Clinical Information of EECP for Physicians

EECP Medical Timeline

Invented in the late 1950’s at Harvard University, early external counterpulsation (EECP) therapy was done with hydraulics at Harvard University. In the 1970’s, EECP was in use for acute myocardial infarction and cardiogenic shock.

The U.S. Food and Drug Administration cleared EECP in:

  • 1995: for chronic stable and unstable angina pectoris, cardiogenic shock, and acute myocardial infarction
  • 2002: for congestive heart failure

How EECP Works

EECP works by pumping blood from the legs upward to the heart while the heart is at rest. This mechanism improves circulation throughout the body, promotes angiogenesis, and has long-term, positive effects.

EECP Therapy Steps

(1) You lay on a comfortable EECP bed. Three blood pressure-like cuffs wrap around the lower extremities, (2) calves, (3) thighs, and (4) buttocks. (5) You are connected to a heart monitor.

To optimize therapeutic benefit, the cuffs are timed to a patient’s ECG while they squeeze the calves, thighs and buttocks in rapid sequence. In early diastole, while the heart is at rest, the cuffs inflate sequentially from distal to proximal, and then deflate in late diastole prior to onset of systole.

Sequential cuff inflation creates a retrograde pressure wave that augments diastolic pressure, increasing pressure of coronary perfusion and venous return to the right side of the heart. This increases preload and cardiac output.

Rapid, simultaneous cuff deflation decreases systemic vascular resistance after load and cardiac workload.

Mechanism of EECP

The squeezing mechanism of EECP improves the hemodynamics of blood flow and shear stress to help generate progenitor and hematopoietic stem cells in the bone marrow. This improves endothelial function while reprofusing organ tissue.

In addition, elevated levels of nitric oxide and vascular endothelial growth factor (VEGF) are evident during EECP. These elevated levels help improve circulation and stimulates angiogenesis, resulting in improved endothelial function, along with a reduction of both circulating inflammatory markers and arterial stiffness.

Mechanism of Action

The EECP mechanism of action provides the following clinical feedback throughout the therapy:

  • Increased venous return
  • Increased preload/stretch
  • Increased cardiac output
  • Retrograde arterial flow
  • Increased diastolic pressure
  • Increased intracoronary perfusion
  • Increased vascular recoil / systolic unloading
  • Decreased systemic vascular resistance
  • Decreased afterload

EECP & Endothelial Progenitor Cell Release

Endothelial Progenitor Cell Release

The Effects of External Counterpulsation Therapy on Circulating Endothelial Progenitor Cells in Patients with Angina Pectoris

Yosef O, Rosenthal E, Barbash IM, Matetzky S, Tal R, Bentancur AG, Sela BA, Nagler A, Leor J.

Cardiology. 2008;110(3):160-6. Epub 2007 Dec 4.

Summary: Circulating endothelial progenitor cells (EPCs) positive for CD34 measured by flow cytometry and kinase insert domain receptor (KDR) measured by the number of colony-forming units in 25 patients with angina pectoris randomized to 35 daily 1-hour EECP® treatment sessions (n=15) and control (n=10) were significantly increased in the EECP-treated group and not in the control group. Patients in the EECP-therapy group also improved their anginal score from 3.0 pre-EECP therapy to 2.0 post EECP therapy (p<0.001). The improvement of angina post EECP treatment is associated with an increased number of colony-forming capacities of circulating EPCs.


At Vasomedical, there is a bibliography of clinical research and evidence-based documentation proving benefit of EECP treatment. are available on many of the following:

  • Hemodynamic Effects of EECP Therapy
  • Endothelial Cell Function
  • Arterial Stiffness
  • Inflammatory Markers
  • Endothelial Progenitor Cell Release
  • MUST Trial
  • PEECH Trial
  • Perfusion to Ischemic Region

EECP, Angina Pectoris & Disease

The Centers for Medicare and Medicaid Services (CMS) and other third-party insurance payers have been providing reimbursement for the treatment of angina symptoms since 1999.

EECP is proven to help patients with the following angina symptoms:

  • Ischemic heart disease with associated symptoms of fatigue
  • Dyspnea
  • Angina pectoris and unspecified angina  pectoris
  • Heart failure occurring with less than ordinary exertion and chronic stable angina pectoris


Documented minimal cardiovascular disease (Objective Assessment):

  • Angiography
  • Stress Test
  • Nuclear Scan
  • Cardiac Ultrasound
  • ECG Holter


Symptoms with Physical Exertion:

Patients who are comfortable at rest with less than ordinary physical activity experience:

  • Chest or atypical pain
  • Shortness of breath
  • Fatigue
  • Palpitation
  • Symptoms of ischemic heart failure
EECP promotes angiogenesis to help grow new collaterals for blood to flow, like a NaturalBypass® around blocked arteries.

More Patient Groups to Consider

  • Patients that are in-operable
  • Patients with excessive risk or co-morbid conditions that create unnecessary risk for invasive procedures
  • Patients who refuse or are unwilling to risk another invasive procedure due to age
  • Inadequate relief from medication or complication from excessive medication

Post-Invasive Patients. These are patients who have had Bypass Surgery (CABG) or Percutaneous Coronary Intervention (PCI) within the last five years or more. Statistics show that these patients will be symptomatic as early as a year post procedure. EECP is a safe, non-invasive treatment option.

Diabetic patients with underlying ischemic heart disease. These are patients who suffer from neuropathy and often have symptoms of shortness of breath on physical exertion. Many of these patients are NOT good candidates for surgery as many have excessive risk factors and post-operative complications.

Inactive or Sedentary Lifestyle. These patients avoid any activity that brings them discomfort. Many experts say that EECP therapy provides as much as six times the amount of exercise benefit per hour of treatment than any other form of tolerated physical exercise. Many of these patients are obese or elderly with many health complications that pose significant risk factors for other traditional invasive procedures.

EECP Prescription Guidelines

Candidates to Consider:

  • Small vessel or diffuse disease resulting in symptoms
  • CAD patients who live sedentary lifestyles
  • Patients looking to restore exercise tolerance / functional capacity
  • Patients who take excessive medication (Nitroglycerin, Ranexa) or do not get ample relief
  • Patients looking to restore and improve overall quality of life
  • Cardiac Syndrome X (microvascular angina)
  • Left main disease
  • Mild refractory angina (CCS Class II)
  • Diabetes mellitus
  • Patients looking to improve exercise capacity and oxygen consumption in heart failure patients with New York Heart Association Class II/III
  • Systolic or diastolic heart failure
  • Severe, diffuse coronary atherosclerosis
  • Significant silent ischemia
  • Unsuccessful or incomplete coronary revascularization
  • High risk of adverse events related to invasive revascularization
  • Challenging coronary anatomy, heart failure, renal failure, or pulmonary disease


Post PCI and EECP. Clinical studies have shown that there is a definite trend demonstrating EECP therapy may reduce restenosis rates when done post PCI.

“PCI and CABG target the lesion. EECP with its mechanisms of action targets the disease.”

~ Ozlem Soran, MD, MPH, FACC, FESC. Director ofEECP Research Lab, Associate Professor of Medicine,Epidemiology and Research, University of Pittsburgh,Heart and Vascular Institute

Clinical Benefits

Although the patient benefits of EECP® therapy have been proven to last for more than 5 years, it is not uncommon for Medicare or other third-party payers to reimburse for repeat treatment session (35 days) twice each year.

Patient Benefits of EECP Therapy (Proven in Clinical Studies):

  • Increase in energy and exercise tolerance
  • Increased alertness (brain function)
  • Reduced or eliminated symptoms of chest pain
  • Reduced symptoms of shortness of breath
  • Reduced symptoms of fatigue Reduced heart palpitation
  • Reduced leg pain from peripheral vascular disease
  • Strengthened heart muscle by reviving parts of the heart that have hibernated from lack of blood flow Increased perfusion and collateralization by creating a NaturalBypass around narrowed arteries in heart as well as other organs
  • Sustainable relief of symptoms related to ischemic heart disease
  • Sustainable increase in coronary perfusion Improvement in sexual function for men
  • Reduced symptoms of Parkinson’s Disease
  • Reduced symptoms of dementia (Alzheimer’s Disease)
  • Reduced blood pressure


Clinical Benefits of EECP

  • Sustainable increase in coronary perfusion
  • Retrograde arterial flow (shear stress) increases endothelial function
  • Peripheral training effects (similar to exercise)
  • Cardiac remodeling (stunned and hibernated myocardium)
  • Improvement in oxygen consumption (VO2)
  • Regression of atherosclerosis Improvement in ventricular function Increase in cardiac output
  • Decrease in cardiac workload of the heart
  • Release of growth factors Increased coronary pressure Increased levels of nitric oxide and decreased levels of ANP and BNP
  • Acute improvement in peripheral endothelial function (increase in RH-PAT index)
  • Increased time to the onset of ischemia
  • Decrease in number and severity of angina episodes
  • Reduction in angina and heart failure classifications
  • Decreased medication (including Nitroglycerin and Ranexa)
  • Decrease in arterial stiffness

Clinical Proof Points

Arterial Stiffness

Enhanced External Counterpulsation Treatment Improves Arterial Wall Properties and Wave Reflection Characteristics in Patients With Refractory Angina

Nichols WW, Estrada JC, Braith RW, Owens K, Conti CR.

Journal of the American College of Cardiology. 2006 Sep 19;48(6):1209-1215. Epub 2006 Aug 25.

Summary: 34, 1-hour EECP treatments in 20 stable angina patients caused a significant decline in the augmentation index and an increase in reflected wave travel time, demonstrating improvement in endothelial function.

Clinical Trials

Throughout the years, randomized, controlled clinical trials have been conducted to prove the efficacy of EECP® for angina pectoris. There have been more than 200 published papers in peer-reviewed medical journals demonstrating safety and efficacy of EECP in the treatment of angina pectoris and chronic heart failure.

“The long-term care of patients with chronic coronary artery disease requires the cardiologist to use aggressive preventive methods and more cost-effective treatment to improve clinical and financial outcomes. EECP treatment is a safe, cost-effective, non-invasive method of restoring myocardial perfusion and reducing symptoms of angina. EECP treatment is the perfect disease management tool for chronic coronary artery disease.”

~ John E. Strobeck, MD, PhD, Interventional Cardiologist, Co-founder of the Heart Failure Society of America, Medical Director, The Heart & Lung Center, Hawthorne, NJ

Publications Showcasing EECP

Throughout the years, randomized, controlled clinical trials have been conducted to prove the efficacy of EECP for angina pectoris. There have been more than 200 published papers in peer-reviewed medical journals demonstrating safety and efficacy of EECP in the treatment of angina pectoris and chronic heart failure.

January 20, 2012
Chapter Dedicated to EECP® Therapy in New Textbook on Coronary Artery Disease

Throughout the years, randomized, controlled clinical trials have been conducted to prove the efficacy of EECP for angina pectoris. There have been more than 200 published papers in peer-reviewed medical journals demonstrating safety and efficacy of EECP in the treatment of angina pectoris and chronic heart failure.

“The long-term care of patients with chronic coronary artery disease requires the cardiologist to use aggressive _preventive methods and more cost-effective treatment to improve clinical and financial outcomes. EECP treatment is a safe, cost-effective, non-invasive method of restoring myocardial perfusion and reducing symptoms of angina. EECP treatment is the perfect disease management tool for chronic coronary artery disease.”

– John E. Strobeck, MD, PhD, Interventional Cardiologist,
Co-founder of the Heart Failure Society of America, Medical Director

Passing on Bypass
George Juetersonke, DO
Pikes Peak Press, 2001
Chapters 8-10

External Counterpulsation: A Novel Therapy to Stimulate Arteriogenesis
Nikolaos Pagonas,MD
Südwestdeutscher Verlag für Hochschulschriften
AG Co. KG, 2011

Enhanced External Counter-Pulsation
Jami Shakibi, MD,
FACC Self-Published, Tehran, Iran 2008

Heal Your Heart with EECP:
The Only Noninvasive Way to Overcome Heart Disease

Debra Braverman, MD
Berkley, California: Celestial Arts, 2005.

Heart Failure: Device Management
Arthur Feldman, MD, PhD
151-164West Sussex, UK: Blackwell
Publishing 2010
(Chapter 13. The Role of Enhanced
External Counterpulsation in Heart
Failure Management)

Angina Pectoris
Federico Piscione
137-158Ozlem Soran. Rijeka, Croatia:
InTech, October 2011
(Chapter 6, The Role of Enhanced
External Counterpulsation Therapy in
Management of Coronary Artery

EECP Research Studies

Below are some of the more than 200 clinical EECP research studies and papers published world-wide featuring EECP.

For a comprehensive compilation of research, please visit Vasomedical, Inc., owner of the registered trademark EECP:

  • EECP is a Regenerative Disease, Frontiers in Bioscience, Jan. 1, 2010
  • Enhanced External Counterpulsation Attenuates Atherosclerosis Progression Through Modulation of Proinflammatory Signal Pathway, Arterioscler Thromb Vasc Biol 2010;30;773-780; originally published online Feb 11, 2010 John C.K. Hui and Zhensheng Zheng Zhimin Du, Yugang Dong, Yafei Jin, Wen He, Kuijian Wang, William E. Lawson,Yan Zhang, Xiaohong He, Donghong Liu, Guifu Wu, Xiaolin Chen, Hong Ma
  • Journal of Geriatric Cardiology, June 2010; Acute hemodynamic effects of enhanced external counterpulsation; Bhavananda T. Reddy, Andrew D. Michaels Department of Medicine, Division of Cardiology, University of Utah, Salt Lake City, Utah, United States.
  • India Heart Journal, 2010 Enhanced External Counterpulsation (EECP) Therapy: Current Evidence For Clinical Practice And Who Will Benefit?
  • Impact of Enhanced External Counterpulsation on Canadian Cardiovascular Society Angina Class in Patients with Chronic Stable Angina: A Meta-analysis; Sachin A. Shah, Pharm.D., Robert J. Shapiro, Pharm.D., Rina Mehta, Pharm.D., and Jeffrey A. Snyder, Pharm.D.
  • Enhanced External Counterpulsation-A Review; LA Sayami, M Ullah, MT Rahman, Z Rahman, D Roy, AAS Majumder; Department of Cardiology, NICVD, Dhaka, Bangladesh.(Cardiovasc. j. 2010; 2(2) : 236-244)
  • Spine, 2010 Jul 1;35(15):1415-22.Enhanced external counterpulsation and traction therapy ameliorates rotational vertebral artery flow insufficiency resulting from cervical spondylosis.Xin W, Fangjian G, Hua W, Jiangtao X, Shouyi W, Yingchun Z, Xiong L.Department of Orthopedics, Zhongnan Hospital of Wuhan University, Wuchang, Wuhan, People’s Republic of China.
  • Enhanced External Counter Pulsation (EECP) for Refractory Angina Pectoris (RAP); Results from a first case seriesWaqas Ahmed, Naveed Akhter, Ayesha Masood Department of Cardiology, Shifa International Hospital, Islamabad, Pakistan; 2010
  • Circulation published online Oct 4, 2010; Khuddus, Darren T. Beck and Darren P. Casey, Randy W. Braith, C. Richard Conti, Wilmer W. Nichols, Calvin Y. Choi, Matheen A. Sham-Controlled Study Flow-Mediated Dilation in Patients With Chronic Angina. A RandomizedEnhanced External Counterpulsation Improves Peripheral Artery
  • Heart 2010 96: 202-207 originally published online November 5, 2009 Steffen Gloekler, Pascal Meier, Stefano F de Marchi, et al.Coronary collateral growth by external counterpulsation: a randomised controlled trial;
  • Journal of Geriatric Cardiology, June 2010; Role of external counterpulsation in the treatment of ischemic stroke Jing-Hao Han, Wai-Hong Leung, Ka-Sing Wong Departments of Medicine & Therapeutics; The Chinese University of Hong Kong, Shatin, Hong Kong SAR
  • Journal of Geriatric Cardiology, June 2010; EECP in the treatment of endothelial dysfunction: preventing progression of cardiovascular disease; John CK Hui, William E Lawson, Gregory W Barsness
  • Journal of Geriatric Cardiology, June 2010; The four stages of development: a historical prospective of external counterpulsation; John CK Hui, Zhen-Sheng Zheng
  • Cerebrovascular Disease, Oct. 2010; Does External Counterpulsation Augment Mean Cerebral Blood Flow in the Healthy Brain? Effects of External Counterpulsation on Middle Cerebral Artery Flow Velocity and Cerebrovascular Regulatory Response in Healthy Subjects; G.J. Jungehuelsing a T.G. Liman a P. Brunecker a A. Ebel a M. Endres a I. Buschmann b N. Pagonas b E.E. Buschmann b, c on behalf of the Arteriogenesis Network and of the Center for Stroke Research Berlin a Center for Stroke Research Berlin, Department of Neurology, and Arteriogenesis Research, Department of Cardiology and Center for Cardiovascular Research, Charité University Medicine Berlin, and c Department of Cardiology, Helios Klinikum Berlin Buch, Berlin, Germany
  • International Journal of Cardiology, 2010; Effect of enhanced external counterpulsation on circulating CD34+ progenitor cell subsets; T.J. Kiernan 1, B.A. Boilson 1, L. Tesmer, A. Harbuzariu, R.D. Simari, G.W. Barsness
  • ARYA Atherosclerosis Journal, 2009; Effect of Enhanced External Counter Pulsation on Plasma Level of Nitric Oxide and Vascular Endothelial Growth Factor. Masoud Pourmoghadas(1), Hajar Nourmohamamadi(2), Faezeh Tabesh(2), Shaghayegh Haghjoo(3), Elham Tabesh(2)
  • Review: Enhanced external counterpulsation and future directions: step beyond medical management for patients with angina and heart failure. [J Am Coll Cardiol. 2007]
  • Effect of enhanced external counterpulsation treatment on renal function in cardiac patients. BMC Nephrology 2013, 14:193 doi:10.1186/1471-2369-14-193.Prajej Ruangkanchanasetr, Nithi Mahanonda, Ongkarn Raungratanaamporn, Piyanuj Ruckpanich Chagriya Kitiyakara, Amnart Chaiprasert, Surawat Adirekkiat, Dollapas Punpanich, Somlak Vanavanan, Anchalee Chittamma, Thanom Supaporn.
  • Increasing pressure of external counterpulsation augments blood pressure but not cerebral blood flow velocity in ischemic stroke. Journal of Clinical Neuroscience, 8 December 2013. Wenhua Lin, Li Xiong, Jinghao Han, Howan Leung, Thomas Leung, Yannie Soo, Xiangyan Chen, Ka Sing Lawrence Wong.
  • Enhanced External Counterpulsation (EECP) Improves Peripheral Artery Function and Glucose Tolerance in Subjects with Abnormal Glucose Tolerance. First published December 22, 2011; doi:10.1152/japplphysiol.01336.2011 J Appl Physiol 2012;112: 868–876.Martin JS, Beck DT, Aranda Jr. JM, Braith RW.
  • Effect of enhanced external counterpulsation on C-reactive protein and interlukin-6 in patients with coronary heart disease. Hainan, China Hainan Medical J. 2011; 22(3):56-57.WEI Hai-zhu.
  • Microvascular response to metabolic and pressure challenge in the human coronary circulation. Am J Physiol Heart Circ Physiol 301: H434–H441, 2011. First published May 13, 2011; doi:10.1152/ajpheart.01283.2010Stefano F. de Marchi, Steffen Gloekler, Stefano F. Rimoldi, Patrizia Rölli, Hélène Steck, and Christian Seiler.
  • Hospital utilization and costs for spinal cord stimulation compared with enhanced external counterpulsation for refractory angina pectoris. Journal of Evaluation in Clinical Practice. 2011 Epub 31 OCT 2011. Bondesson, S. M., Jakobsson, U., Edvinsson, L. and Hallberg, I. R.
  • Enhanced External Counterpulsation improves endothelial function, inflammatory markers and depression. ACC 60th Scientific Session 2011; J Am Coll Cardiol 57(14): E2011 Title: Best Fellows-In-Training Poster AwardsDeepak Hooda, Ravindra Bhardwaj, Wissam Gharib, Bradford E. Warden, Robert Beto, Abnash C. Jain.
  • Improvement of angina, quality of life, and working capacity after enhanced external counterpulsation. Ugeskr Laeger. 2013 Jan 14; 175(3):114-116.Jørgensen MT, May O.
  • Are peripheral arterial changes during enhanced external counterpulsation necessary for and/or evidence of an adequate cardiovascular response? Hypertension Research advance online publication, 24 January 2013; doi:10.1038/hr.2012.210.Daniel Bia and Yanina Zo´ calo.
  • The collateral circulation of the heart. BMC Medicine 2013, 11:143 doi:10.1186/1741-7015-11-143. Pascal Meier, Stephan H Schirmer, Alexandra J Lansky, Adam Timmis, Bertram Pitt, Christian Seiler.
  • Therapeutic effects of Enhanced External Counter Pulsation (EECP) on clinical symptoms, echocardiographic measurements, perfusion scan parameters and exercise tolerance test in coronary artery disease patients with refractory angina. Int J Med Sci Public Health. Online First: 24 Dec, 2012. doi:10.5455/ijmsph.2013.2.179-187 Int J Med Sci Public Health. 2013; 2(2): 179-187. doi: 10.5455/ijmsph.2013.2.179-187.Eslamian F, Aslanabadi N, Mahmoudian B, Shakouri SK.
  • Enhanced external counterpulsation in patients with refractory angina pectoris: a pilot study with six months follow-up regarding physical capacity and health-related quality of life. Eur J Cardiovasc Nurs. 2012 Dec 21. DOI:19.1177/1474515112468067.Wu E, Mårtensson J, Broström A.
  • Anti-inflammatory effects of enhanced external counterpulsation in subjects with abnormal glucose tolerance. Applied Physiology, Nutrition, and Metabolism, 10.1139/h2012-112. Published on the web 11 October 2012.Jeffrey S. Martin, Randy W. Braith.
  • Comparison of long term clinical outcomes, event free survival rates of patients undergoing enhanced external counterpulsation for coronary artery disease in the United States and Turkey.Turk Kardiyol Dem Ars – Arch Turk Soc Cardiol 2012;40(4):323-330Ozlem Soran, Coskun Ikizler, Atilla Sengui, Bilal Cuglan, Elizabeth Kennard, Sheryl Kelsey.
  • Enhanced External Counterpulsation for Ischemic Heart Disease: A Look Behind the Curtain.The American College of Sports Medicine Exercise and Sport Sciences Reviews 2012;40 (3):145-152.Randy W. Braith, Darren P. Casey, and Darren T. Beck.
  • The Effect of Enhanced External Counterpulsation on C-reactive protein and flow-mediated dilation in porcine model of hypercholesterolaemia.Clinical Physiology and Functional Imaging. 2012; 32 (4): 262–267Yanqiu L, Yan X, Dongshong L, Chufan L, Yan Z, Wu G, Qiang X, Yugang D, Zhensheng Z.
  • The therapeutic effects of enhanced external counterpulsation on refractory angina in patients, unsuitable for invasive interventions. The J of Urmia University of Medical Sciences 2012;April-May, 23(1):7-14Aslan Abadi Naser, Salehi Rezvaneyeh, Alizadeh Azin, Eslamityan Fariba, Ahmadzadeh Pournaky Ahmad, Tsban Sadeghi Mohamad Reza.
  • The Effects of Enhanced External Counterpulsation on Health-related Quality of Life in Patients with Angina Pectoris. Iranian Journal of Nursing and Midwifery Research 2012:17(1):1-7.Ziaeirad M, Ziaei GR, Sadeghi N, Motaghi M, Torkan B.