation between aortic root blood pressure and flow rate. Based on the optimized order of ODE, a lumped parameter model (LPM) under EECP was developed taking into consideration of the simultaneous action of cardiac and EECP pressure sources. The ventricular output work, in terms of aortic pressure and flow rate cooperated with the LPM, was used to characterize the VAC of ventricle and its afterload. The VAC subjected to the principle of minimal ventricular output work was validated by solving the Euler-Poisson equation of cost function, ultimately determining the waveforms of aortic pressure and flow rate.

RESULTS

A third-order ODE can precisely describe the hemodynamic relationship between aortic pressure and flow rate. An optimized dual-source LPM with three energy-storage elements has been constructed, showing the potential in probing VAC under EECP. The LPM simulation results demonstrated that the VAC in terms of aortic pressure and flow rate yielded to the minimal ventricular output work under different EECP pressures.

CONCLUSIONS

The ventricular-arterial coupling under EECP is subjected to the minimal ventricular output work, which can serve as a criterion for determining aortic pressure and flow rate. This study provides insight for the understanding of VAC and has the potential in characterizing the performance of the ventricular and arterial system under EECP.

A Randomized Controlled Study of Enhanced External Counterpulsation with Cardiac Rehabilitation in Patients with Nonobstructive Coronary Artery Disease and Coronary Microvascular Dysfunction

Treatment with enhanced external counterpulsation (EECP) or cardiac rehabilitation (CR) benefits patients with coronary heart disease; this paper intends to explore the feasibility of EECP combined with CR in patients with nonobstructive coronary heart disease (NOCAD) and coronary microcirculation disorders (CMD).In January 2021-2022 month June our income NOCAD patients as the research object, the line of cardiac magnetic resonance (CMR), myocardial perfusion reserve (MPR) < 2.0 coronary microcirculation disorders (CMD, 80 cases). Random indicator method 80 CMD patients divided into two groups, 40 cases in each. Usual treatment group: conventional drugs and CR therapy. EECP treatment group: on the basis of standard treatment group, employ EECP therapy. Comparing the two groups before and after the treatment curative effect cardiac function index, endothelial unction index, adverse cardiovascular events, etc.After EECP treatment, the treatment group showed a higher effective rate compared to the usual treatment group (P < 0.05). EECP group curative effect, left ventricular ejection fraction,plasma NO and vascular endothelial growth factor levels higher than the usual group, the incidence of adverse cardiovascular events is lower than the usual group. The difference was statistically significant (P < 0.05).EECP combined with cardiac rehabilitation in patients with CMD symptoms has better effect and safety and provides reference for treatment of CMD patients.

Enhanced external counterpulsation increases coronary flow reserve in coronary microvascular disease

OBJECTIVES

To investigates the outcomes of enhanced external counterpulsation (EECP) among coronary microvascular disease (CMD) patients.

METHODS

Coronary microvascular disease patients were separated into the EECP (n=41) and control cohorts (n=42). Prior to and following the 4-week EECP program, coronary flow reserve (CFR) was recorded using transthoracic Doppler echocardiography. The serum endothelial nitric oxide synthase (eNOS) and endothelin-1 (ET-1) contents were analyzed by ELISA. Quality of life (QoL) was assessed by the Seattle Angina Questionnaire (SAQ) and the Canadian Cardiovascular Society (CCS) angina class.

RESULTS

After four weeks, CFR was substantially enhanced in the EECP versus control cohort (p<0.05). Endothelin-1 was strongly diminished whereas eNOS was considerably upregulated in the EECP cohort. EECP also enhanced patients' SAQ scores and decreased the CCS angina class.

CONCLUSION

Enhanced external counterpulsation may improve CFR and enhance the CMD patient QoL.

Impact of Enhanced External Counter-pulsation Therapy on Glycaemic Control in People With Prediabetes and Type 2 Diabetes Mellitus: A Systematic Review and Meta-analysis

Background: Enhanced external counter-pulsation (EECP) therapy is approved for refractory angina in coronary artery disease (CAD). EECP is being explored as a treatment modality in type 2 diabetes mellitus (T2DM). Methods: The Embase, Web of Science, Cochrane Library, MEDLINE (PubMed), ClinicaltTrials. gov, CNKI database, Clinical Trials Registry-india (CTRI), and Google Scholar databases were searched for randomized controlled trials (RCTs) involving patients receiving EECP therapy in the intervention arm. The primary outcome was the changes in glycated haemoglobin (HbA1c). The secondary outcomes were the changes in blood glucose parameters, inflammatory markers and any adverse events. Results: Data from 3 RCTs involving 71 people with T2DM/prediabetes was analysed to find out the impact of EECP therapy compared with placebo. As compared with placebo, patients receiving EECP had significantly lower HbA1C immediately after completion of therapy (mean difference [MD] -0.70%, 95% confidence interval (CI) -0.95. -0.45;p<0.00001), at 2-4 weeks post completion of therapy (MD -1.04%, 95%CI -1.32. -0.77; p<0.00001) and 7-12 weeks after therapy completion (MD -0.98%, 95% CI -1.22, -0.74; p<0.00001). EECP therapy was well tolerated without any increased side effects (risk ratio 2.36, 95% CI 0.11-52.41; p=0.59. Conclusion: EECP therapy is effective in blood glucose and pressure lowering over at least 7-12 weeks of therapy completion. Blood glucose and pressure should be monitored with suitable modulation of drug doses to prevent hypoglycaemia and hypotension in patients with angina undergoing EECP therapy. The PROSPERO registration number is CRD42023434533.