EECP- Current Use and Patient Selectionmedcom.nz/wp-content/uploads/2015/05/E-Lawson-ACC031602-Use...
Transcript of EECP- Current Use and Patient Selectionmedcom.nz/wp-content/uploads/2015/05/E-Lawson-ACC031602-Use...
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EECP- Current Use and Patient Selection
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Current Patient Population Receiving EECP Therapy
Symptomatic coronary artery disease patients, responding inadequately to
medical therapy, who are poor candidates for PCI or CABG
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Symptomatic Coronary Artery Disease Patient distribution by treatment need and suitability
Medication
Needing intervention
Inoperable or high risk
Inoperable or high risk
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Treatments for Symptomatic CAD
Conventional • Calcium channel
blockers • Beta blockers • Nitrates • Percutaneous
Interventions • Coronary artery
bypass grafting
Other ■ Transmyocardial
revascularization ■ Spinal cord
stimulation ■ Enhanced External
Counterpulsation
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EECP Treatment consistent benefits...
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Precautions
(Few data exist on which to draw definitive conclusions but to ensure patient safety avoid)
• Decompensated heart failure or mote than trace edema
• Aortic insufficiency (moderate or severe) • Severe peripheral arterial disease (PAD) or active
thrombophlebitis • Arrhythmias interfering with system triggering
• Severe hypertension ( ≥ 180/110 mmHg) • Bleeding diathesis, INR > 2.0 • Pregnancy or potential for pregnancy
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Changes in retrograde diastolic aortic flow and cardiac output
0 0.5 1.0 1.5 2.0 2.5 3.0 EECP Effectiveness Ratio (D/S)
DTVI
STVI
0
5
10
15
20
25
30
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Pre-EECP During EECP (1 hour daily) Post-EECP
* p≤ 0.05 ** p ≤ 0.01 + p ≥ 0.05
*
* **
**
*
+
Wu GF, Quiang SZ, Zheng ZS, Zhang MQ, Lawson WE, Hui JCK, Circulation 1999; 100(18);I-832.
N = 43 CAD pts
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Independent Predictors of Improvement in Angina Class Post EECP
Variable Odds Ratio
CCS Class II 2.17
CCS Class III 5.29
CCS Class IV 6.69
Treatment Hours 3.47
Diabetes Mellitus 0.67
History of CHF 0.81
Prior CABG 0.76
Lawson W, Kennard E, Hui JCK, et al. Circulation 2000;102:II-689
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Pre-
EEC
P Po
st-E
ECP
Stress
Rest
Stress
Rest
Lawson WE, Hui JCK, et al. J Crit Illness 2000;15(11):629-36
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Improvement in Perfusion (as documented by thallium perfusion imaging)
Lawson WE, Hui JCK, et al. Am J Cardiol 1992;70:859-862
Improved reversible perfusion defects
Resolution of reversible perfusion defects
Per
cent
of p
atie
nts
Improved or resolved Perfusion defects
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Lawson W, Hui J, Lang G. Cardiology 2000;94:31-35
Enhanced External Counterpulsation Consortium
Patients improved after EECP treatment (%)
* Canadian Cardiovascular Society (Angina) Class
* (N = 2,289 pts)
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Lawson, Hui, et al: Am J of Cardiol, 77,1107-1109,1996
Resolved Partial No Effect 0
20
40
60
80 %
in E
ach
Gro
up
Resolved Partial No Effect 1 Vessel 2 Vessel 3 Vessel
74
8
58
33
21
32
5 10
59
Chi-square analysis p < .005 N=50
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EECP Benefit with CABG (N=60)
CABG No CABG 0
20
40
60
80
100
p<0.05 12/15 8/10 23/26
2/9
80% 80% 88%
22%
Lawson WE, Hui JCK, et al. Clin. Cardiol. 1998; 21:841-844.
86
14
85
15
53 47
Improved Unchanged 0
20
40
60
80
100
1 Vessel 2 Vessel 3 Vessel
% IN
EA
CH
GR
OU
P
18/21
3/21
% %
%
% %
% 17/20
3/20
10/19 9/19
p<0.05
1 & 2 Vessel 3 Vessel 3 Vessel 3 Vessel
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N=15 CAD pts
Sham <50 mmHg 12 hrs 24 hrs 36 hrs
Follow-up (6 months)
0
900
1800
2700
3600
4500
5400
12150
ZS Zheng: Trans of Am Society of Artificial Internal Organs, 1983;29:599-603
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Improvement in CCS Angina Class Post EECP Treatment (IEPR)
Lawson WE, Hui JCK, Kennard ED, et al JACC 2001;37:328A
Perc
enta
ge
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Sustained Improvement in CCS Angina Class Post EECP Treatment (IEPR)
Lawson WE, Hui JCK, Kennard ED, et al JACC 2001;37:328A
Perc
enta
ge
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International EECP Patient Registry (N=905)
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Cardiac Events in 6 Months Following EECP in Patients with and without CHF History (IEPR)
Lawson WE, Kennard ED, Holubkov R, et al. Cardiology 2001;96:78-84.
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Medicare Coverage For patients with a diagnosis of disabling angina pectoris who, in the opinion of their cardiologists or cardiac surgeons, are not readily amenable to invasive procedures because…
! They are inoperable or at high risk of operative complications or failure
! Their coronary anatomy is not readily accessible to such procedures
! Co-morbid states create excessive risk
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Future Indications for EECP
• CAD patients with inadequate response to medical therapy
• Treatment of MI (acutely, to prevent adverse remodeling, and to promote functional recovery)
• Treatment of Ischemic and ? Non-ischemic cardiomyopathy
• Secondary and ? Primary prevention of vascular disease progression