THERE IS A COMPANY HERE IN CALGARY, ALBERTA, CANADA, THAT HAS THE MACHINE; ONE MAN I KNOW WHO WAS ON DEATH'S DOOR 3 YEARS AGO DID THIS THERAPY INSTEAD OF BY-PASS SURGERY; IT WORKED EXTREMELY WELL; HE'S STILL ALIVE AND DOING GOOD - Keith Hunt
Enhanced External Counterpulsation Therapy for Heart Disease and More
Dr. S. Ramasamy1 is a cardiologist and noninvasive cardiology consultant specializing in heart failure management, whose innovative work centers around the use of enhanced external counterpulsation (EECP). In this interview, he discusses the use of EECP as an adjunct to or primary therapy for heart disease, and how it may benefit a number of other conditions as well, including diabetes.
I had the pleasure of meeting him and his wife at last year's annual Academy of Comprehensive and Integrative Medicine (ACIM) conference in Orlando. EECP is a really valuable yet oft-ignored resource in the treatment and prevention of heart disease. Ramasamy began working on an EECP research project when he came to the U.S. as a medical resident in 1998.
"When you have coronary artery disease or cardiac disease, you have multiple options to solve that," he says. "You have medical management. After the medical management phase, then you go for an angiogram. Through the angiogram, they are able to find out how many blocks you have in your coronary arteries.
Based on the blocks, you're either going to be a candidate for bypass surgery or peripheral angioplasty, or they may use a stent, which can be a bare metal stent, or a drug-eluting stent or a biodegradable stent. But what people don't know is there's another option called EECP, enhanced external counterpulsation.
What does EECP actually do? EECP, is a noninvasive way of treating the same cardiac disease without the intervention. At the same time, this treatment is able to significantly increase blood flow across the blocked artery, so the heart muscle can get more blood supply without you actually going for these invasive procedures, like bypass surgery and angioplasty."
Why EECP Is a Superior Treatment Choice for Heart Disease
A principal benefit of this treatment is that rather than surgically grafting one or more vessels, EECP allows your body to create new vessels without surgical intervention. It triggers the creation of thousands of tiny vessels that provide as much, if not greater, volume of blood to your heart. As noted by Ramasamy, while the main blood vessel that gets the graft or stent only contributes 30 to 40 percent of the blood supply going to your heart, the remaining majority is actually supplied by microvessels, which number in the millions.
When you do EECP, you not only increase the blood supply in the area that is blocked, but you're also increasing blood flow to the entire cardiac muscle. In other words, it's not specific to the ischemic area. Rather, it globally increases the blood supply across your heart muscle. "That's the great thing about EECP," Ramasamy says, "It's noninvasive. It can significantly increase the blood flow by using microvessel circulation, profoundly much better than the main vessel is able to supply."
How EECP Is Performed
EECP is a treatment name trademarked by VasoMedical, so what we're really talking about here is the concept of external counterpulsation or ECP. That said, during ECP treatment, the patient is asked to lie down on a treatment table that has a valve system. They wrap your lower limbs, including your calves, lower thighs and upper thigh region with inflatable cuffs, similar to that of a blood pressure cuff, which is hooked up to an electrocardiograph (EKG) machine.
The machine, through the EKG, senses your heart rhythm beat by beat. It then precisely times the inflation of large bladders around your pelvis and legs (similar to blood pressure cuffs) with the diastolic phase of your cardiac cycle. The cuffs inflate to a pressure around 260 to 300-millimeter mercury pressure. The compression starts at the bottom of your calves, moving sequentially upward, forcing blood from your lower limbs toward your heart.
The compression affects both the venous compartment and the arterial compartment. When the arterial compartment is compressed, the blood goes in the reverse direction.
Ramasamy explains, "It is timed in such a way that the main valve, the aortic valve, is closed, so the blood can directly route into the coronary arteries, which arise from the root of the aorta." As a consequence, it increases the blood supply to your coronary artery two- to threefold, which is similar to what you achieve with anaerobic or high-intensity interval training.
"Basically, your heart thinks you're performing something like a 6-kilometer fast running. That much blood is increasing in your coronary circulation. At the same time, it also compresses the venous system and increases the blood sent to your heart. In fact, it increases the cardiac output. These two functions are very important.
Increasing blood flow to the coronary artery is helpful for patients who have ischemia or blockage in the coronary artery. It is helpful to patients with heart failure, because it can increase the cardiac output. This procedure is done every day for one hour, done ideally five days or six days a week. It goes up to six to seven weeks continuously. In some patients, it can be also performed twice a day, [in which case] the treatment can be cut short and completed in almost three weeks' time."
EECP Is a Medicare-Approved Treatment That Can Benefit Many
In the U.S., EECP is covered by most insurance plans, including Medicare, if you have a diagnosis of angina or coronary heart disease resulting in angina. If you don't have insurance, it's still a far more effective and safer approach than surgical intervention. Thirty-five treatments will typically cost you about $5,000, and the results often last for about five years.
In India, EECP is offered to a much wider array of patients, including those with heart failure, coronary artery disease or a history of heart attack, and Ramasamy believes it has great potential not only for angina but also as a primary treatment for heart failure.
I first became aware of EECP in the mid-'90s. I was very skeptical at the time because I felt one could just exercise and get the same benefit. I was wrong about that, however, as it's absolutely impossible to reproduce the "exercise" that EECP creates. Physics and biomechanics simply don't allow it.
The Difference Between Exercise and EECP
Exercise alone cannot cause the pressure to increase during the diastolic (resting) phase of the cardiac cycle, causing the blood to flow upward. Your body simply does not work that way. That's the magic of EECP, because during the diastole phase, when you have an increase in blood return to your heart, it pushes the blood upward, causing this massive increase in collateral blood vessels in the heart.
Exercise will promote microvessel formation too — but you must be healthy to do it, since it requires high levels of exertion. Ramasamy explains the difference between EECP and exercise further:
"No. 1, most cardiac patients are so sick they cannot even walk for three or four minutes without resting. Probably, they have an effort angina or an exertional angina. Even a minor increase in exercise [causes] angina pain. This group of patients, obviously, you cannot push them to do exercise. Even if you push them to do an exercise, they may not be able to achieve more than three to four minutes of walking. Basically, for patients who cannot exercise, EECP is a good option.
I will also add another thing. If you compare EECP to exercise, that's a good comparison. But let's say that somebody who is not athletic, or they have body strain, you put them on a sudden increase in exertion, you ask them to run maybe a kilometer or a mile, they're not trained to do so. So, their heart rate increases and their blood pressure shoots up. Basically, the heart is trying to pump so hard because of the increased pressure and heart rate.
Probably the effort of exercise won't reach them, because they're going to struggle by increasing their exercise. But when you do EECP, the opposite happens. It keeps your blood pressure down. In fact, during EECP, because it relaxes your vessels, your systolic pressure goes down. Your heart rate is kept constant.
By keeping your blood pressure down and heart rate constant, you only increase the blood flow to the coronary [artery]. You're getting maximum benefit — more than exercise can do — without actually doing exercise. It's kind of a passive exercise that we can do for anybody. This is an advantage of EECP — in both the cardiac patient and also noncardiac patient who are not doing regular exercise."
How Quickly Can You Get Results and How Long Do Benefits Last?
Here's yet another way to explain it: During normal systolic blood pressure, the 120 systole — the top number of your blood pressure — all your organs get maximum blood supply. During the diastole phase (the bottom number of your blood pressure) the pressure drops — in the case of "ideal" blood pressure, it's down to 80.
During EECP, the opposite occurs. In the systolic phase, due to increased cardiac output, all the organs get increased blood supply, and during the diastolic phase, because of the cuff compression, blood supply is increased, allowing all your organs to get again maximum blood supply both during the systolic and diastolic phases.
"Basically, during EECP, you're getting a dual blood supply rather than the single blood supply fully depending on the systolic phase," Ramasamy says. Typically, in cardiac patients, by the 15th to 20th session, collateral circulation starts increasing, and most patients start to feel much better at this point.
Also, during EECP the sheer stress due to increased flow across the entire vascular system causes your body to respond through endothelial cells that line your blood vessels. It secretes growth hormones, and nitric oxide is also increased, which benefits your health.
"We have seen in a lot of trials that the nitric oxide levels shoot up three to four times the normal value. Because of that, in cardiac patients, vasodilatation can happen and symptoms drastically [reduce]. At the same time, the collateral circulation also starts taking place after 15 sessions. Another 20 sessions are given for the maintenance for the cells.
When you do the treatment for a long period of time, up to 35 sessions, all the new collateral vessels formed will become a permanent conduit. Even after you stop the treatment the benefit has been shown to last for up to five years."
Now, I want to make it really clear here that ECP is not a magic bullet. But it's a very useful tool, and a far safer and less expensive and superior treatment than angioplasty or bypass. Ideally, it would be used in addition to lifestyle changes such as implementing a cyclical ketogenic diet, so that, eventually, you can get into a regular fitness program. In such a case, EECP can be a very powerful synergistic tool to change your life around.
EECP can also be helpful for erectile dysfunction, as it increases blood flow in the lower part of your body. "We never even recommended it, but there are people coming [to our clinic] from the Middle East, just for erectile dysfunction," Ramasamy says. It will also help flush out your lymphatic system, reducing peripheral edema.
How EECP Can Benefit Prediabetics and Type 2 Diabetics
While treating cardiovascular disease is probably is the most important benefit, EECP also has a number of other health benefits. It's really useful to view this modality as a form of passive exercise. Like exercise, it has many of the same benefits. For example, it decreases insulin resistance and is useful for the treatment of diabetes. According to Ramasamy, increased attention is now being given to EECP as preventive care.
"For example, we have seen patients with the glucose intolerance … These are the group of patients who are not considered normal or diabetic; they are in between. The blood sugar level is not close to normal, which it is supposed to be.
When we put them on EECP, it actually reverses the blood glucose level to normal. That's a fantastic finding, because what happens is it drastically reduces both the fasting as well as the postprandial blood sugar level, and now these patients are considered normal (nondiabetic). We still don't know the exact mechanism of how it is able to reduce insulin resistance and how it is able to reverse the diabetic to normal.
But one of the reasons is because EECP is a form of aggressive exercise. It has the effect of increasing blood flow to the pancreas. It also increases glucose utilization in skeletal muscle. Because when you put on the cuff and it inflates and deflates for 35 days, somehow, the receptors in the muscles are stimulated. They are able to absorb this blood sugar level from the circulation and blood sugar level comes under control.
When treating cardiac patients who are also diabetics with EECP, we've seen them go hypoglycemic (a significant decrease in blood sugar level). When we evaluated these patients, we realized EECP caused a significant drop in blood sugar level, and we were able to reduce their antidiabetic drug and insulin dosage.
It also reduces the bad (low-density lipoprotein or LDL) cholesterol and significantly increase high-density lipoprotein (HDL) levels … [S]tatins can reduce your LDL level, but it won't increase your HDL level. If you want to look into increasing the HDL in addition to the exercise, you'd want to be taking some fish oil. But I think EECP is a first treatment modality, which not only decreases your LDL, but significantly increase your HDL levels also,"Ramasamy says.
EECP for Heart Failure and Hypertension
Diastolic dysfunction is one of the most important and interesting issues. Most people think heart failure is when the systolic function declines, such as when your ejection fraction number goes down from 60 to 50 percent.
This is called reduction in left ventricular function. Heart failure occurs at 40 percent. It's known as systolic dysfunction. The second type of dysfunction, which is equally common and comprises half of all heart failure is diastolic dysfunction. We still don't have any proper medical management for the treatment of diastolic dysfunction.
"EECP has shown very good promise in initial studies. We have good experience in treating these patients with diastolic dysfunction. How does EECP help these patients? When we inflate and deflate the cuffs, the deflation causes dilation of your blood vessels.
So, your heart can now easily pump the blood in to the dilated vessels, causing the diastolic pressure to come down. It's a very important parameter to assess the diastolic dysfunction. The overall stiffness of the ventricle is reduced.
Heart failure is becoming a big epidemiological disaster in the U.S. We have medical management and device-based management for heart failure. This has shown to improve quality of life and decrease the mortality, but what they couldn't achieve is a decrease in repeat rehospitalization."
This is an area where EECP can be very useful. Once you are admitted for heart failure, your chances of repeat hospitalization within 30 to 60 days is between 30 and 50 percent. "It's a huge percentage. We have shown that if you put them on EECP immediately after they come back from being hospitalized, the rehospitalization rate drops to 15 percent," Ramasany says, adding:
"EECP is a very good treatment for heart failure because it improves the circulation to the myocardium. Because it increases the blood supply to the myocardium, the muscle contracts much better than before. It improves your LV function, which is the ejection fraction. It improves your quality of life. It is also able to reduce rehospitalization rates, and improve survival."
One of the side effects of heart failure is that it causes the left ventricle to enlarge, a condition called left ventricular hypertrophy. Initially, when EECP was introduced in the U.S., heart failure was a contraindication for EECP, and the reason for that is because when you push blood back into the heart, if the heart is too weak to pump the blood outside the ventricle, if there was a back pressure, the blood will go to the pulmonary artery.
When the pulmonary artery wedge pressure increases, it causes pulmonary edema, which was very common among heart failure patients undergoing EECP. However, we can now successfully treat heart failure patients by altering the timing of the inflation and deflation of the cuffs.
"Thereby we can increase the cardiac output without putting the patient at the risk of pulmonary edema. Also, one of the important factors, which can predict the outcome in patients with heart failure, is left ventricular end diastolic volume.
If the ventricle is dilated then your end diastolic volume will be greater, causing increased mortality and repeat hospitalization. We have shown in our study that 35 sessions of EECP treatment actually reduces the end diastolic volume, so left ventricular enlargement improves with increase ventricular contraction power."
High blood pressure is another condition that can be improved with EECP. Most of the patients undergoing EECP for coronary artery disease will also have hypertension. They are on medication to control their hypertension, and sometimes they have high blood pressure in spite of medication. EECP has been shown to decrease systolic blood pressure by about 15- and 10-millimeter mercury pressure respectively after a one-hour session, which is quite significant.
The reason for this decrease is because you inflate and deflate the cuff around the lower limbs, which constitutes to 60 percent of your peripheral vascular resistance, which is the cause for increases in blood pressure.
After about 35 days of treatment, the increased nitric oxide secretion from the endothelial cells will begin to dilate your blood vessels. Once the blood vessel is dilated there is a drop in the peripheral vascular resistance, thereby lowering your systolic blood pressure. So, EECP treatment has a positive effect on your cholesterol level, blood sugar level and systolic pressure level. These effects show EECP has a great potential as a preventive tool.
EECP Effect on Your Lymphatic System
EECP can also flush out the lymphatic in the lower extremity. Many of the patients undergoing EECP have edema, either venous or lymphatic, but after EECP the pedal edema does go away. "Probably, EECP not only causes reverse flow in arterial system and improves venous flow, it may also have some effect on the lymphatic system, but it's not been studied yet," Ramasamy says. A common experience during EECP is the urge to empty your bladder. In response to why that happens, Ramasamy says:
"I would comment if the patient wants to empty the bladder often during the treatment, then their lower limb vasculature is very good. When we give the compression in the lower limbs, there is an increase in coronary perfusion pressure around 40 percent, then a 20 percent increase in cerebral perfusion pressure, but in renal there's a 130 to 140 percent increase in blood flow.
Such an amount of blood flow can increase your glomerular filtration rate and increase urine output in the bladder. Also, since there is an increase in blood flow in the pelvic area, it's very effective in patients with erectile dysfunction."
EECP Shows Promise for Alzheimer's
Last but not least, EECP also shows promise in the prevention of dementia, as it increases vascular flow to your brain. During EECP, there's a 20 percent increase in the cerebral perfusion pressure. This increases the blood flow to your cerebral cortex also.
"I think this should be a treatment for senile dementia or Alzheimer's disease," Ramasamy says. However, randomized studies are still needed to confirm the benefits. Again, just like in the treatment of heart disease or coronary artery disease, EECP is not a magic bullet. But certainly, in conjunction with other effective strategies, such as those detailed in Dr. Dale Bredesen's book, "The End of Alzheimer's: The First Program to Prevent and Reverse Cognitive Decline."
Again, the primary condition that EECP is recommended for is heart disease, and angina more specifically. If your doctor has been recommending that you get a bypass, or angioplasty or a stent, then EECP is something you should seriously consider before you opt for surgery. Even if you have to pay for it out of pocket, it's going to be far better than subjecting yourself to surgery, which does nothing to treat the cause of the disease.
At least ECP addresses the physiological mechanisms, giving you not just one, but thousands of bypasses all over your entire heart, while simultaneously improving your blood pressure, cholesterol ratios, insulin sensitivity and lowering your risk for dementia. It even increases cardiac stem cells naturally, which decreases your risk of myocardial infarction and death. Stem cells also increase in peripheral circulation, so EECP appears to have a global effect on stem cell production.
"I would explain EECP as a vascular reversal treatment. Anything that is related to vascular or blood flow, I think EECP can be worth it," Ramasamy says. "It's like aggressive exercise on your vascular system. Any vascular disease usually responds to EECP." That also includes peripheral vascular disease or peripheral arterial disease, which can be very painful, and has few effective treatment options.
"Peripheral vascular disease patients have severe classification pain. The calf muscle will be severely painful when the patient starts walking due to lack of blood supply to the skeletal muscle.
The EECP effect is not specific to any vessels but it's a vascular reversal treatment. In patients with peripheral vascular disease and claudication pain, when we apply EECP there is a decrease in peripheral vascular resistance and promotion of collaterals in lower limb. So the patient is able to improve their exercise time," Ramasamy says.
On Chronic Stable Angina Management
The management of chronic stable angina is complex. Angioplasty and stents have failed to show benefit in multiple randomized control trials. Studies show it cannot improve quality of life, cannot increase longevity or prevent a heart attack. EECP, on the other hand, has been shown quite useful. Ramasamy explains:
"EECP has three important functions. It can be initially used as a primary treatment. If you have diabetes, hypertension or hypercholesterolemia, you can use it as a preventive tool and improve your endothelial function to secrete more nitric oxide and restore your endothelial function to normal.
If you don't use it as a preventive tool and you have a coronary heart disease and chronic stable angina, EECP may also play a major role because, again, it can improve your collateral circulation and angiogenesis. It can improve your blood supply to the ischemic area, without manipulating your coronary artery by bypass and angioplasty.
Third, if you did a bypass and angioplasty and it fails due to graft occlusion or stent restenosis, which are very common, then EECP is the only option. Finally, the end stage: If you did all these things, and your heart is still not able to recover from the shock due to myocardial infarction and you go into heart failure, EECP again plays a major role. I think EECP should be used more than what is currently being used in the U.S. and India.
When you have a heart attack … your heart muscle is going to die. There is no metabolic activity that happens in the myocardia. The surrounding myocardium is also suffering from ischemia, which is always associated with death. There are dead cells when there is ischemia. Procedures, whether bypass surgery, an angioplasty or an EECP, are able to recover this ischemic cell back to normal.
But once the damage is done, which happens in heart failure, I don't think the EECP or any other interventional procedure is able to recover or reverse the dead cells. For infarction, they usually go for fibrosis and It cannot be recovered. But the ischemic cells surrounding the infarction can recover."
For more information about Ramasamy and how EECP can help you, see https://www.healurheart.com There, you'll also find a long list of scientific studies relating to the use of EECP. Physicians who want to learn more about EECP and how you can offer it to your patients, check out ECPTherapy.com.