EXTERNAL COUNTER PULSATION has applications for

many diseases relevant to India particularly cardiac

diseases. Now the treatment is available in most of the
leading hospitals of the world. In India, ECP is available at
Sibia Medical Centre, Ludhiana besides Escort Heart
Institute.
By Dr A.P.J.Abdul Kalam
President of India
2nd World Congress
On Interventional Cardiology
INTERNATIONAL NEWS

MEDICAL NEWS OF USE

 The no option patient
Even with bypass, ballooning and stent
the population of patients with angina
and no conventional treatment options
is increasing.

PROBLEM:
•Patients unfit for interventional procedures.
•Patients with failed intervention procedures.
•Patients with post intervention recurrence
•Patients not wanting intervention procedures.
•Patients not affording intervention procedures.
Option for no option patient
ANSWER:
ECP is an FDA approved treatment documented to increases
blood supply to the heart by 20-42%.

ECP (External Counter Pulsation) is the generic name

EECP, ASECP, Lifepulse, Cardiacassist, etc are brands

Life saving for many

APPROVED WORLD OVER:
•FDA (USA)
•CE (Europe)
•NHS (UK)
•National Drug Authority (China)
MENTIONED IN JOURNALS:
• Journal of the American College of Cardiology
• Cardiovascular Reviews Reports
• Cardiology
• Clinical Cardiology
• Journal of Critical Illness
• Journal of External Counter Pulsation, etc.
Papers published in Indexed medical journals
MENTIONED IN TEXT BOOKS:
Harrison’s principles of Int. medicine:
Edition 16th, Vol. II, Page 1441

ECP utilizes pneumatic cuffs on the lower extremities to

provide diastolic augmentation and systolic unloading of
blood pressure in order to decrease cardiac work and
oxygen consumption while enhancing coronary blood flow.
Recent trials have shown that regular application improves
angina, exercise capacity, and regional myocardial
perfusion.

Now in medicine books

Braunwald’s text book of Cardiovascular
Medicine: Edition 7th, Page 1308
“External counter pulsation is another promising alternative
treatment of refractory angina. Data suggest that ECP
reduces the frequency of angina and the use of nitroglycerin
and improves exercise tolerance and quality of life. In a
randomized, double-blind, sham – controlled study of ECP
for patients with chronic stable angina, counter pulsation
was associated with an increase in time to ST segment
depression during exercise testing and a reduction in angina.
It also reduced the extent of ischemia detected with
myocardial perfusion imaging.”

Now in medicine books

AVAILABLE WORDWIDE:
USA
Mayo Clinic
Johns Hopkins
Cleveland Clinic
JFK Medical Centre-Atlantis
Miami Heart Institute
Texas Heart Institute In countries big and small
Heart Institute of Nevada
Orange County Cardiology Accepted worldwide
UCSD Medical Centre
Beth Israel Medical Centre - New York City
CANADA
Uphill Cardiac Wellness Centre, Ontario
Inter-Link Vascular Solutions Inc., North York, Ontario
UK INDONESIA
The National Refractory Angina ISRAEL
Centre, Liverpool, ITALY
Hammersmith Hospital, London, MACAO
Hull Royal Infirmary, MALAYSIA
Beaumont Hospital, Dublin, JAPAN
AUSTRALIA SAUDI ARABIA
COLUMBIA TURKEY
FRANCE HONGKONG
GERMANY PAKISTAN
ARGENTINA
CHINA
THILAND INDIA

Available every where

The Natural History
As an artery develops plaques and causes increasing blockages,
- body compensates by expanding tiny branches (collaterals)
to make it possible for blood to detour around blockages.

PROBLEM ARISES WHEN

Collaterals are not enough to restore circulation because:
1. Development of collateral circulation is a gradual process
2. All do not have same natural ability to develop collaterals

ROLE OF ECP - To create collaterals naturally

i.e. NATURAL BYPASS

Creating Bypass naturally

ABOUT ECP
External = outside the body – no catheters, surgery or lasers.
Counter = raise diastolic & lower systolic blood pressure
Pulsation = in a pulsatile fashion.
* Effective
* Clinically Tested
* Non-surgical
* Non-invasive
* Non-pharmaceutical
* No Anaesthesia
* No Hospital Stay - No work loss
* Economical
* Safe & well tolerated

When there is little else medical science can offer

Brief Introduction
Developed by - Guangdong Provincial & Guangzhou Municipal
Commission of Science & Technology, Guangzhou Medical
Apparatus & Instrument Factory.
1983 - an America’s “Cardiovascular News”
reported this achievement on the front page.
1990 - approved by China National Drug
Administration.
2000 - approved by the FDA.
2001 Escort got India’s first ECP machines.
2002 Sibia Medical Centre got first ECP
(now have 3 ECPs)

Technology goes from East West

 All ECP systems consists of a:
 Control console
 Compressor Pumps and valves
 Cuffs

 1st generation - Hydraulic, positive pressure, Leg cuffs

 2nd generation - + Pneumatic (instead of Hydraulic)
 3rd generation - + Sequential
 4th generation - Positive + Negative pressure
 5th generation - + Arm cuffs
PATIENT SELECTION
INDICATIONS:
• Coronary Artery Disease
 Angina
 Patients not fit for surgery
 Those who do not want surgery or angioplasty
 Failed / Reblock after angioplasty or bypass surgery
 To improve cardiac status before surgery.
 Preventive for persons at high risk of heart disease
 Congestive Heart Failure (CHF)

First thing first

OTHER NON-CARDIAC INDICATIONS:
Cerebral ischemia
 Cerebral ischemia /Thrombosis/ Lacunar infarction
 Brain injury due to trauma or toxic gas inhalation.
 Transient ischemic attack (TIA)
 Senile Dementia of the Alzheimer's type
 Cerebellar ataxia
 Parkinsonism
 Hearing loss
 Erectile dysfunction(ED)
 Peripheral Vascular Disease
Note: ECP is used for heart diseases in USA.
• Being studied for ED and renal blood flow in USA
• Used for all the above indications in China.

Helps every where when circulation fails

CONTRAINDICATIONS
• Aortic Regurgitation
• Hypertension >180/110 mm Hg
• Uncontrolled arrythmia
• Heart rate of more than 120 beats per minute
• Sensitive skin
• Acute myalgia
• Inter-vertebral disc problems
• Hemorrhage / Coagulopathy
• Thrombophlebitis
• Amputated legs
• Uncontrolled congestive heart failure
Secret of success is to keep out of trouble
PATIENT PREPARATION
Inspect skin for cuts, bruises, or irritation.
Take all medications as ordered.
If using a diuretic – take after ECP.
No coffee, tea, etc before ECP.
No food or drink for 1½ hrs before ECP.
Wear tight-fitting / form-fitting underwear.
Wear exercise tights.
Before treatment sister notes progress in condition
Patients advised to urinate immediately prior to treatment.
Note weight, blood pressure, pulse, Respiratory rate
Patients advised: if uncomfortable inform immediately.
Patient demonstrated the use of alarm switch if any problem
Patients asked to keep an angina daily
Patient is encouraged to talk freely with the staff.
 THE TREATMENT
Patient wears exercise tights.
Patient lies on a padded bed.

Electrodes are applied to the chest.

Plethysmograph sensor placed on finger
or ear.
Compressive air cuffs wrapped around
each leg - calf, thighs, buttocks and
upper arm.

Steps to success
Cuffs attached to air hoses

Cuffs inflate / deflate: Microprocessor Timed and controlled

Inflation:
- During diastole - By compressed air.
- Sequentially: calves > thighs > buttocks.
Deflation:
- Just before systole - By negative pressure
Monitoring not guessing
• ECG
• Heart rate
• Counter pulse / Arterial pressure
• Inflation Deflation curve
• Inflation onset time
• Deflation onset time
• Treatment time
• Pressure (0.3 to 0.5 kgf/cm2)
29.4 to 49 KPa
A. Unassisted End Diastolic Pressure D. Reduced Systolic Pressure
B.Unassisted Systolic Pressure E. Diastolic Augmentation
C.Unassisted Diastole F. Assisted End Diastole Pressure
OPTIONS / ADJUSTMENTS:
Duration of treatment – 1 hour
Daily - one or two sessions
Total sessions – 35
Every or alternate beat inflation
Inflation onset
Deflation onset
ECP MECHANISM – SIMPLIFIED EXPLANATION
Cuffs inflate electronically timed during diastole using QRS signal

Cuffs inflation squeezes vascular beds in leg muscles

Blood is forced retrograde into the arteries > Aorta

Higher pressure in ascending Aorta transmitted into coronaries

Repeated increased Vaso-endothelial Cuffs deflate just

pressure & flow GF, etc secretion prior to systole &
during systole

Decreased vascular
1.Blood vessels Stimulates impedance & Vent
dilate formation of new workload
2.Dormant blood vessels
(angiogenesis)
blood vessels Increased cardiac
open up output.
Effect of ECP in Coronary Blood Flow
 EFFECTS OF ECP
HAEMODYNAMICS OF ECP
ECP increases blood flow to the heart,
brain and other vital organs
 Heart - 20-42%
 Brain - 22-26%
 Kidneys - 19%
 Increases heart's output (stroke volume) by 12%
 Reduces after load
 Increase in LVEF
- improves memory, renal function, erectile dysfunction etc
ASSESSMENT OF RESULT:
Feel better- Test better
Feel better-
 Reduced frequency of chest pain
 Reduced intensity of chest pain
 Reduced need for medication
 Increased exercise tolerance
 Improved quality of life
 Improved sense of well-being

Nothing like wellness

Test better
•Treadmill test (TMT)

Confirming success
Pre and post ECP
Stress Thallium

Success documented
CARDIOVASCULAR CARTOGRAPHY
MYOCARDIAL BLOOD FLOW PROFILE

Antero-septal 46 ml/min 32 % reduction Antero-septal 65 ml/min 4 % reduction

Infero-septal 35 ml/min 31 % reduction Infero-septal 50 ml/min 2 % reduction
Lateral 48 ml/min 32 % reduction Lateral 69 ml/min 4 % reduction
Global 61 ml/min 29 % reduction Global 87 ml/min 0 % reduction

Proving not guessing

 ANGIOGRAPHY
Collateral Development in Experimental Heart (Dog)
Before ECP After ECP

Subjective & Objective assessment

 ANGIOGRAPHY
Collateral Development in PAD

Before ECP After ECP

Evidence based
ECP in retinal ischemia
Clinical example

Before EECP

After EECP

2 days
follow-up

Werner D, Michalk J et al., Graefe’s Arch Clin Exp Ophthalmol (2001) 239:599-602
 SUCCESS:
Studies - up to 90% patients improve
DURATION OF EFFECTS:
Beneficial effects last 3 to 7 years or longer
ACCEPTANCE:
* In USA insurance reimbursement
* ECP - gone up by 6 %
* Angioplasty, CABG, etc: decreased by 7%
Side effects are mild but may include:

Very rare

Discomfort from the pulsatile movement / pressure buttocks

Chaffing, rash or skin irritation
Mild headache or dizziness
Muscle aches
MENTAL BLOCKS FOR ECP POPULARITY
It is useless – we have not read about it
How can such easy concept work
Quackery – if from east is suspect

2. Volume
1. Resistance

4. Pipe size
3. Pipe elasticity

5. Another Pipe
To easy to be true
MENTAL BLOCKS FOR ECP POPULARITY
It is useless – we have not read about it
How can such easy concept work
Quackery – if from east is suspect

Nitrates, Ballooning, Stent

2. Volume
1. Resistance

4. Pipe size
3. Pipe elasticity

5. Another Pipe
To easy to be true
MENTAL BLOCKS FOR ECP POPULARITY
It is useless – we have not read about it
How can such easy concept work
Quackery – if from east is suspect

2. Volume
1. Resistance
BP, IABP,
ECP 4. Pipe size
3. Pipe elasticity

5. Another Pipe
To easy to be true
MENTAL BLOCKS FOR ECP POPULARITY
It is useless – we have not read about it
How can such easy concept work
Quackery – if from east is suspect

2. Volume
1. Resistance

4. Pipe size
3. Pipe elasticity
Chelation
5. Another Pipe
To easy to be true
MENTAL BLOCKS FOR ECP POPULARITY
It is useless – we have not read about it
How can such easy concept work
Quackery – if from east is suspect

2. Volume
1. Resistance

4. Pipe size
3. Pipe elasticity ECP

5. Another Pipe
To easy to be true
MENTAL BLOCKS FOR ECP POPULARITY
It is useless – we have not read about it
How can such easy concept work
Quackery – if from east is suspect

2. Volume
1. Resistance

4. Pipe size
3. Pipe elasticity

5. Another Pipe/Collaterals
To easy to be true ECP, CABG,TMR, Stem cell
MENTAL BLOCKS FOR ECP POPULARITY
It is useless – we have not read about it
How can such easy concept work
Quackery – if from east is suspect

2. Volume
1. Resistance
ECP
4. Pipe size
ECP

5. Another Pipe
To easy to be true ECP
 Take home message
ECP should be considered in
anybody who still has angina despite
maximal medical therapy and prior to
purely elective revascularization
(angioplasty or bypass surgery) for
chronic stable angina and for those
having no other treatment option.
ECP is not the solution for every patient
– but it can be the right choice for many patients

The right choice

 Dare to Explore new treatments

SIBIA MEDICAL CENTRE

Mb: 98140-34818
Email: drsibia@gmail.com,
Web: www.SibiaMedicalCentre.com