EECP Treatment Advantages and Disadvantages

Enhanced external counterpulsation (EECP) is a mechanical form of treatment for angina (chest pain).

While several clinical studies appear to show that this treatment can help reduce symptoms of angina in people with coronary artery disease (CAD), EECP has yet to be accepted by most cardiologists and has not entered mainstream cardiology practice.

Doctor and patient talking
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What Is EECP?

EECP is a mechanical procedure in which long inflatable cuffs (like blood pressure cuffs) are wrapped around both of the patient’s legs. While the patient lies on a bed, the leg cuffs are inflated and deflated synchronously with each heartbeat.

The inflation and deflation are controlled by a computer, which uses the patient’s electrocardiogram (ECG) to trigger inflation early in diastole (when the heart relaxes and is filled with blood), and deflation just as systole (heart contraction) begins.

The inflation of the cuffs occurs sequentially, from the lower part of the legs to the upper, so that the blood in the legs is “milked” upwards, toward the heart.

EECP has at least two potentially beneficial actions on the heart:

  • First, the milking action of the leg cuffs increases the blood flow to the coronary arteries during diastole. (Unlike other arteries, coronary arteries receive their blood flow in between heartbeats, not during them.)
  • Second, by deflating just as the heart begins to beat, EECP creates something like a sudden vacuum in the arteries, which reduces resistance in the blood vessels of the legs so that blood can be pumped more easily from your heart. It is also speculated that EECP may help reduce endothelial dysfunction.

EECP also may improve peripheral arterial function, which serves to reduce myocardial oxygen demand.

EECP is administered as a series of outpatient treatments. You'll receive five one-hour sessions per week for 7 weeks. The 35 sessions are aimed at provoking long-lasting beneficial changes in the circulatory system.

How Effective Is EECP?

Several studies suggest that EECP can be quite effective in treating chronic stable angina.

A small randomized trial showed that EECP significantly improved both the symptoms of angina (a subjective measurement) and exercise tolerance (a more objective measurement) in people with CAD. EECP also significantly improved quality-of-life measures compared to placebo therapy.

Other studies have shown that the improvement in symptoms following a course of EECP seems to persist for up to five years (though 1 in 5 patients may require another course of EECP to maintain their improvement).

How Does EECP Work?

The mechanism for the apparent sustained benefits seen with EECP is unknown. Some evidence suggests EECP can help induce the formation of collateral vessels in the coronary artery tree by stimulating the release of nitric oxide and other growth factors within the coronary arteries.

There's also evidence that EECP may act as a form of “passive” exercise, leading to the same sorts of persistent beneficial changes in the autonomic nervous system that are seen with real exercise.

Can EECP Be Harmful?

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

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

For anyone else, the procedure appears to be safe.

When EECP Is Recommended

Based on what we know so far, EECP should be considered in anybody who still has angina despite maximal medical therapy, and in whom stents or bypass surgery are deemed not to be good options.

Medicare has approved coverage for EECP for patients with angina who have exhausted all their other choices.

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

  • The American College of Cardiology
  • American Heart Association
  • American Association for Thoracic Surgery
  • Preventive Cardiovascular Nurses Association
  • Society for Cardiovascular Angiography and Interventions
  • The Society of Thoracic Surgeons

Why Isn’t EECP Used More Often?

The cardiology community has largely chosen to ignore such an unconventional form of therapy, and many cardiologists fail to even consider offering EECP as a therapeutic option. Consequently, most people with angina never hear about it.

That's unfortunate, as it doesn't seem unreasonable to allow patients with stable angina to opt for a trial of a noninvasive therapy, perhaps even before they are pushed into invasive therapy, when:

  • A noninvasive treatment exists
  • It's safe and well tolerated
  • It's supported by available evidence (albeit imperfect) that strongly suggests the treatment is quite effective in many
  • Those being treated can tell pretty definitively whether it substantially reduces angina symptoms

If you're being treated for stable angina and still have symptoms despite therapy, it's entirely reasonable for you to bring up the possibility of trying EECP. Your healthcare provider should be willing to discuss this possibility with you, objectively and without prejudice.

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

  3. Zhang C, Liu X, Wang X, Wang Q, Zhang Y, Ge Z. Efficacy of Enhanced External Counterpulsation in Patients With Chronic Refractory Angina on Canadian Cardiovascular Society (CCS) Angina Class: An Updated Meta-AnalysisMedicine (Baltimore). 2015;94(47):e2002. doi:10.1097/MD.0000000000002002

  4. Ziaeirad M, Ziaei GR, Sadeghi N, Motaghi M, Torkan B. The effects of enhanced external counterpulsation on health-related quality of life in patients with angina pectoris. Iran J Nurs Midwifery Res. 2012;17(1):41-6.

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

  6. Manchanda A, Soran O. Enhanced external counterpulsation and future directions: step beyond medical management for patients with angina and heart failure. J Am Coll Cardiol. 2007;50(16):1523-31. doi:10.1016/j.jacc.2007.07.024

  7. Frankel Cardiovascular Center Michigan Medicine. EECP (Exhanced External Counter Pulsation Therapy).

Additional Reading
  • Arora RR, Chou TM, Jain D, et al. The Multicenter Study of Enhanced External Counterpulsation (MUST-EECP): Effect of EECP on Exercise-Induced Myocardial Ischemia and Anginal Episodes. J Am Coll Cardiol 1999; 33:1833.

  • Fihn SD, Blankenship JC, Alexander KP, et al. ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2014; 64:1929.

  • Soran O, Kennard ED, Kfoury AG, et al. Two-Year Clinical Outcomes After Enhanced External Counterpulsation (EECP) Therapy in Patients With Refractory Angina Pectoris and Left Ventricular Dysfunction Am J Cardiol 2006; 97:17.