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What is Angina?

Angina pectoris literally means ‘strangling in the chest’. It is the most common symptom of coronary artery disease. The majority of patients with angina complain of chest discomfort provoked by mental, physical or emotional stress. The discomfort can vary widely among patients who report shortness of breath, fatigue, indigestion, faintness, pain in the chest, arm, neck, or jaw and other symptoms.

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What causes Angina?

Angina signals the brain that a part of the heart muscle is not receiving an adequate supply of blood and oxygen. The heart requires a particularly rich blood supply because of its heavy workload, and receives this nourishing blood supply through the coronary arteries. When narrowed or blocked arteries restrict blood flow, oxygen supply to portions of the heart may at times be insufficient. Increase in oxygen demand can occur during exercise, fever, rise in emotion, periods of hypoglycemia, or after meals, triggering the onset of angina.

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How does Angina affect people?

Angina often occurs when exertion outstrips the ability of narrowed or blocked coronary arteries to supply blood to the heart muscle. Angina restricts activity for many patients. They are able to walk on flat surfaces, but not uphill nor while carrying packages. For some, angina is disabling as it interferes with their ability to work or engage in almost any activity.

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What is ECP?

ECP is a non-invasive, non-surgical outpatient treatment for patients suffering from coronary artery disease and heart failure. Clinical studies over the past several years have shown that most patients treated with a single course of ECP experience a reduction in angina and are able to return to an active lifestyle.

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Who will benefit from ECP?

Cardiac Patients who suffer from:

  • Angina
  • Myocardial infarctions (heart attack)
  • Congestive heart failure (even on maximum medication)
  • Poor left / right ventricular function
  • High risk for angioplasty / stent and bypass surgery

Cardiac associated patients who:

  • Are elderly and high risk for surgery
  • Cannot afford angioplasty and bypass surgery
  • Have conditions that increase the risk of surgery e.g. diabetes, heart failure, lung disease and renal disease.
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What other conditions can benefit from ECP?

Other Benefits of ECP include:

  • Decrease in blood pressure
  • Decrease in blood sugar
  • Decrease in erectile dysfunction
  • Decrease in chronic fatigue
  • Quick recovery from sports injuries
  • Improvements in sports performance
  • ECP can also be performed on patients who want to undergo the treatment as a prophylactic (preventative) procedure to ensure a healthy lifestyle. External Counterpulsation (ECP) also has great benefits as a treatment for sports medicine.
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What does ECP do?

ECP causes immediate and sustained increase in the heart’s blood supply by:

  • Dilating coronary blood vessels
  • Opening dormant (unused) collateral vessels
  • Stimulating the release of growth factors
  • Establishing shunts from other vessels
  • Forming new blood vessels (angiogenesis)
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How is ECP treatment performed?

During the treatment patients are hooked onto an ECG machine while they lie on a bed on which sets of electronically controlled inflation valves are located. These valves are connected to specially designed adjustable cuffs that are wrapped firmly and comfortably around the patient’s calves, thighs and buttocks. While the heart is in the resting phase, the cuffs are inflated rapidly and sequentially from the calves towards the buttocks. The cuffs are then deflated instantaneously just before the heart beats. This causes the heart muscle to receive an increased blood supply while reducing the heart’s workload.

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What is the duration of ECP treatment?

A typical course of treatment requires patients to attend one-hour treatment sessions once a day, five days a week, for seven weeks in order to complete 35 sessions altogether. Alternatively, patients can attend two one-hour sessions, thirty minutes apart, in order to complete the treatment in 17 sessions. Some patients may require more than 35 hours of treatment to achieve optimal benefits. Patients can continue working during the course of the treatment by scheduling early or late afternoon appointments.

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Is the treatment safe and comfortable?

Yes, the treatment is very safe. ECP is painless and patients will only feel a tight hugging from the cuffs. Patients may read, listen to music, watch a movie or simply relax during the therapy.

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Is ECP approved?

  • External Counterpulsation (ECP) was cleared by the Federal Drug Administration (FDA) in 1987.
  • Medicare/Medicaid insurance coverage began in 1999.
  • Leading cardiology centers like Mayo Clinic and Cleveland Clinic use ECP.
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What are the advantages of ECP over other treatment?

  • ECP is the only treatment which is neither invasive nor pharmacological
  • ECP is a completely non-invasive and outpatient procedure
  • ECP treatment carries very low or no major adverse event during treatment
  • ECP is effective in small vessel of the heart and those that are too small for bypass surgery and angioplasty and is the main reason why ECP is still effective when other procedures have failed
  • The effectiveness of ECP seems to be similar in both diabetes and non-diabetes (Circulation 000; 02-18)
  • ECP can be safely administered even in patients with left ventricular dysfunction with ejection fraction lower than 35%
  • ECP benefit seems to be similar in both ischemic and idiopathic cardiomyopathy (CHF. 2002; 04-8,227)
  • ECP is cost effective and a very safe treatment that is painless and needs no hospitalization will feel much more energized.
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Are there downsides to the procedure?

The length of treatment may be a consideration for some people. It can take between four to seven weeks to complete a course of ECP treatment. During that time, patients must visit an outpatient clinic and receive treatment for one to two hours per day. Some patients with more extensive disease may require more than one course of therapy to achieve optimal relief.

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Are there any risks or complications involved with ECP treatment?

Bruising of skin (ecchymoses) - Literature shows that a very small percentage of patients experience slight bruising when using elastic tights. However, at SAECP, we have not experienced this problem due to the microfiber attire that we supply our patients with.

Tightness of calf muscles - This generally happens in the less agile patients and may last one to two days. NB. Patients should be properly assessed to ensure that they are suitable candidates for ECP in order to reduce the risks or complications.

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Doesn’t the inflation of the cuffs put added stress on my heart?

Actually, the heart is relaxed while on the ECP machine. On inflation of the cuffs, ECP aids the filling of the heart when the heart is in it’s relaxation phase and expands the coronary arteries. Thereafter, the cuffs deflate when the heart begins to pump again,  and this creates a vacuum effect, or a lower-pressure system for the heart to pump into, thereby decreasing the load on the heart, and thus reducing the work your heart has to do.

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Will ECP remove blockages in the arteries?

The procedure does not remove the blockages, but rather grows new collateral vessels around the blockages. It is in this way that ECP creates the “natural bypass” system. What this means is that instead of going through the process of removing a vessel from the leg, cutting open the chest and grafting this vessel onto the heart, ECP allows your heart to grow new vessels naturally, and non-invasively.

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Are there precautions to take while receiving ECP?

Patients should continue taking their medication at the regular prescribed dosages throughout the course of treatment unless advised otherwise by their physician.

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How will patients know that they have improved?

  • Patients will have symptomatic and clinical relief
  • There will be a reduced need for medicines
  • Frequency and intensity of chest pain will be reduced
  • Exercise tolerance will increase
  • Improvement in one’s sense of well-being
  • Improvement in the quality of life
  • Patients will be able to lead a more active lifestyle
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How soon can the patient expect improvement?

Because each individual’s-condition is unique, results vary from patient to patient. However, studies have shown that patients tend to improve between 10 and 20 treatment sessions, although others may require a longer time.

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How long has ECP been used to treat Angina?

In 1989, researchers at the State University of New York at Stony Brook began clinical studies of ECP treatment. Until the summer of 1995, ECP therapy was only available to patients participating in clinical studies. Today, ECP treatment is available at treatment centers throughout the world.

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Does ECP eliminate the need for Bypass surgery?

Unlike procedures such as bypass surgery and balloon angioplasty, ECP treatment is administered in an outpatient session, carries little or no risk, and is relatively comfortable. Some patient with more extensive disease or who have disease of the left main coronary artery may require bypass surgery. ECP treatment is an option for patients who are unsuitable for invasive procedures or unwilling to undergo them. For patients who have undergone multiple invasive procedures and for whom additional surgery carries excessive risk, ECP treatment may be the only way to obtain relief from crippling angina.

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How sustainable is ECP treatment?

Data from the international ECP Patient Registry (IEPR) by the University of Pittsburgh’s Graduate school of public Health, USA, suggest that the reduction in angina following ECP treatment is frequently sustained for up to 2 years post treatment. Follow up studies suggest that the benefits of ECP persist for up to 5 years or more.

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What evidence is there to show ECP opens dormant collaterals and also stimulate new vessel formation (angiogenesis)?

After ECP treatment the patient will experience the following benefits:

  • Increase exercise time without chest pain
  • Complete freedom from agonizing chest pain or decrease in the chest pain frequency and intensity
  • Improvement in overall health
  • Decrease or no need for anti-anginal medications
  • Patients feel more comfort for participating in social activities without fear of getting chest pain
  • Some patients with severe three-vessel disease may need more than 35 hours of treatment, which will be determined by his cardiologist by assessing his improvement. Usually one course of treatment is sufficient up to 5 years according to the available long time follow up study. Few patients may require additional course of treatment according to the severity of coronary artery disease.
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How can the cardiologist assess the patient’s improvement?

The cardiologist assesses:

  • Treadmill exercise time
  • Time to ST segment depression
  • Stress perfusion study at the same cardiac work load (83%) (American Journal of Cardiology, April 2002)
  • Ejection fraction
  • End diastolic filling pressure
  • Regional ischemial and regional myocardial blood flow reserve evaluated by ammonia positron emission tomography.
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Will angiography or stress thallium show improvement?

Angiography cannot visualize small arteries like arterioles and capillaries and cannot assess overall blood flow in a particular area of heart. For this purpose Stress Thallium and Cardiovascular Cartography are required. Improvement with ECP has also been documented by Stress Thalluim Test.

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Is there a difference between ECP and EECP?

ECP vs. EECP® There has been much discussion in the world of cardiac medicine as to the differences between EECP® (Enhanced External Counter Pulsation) and that of ECP (External Counter Pulsation). Many incorrectly assume that EECP® is an improved version of Cardiomedics, Inc.’s CardiAssistT ECP system and thereby provides more therapeutic value to a cardiac patient. The official governmental definition for both EECP® and ECP is exactly the same and is defined as a non-invasive treatment for patients with coronary artery disease that suffer with angina (chest pain), congestive heart failure (CHF), cardiogenic shock, and myocardial infarction. Coverage for ECP is provided only for patients who are diagnosed with angina (class III or Class IV or equivalent classification) and who, in the opinion of a cardiologist or cardiothoracic surgeon, are not readily amendable to surgical intervention. EECP® is a trademark of one ECP manufacturer and is nothing more than a marketing term. There are also ECP companies who are now promoting SECP (Super External Counter Pulsation) systems, which are standard ECP systems with the term “super” being merely a marketing ploy. All commercially available ECP systems are the same in that they pump the calves, thighs and buttocks of patients.

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If ECP works so well, why haven’t I heard about it before?

ECP is an established form of treatment worldwide and has only been recently brought to South Africa. Hence, patients and health professionals alike are still learning about the benefits of this treatment.

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