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{{Infobox medical intervention
'''Enhanced external counterpulsation''' (EECP) is a procedure performed on individuals with [[ischemic cardiomyopathy]] in order to diminish the symptoms of their ischemia. In various studies, EECP has been shown to relieve [[angina]]<sup>1,2</sup>, improve exercise tolerance<sup>3</sup>, and decrease the degree of ischemia in a [[cardiac stress test]]<sup>2,3</sup>.
| name = External counterpulsation
| synonym = Enhanced external counterpulsation (EECP)
| image = Blausen 0161 Cardiac Enhanced External Counterpulsation.png
| caption = Illustration showing cardiac external counterpulsation
| alt =
| pronounce =
| specialty = <!-- from Wikidata, can be overwritten -->
| synonyms =
| ICD10 =
| ICD9 =
| ICD9unlinked =
| CPT =
| MeshID =
| LOINC =
| other_codes =
| MedlinePlus =
| eMedicine =
}}
'''External counterpulsation therapy''' ('''ECP''') is a procedure that may be performed on individuals with [[angina]], [[heart failure]], or [[cardiomyopathy]].


==Method==
==Medical uses==
The FDA approved the CardiAssistTM ECP system for the treatment of angina, acute myocardial infarction and cardiogenic shock under a 510(k) submission in 1980<ref>{{cite web |url=http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPMN/pmn.cfm?ID=27812 |access-date=March 13, 2006 |title=510(k) Premarket Notification |publisher=FDA}}</ref> Since then, additional ECP devices have been cleared by the FDA for use in treating stable or unstable angina pectoris, acute myocardial infarction, cardiogenic shock, and congestive heart failure.<ref>{{Cite web|url=https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=162&NcaName=External+Counterpulsation+|title = Decision Memo for External Counterpulsation (ECP) Therapy (CAG-00002R2)}}</ref>
⚫
While an individual is undergoing EECP, they have pneumatic stockings (also known as cuffs) on their legs and are connected to telemetry monitors that monitor their heart rate and rhythm. The most common type in use involves three cuffs placed on each leg (on the calfs, the lower thighs, and the upper thighs (or buttock)). The cuffs are timed to inflate and deflate based on the individual's [[electrocardiogram]]. The cuffs should ideally inflate at the beginning of [[diastole]] and deflate at the beginning of [[systole]]. During the inflation portion of the cycle, the calf cuffs inflate first, then the lower thigh cuffs and finally the upper thigh cuffs. Inflation is controlled by a pressure monitor, and the cuffs are inflated to about 300 [[mmHg]].


Studies have found EECP to be beneficial for patients with erectile dysfunction and some COPD patients. Additionally, improvements in exercise endurance in the non-diseased patient has been found in research studies.<ref name="Zhao2020">{{cite journal |vauthors=Zhao M, Huang Y, Li L, Zhou L, Wu Z, Liu Y, Zhang H, Hu C |title=Enhanced External Counterpulsation Efficacy on Exercise Endurance in COPD Patients and Healthy Subjects: A Pilot Randomized Clinical Trial |journal=International Journal of Chronic Obstructive Pulmonary Disease |date=7 January 2020 |volume=15 |pages=25–31 |doi=10.2147/COPD.S225566|pmid=32021141 |pmc=6954827 |doi-access=free }}</ref><ref>{{cite journal |vauthors=Raeissadat SA, Javadi A, Allameh F |title=Enhanced external counterpulsation in rehabilitation of erectile dysfunction: a narrative literature review |journal=Vascular Health and Risk Management |date=3 December 2018 |volume=14 |pages=393–399 |doi=10.2147/VHRM.S181708|pmid=30584313 |pmc=6284534 |s2cid=56836301 |doi-access=free }}</ref>
When timed correctly, this will decrease the [[afterload]] that the heart has to pump against, and increase the [[preload]] that fills the heart, increasing the [[cardiac output]].<sup>4</sup> In this way, EECP is similar to the [[intra-aortic balloon pump]] (IABP).


Some reviews did not find sufficient evidence that it was useful for either angina or heart failure.<ref>{{cite journal |vauthors=McKenna C, McDaid C, Suekarran S, Hawkins N, Claxton K, Light K, Chester M, Cleland J, Woolacott N, Sculpher M |title=Enhanced external counterpulsation for the treatment of stable angina and heart failure: a systematic review and economic analysis. |journal=Health Technology Assessment |date=April 2009 |volume=13 |issue=24 |pages=iii-iv, ix-xi, 1–90 |doi=10.3310/hta13240 |pmid=19409154 |doi-access=free |display-authors=6}}</ref><ref>{{cite journal |vauthors=Amin F, Al Hajeri A, Civelek B, Fedorowicz Z, Manzer BM |title=Enhanced external counterpulsation for chronic angina pectoris. |journal=The Cochrane Database of Systematic Reviews |date=17 February 2010 |volume=2010 |issue=2 |pages=CD007219 |doi=10.1002/14651858.CD007219.pub2 |pmid=20166092 |pmc=7180079 }}</ref> Other reviews found tentative benefit in those with angina that does not improve with medications.<ref>{{cite journal |vauthors=Soran O |title=Alternative therapy for medically refractory angina: enhanced external counterpulsation and transmyocardial laser revascularization. |journal=Cardiology Clinics |date=August 2014 |volume=32 |issue=3 |pages=429–38 |doi=10.1016/j.ccl.2014.04.009|pmid=25091968}}</ref><ref>{{cite journal |vauthors=Qin X, Deng Y, Wu D, Yu L, Huang R |title=Does Enhanced External Counterpulsation (EECP) Significantly Affect Myocardial Perfusion?: A Systematic Review & Meta-Analysis. |journal=PLOS ONE |date=2016 |volume=11 |issue=4 |pages=e0151822 |doi=10.1371/journal.pone.0151822 |pmid=27045935|pmc=4821484|bibcode=2016PLoSO..1151822Q|doi-access=free }}</ref>
===Treatment regimen===
While the number of EECP treatment sessions vary widely, one widely used regimen in the United States is a total of 35 one hour sessions; One session a day, five days a week, for 7 weeks. This particular regimen is used because it is the regimen studied in the MUST-EECP trial, the first prospective, randomized-control multicenter trial on EECP.<sup>2</sup>


For [[stroke]] due to lack of blood flow a 2012 Cochrane review found insufficient evidence to make conclusions.<ref>{{cite journal |vauthors=Lin S, Liu M, Wu B, Hao Z, Yang J, Tao W |title=External counterpulsation for acute ischaemic stroke.|journal=The Cochrane Database of Systematic Reviews |date=18 January 2012 |volume=1 |pages=CD009264 |doi=10.1002/14651858.CD009264.pub2 |pmid=22259001}}</ref>
There are no clear guidelines on how often the treatment regimen can be performed. An individual that has shown benefit with the regimen but later begin having complaints attributable to his or her ischemic cardiomyopathy may benefit from a repeated regimen.


Significantly improved the exercise endurance of normal adults, low endurance adults, and COPD patients.<ref name="Zhao2020" />
==Indications for use==
EECP is usually reserved as a "last resort" treatment of individuals with symptoms of ischemic cardiomyopathy who are not amenable to [[percutaneous coronary intervention]] or [[coronary artery bypass graft]] surgery. It is typically only performed on individuals who continue to have symptoms while on the maximum tolerated doses of conventional medications. To meet these criteria, the individual must have [[coronary artery disease]] that includes at least one vessel that has at least a 70 percent lesion. In addition, the individual must have evidence of either an infarction or significant ischemia on a [[stress test]] with some form of imaging (ie: nuclear or echocardiographic imaging).


==Method==
In addition, individuals with advanced heart failure due to an ischemic etiology may benefit from EECP. This is the object of the PEECH trial, a large multi-center currently ongoing study.<sup>5</sup>
⚫
While an individual is undergoing ECP, they have pneumatic cuffs on their legs and is connected to [[telemetry]] monitors that monitor heart rate and rhythm. The most common type in use involves three cuffs placed on each leg (on the calves, the lower thighs, and the upper thighs (or buttocks)). The cuffs are timed to inflate and deflate based on the individual's [[electrocardiogram]]. The cuffs should ideally inflate at the beginning of [[diastole]] and deflate at the beginning of [[Systole (medicine)|systole]]. During the inflation portion of the cycle, the calf cuffs inflate first, then the lower thigh cuffs, and finally the upper thigh cuffs. Inflation is controlled by a pressure monitor, and the cuffs are inflated to about 200 [[mmHg]].{{citation needed|date=January 2022}}

Of note, therapies are tailored on an individual basis but beginning regimens tend to include daily one-hour treatments that occur 5 days of the week and last 6–8 weeks with an average overall of 35 hours.<ref>{{cite journal |vauthors=El-Sakka A, Morsy A, Fagih B |title=Enhanced External Counterpulsation in Patients with Coronary Artery Disease-Associated Erectile Dysfunction. Part I: Effects of Risk Factors |journal=The Journal of Sexual Medicine |date=May 2007 |volume=4 |issue=3 |pages=771–779 |doi=10.1111/j.1743-6109.2007.00458.x|pmid=17433083 }}</ref>


==Physiological considerations==
==Physiological considerations==
One theory is that ECP exposes the coronary circulation to increased [[shear stress]], and that this results in the production of a cascade of growth factors that result in new blood vessel formation in the heart (arteriogenesis and [[angiogenesis]]).<ref>{{cite journal |vauthors=Soran O, Crawford LE, Schneider VM, Feldman AM |title=Enhanced external counterpulsation in the management of patients with cardiovascular disease |journal=Clin Cardiol |volume=22 |issue=3 |pages=173–8 |date=March 1999 |pmid=10084058 |doi=10.1002/clc.4960220304 |pmc=6655819 }}<br />{{cite journal |vauthors=Manchanda A, Soran O |title=Enhanced external counterpulsation and future directions: step beyond medical management for patients with angina and heart failure |journal=J. Am. Coll. Cardiol. |volume=50 |issue=16 |pages=1523–31 |date=October 2007 |pmid=17936150 |doi=10.1016/j.jacc.2007.07.024|doi-access= }}</ref><ref>https://epub.ub.uni-muenchen.de/12337/1/Deindl_Schaper_12337.pdf {{Bare URL PDF|date=March 2022}}</ref>
As mentioned above, the deflation of the cuffs at the beginning of systole with decrease the afterload that the heart has to pump against. Because of this, myocardial oxygen demand (the amount of oxygen required by the heart to function properly) will decrease during the EECP session. This is a relatively short-term improvement, however, and is limited to the session of EECP.


To best understand the pathophysiology of the therapy it is easiest to understand what each step does. To begin with, as the cuffs on each leg inflate, starting at the calf and working up to the upper thighs, blood is propelled back to the heart thereby increasing the venous return or preload. This increase in preload occurs simultaneously with diastole which happens to be the time during the cardiac cycle in which coronary perfusion occurs. So, by increasing the coronary perfusion, you allow more oxygen to perfuse the heart and ultimately generate more collateral circulation without actually increasing the work of the heart. Additionally, cardiac output is increased via the Frank-Starling mechanism secondary to the increased venous return. As the cardiac cycle progresses to systole, the cuffs on the extremities deflate, allowing for the increased cardiac output to adequately perfuse all tissues including the extremities.<ref>{{cite journal |title=EECP-Enhanced External Counterpulsation* |journal=Journal of the American College of Cardiology |date=June 1999 |volume=33 |pmid=10362182 |url=https://www.onlinejacc.org/content/accj/33/7/1841.full.pdf|last1=Conti |first1=C. R. |issue=7 |pages=1841–1842 |doi=10.1016/s0735-1097(99)00136-9 |doi-access=free }}</ref>
The inflation of the cuffs during diastole (when the [[aortic valve]] is closed) increases blood flow to the [[myocardium]] (the muscle of the heart). This is because, unlike the tissues of the rest of the body, the myocardium receives the majority of it's blood during diastole. The increased flow during diastole caused by EECP is believed to promote the formation of collateral arteries in the coronary circulation.

Presumably, it is these newly opened collateral arteries that produced the sustained benefit that EECP provides to individuals after the EECP sessions are complete. While EECP has been in use since the 1980s, the mechanism in which it provides a lasting clinical benefit is still poorly understood. One theory is that EECP exposes the coronary circulation to increased sheer stress, and that this results in the production of a cascade of growth factors that result in [[angiogenesis]].<sup>6</sup>

===Hemodynamic effects===
The acute hemodynamic effects of EECP are transitory and only occur during a treatment session. These effects are also related to the number of cuffs that are placed on each leg. It has been shown that if only calf and lower thigh cuffs are used, flow is increased by 19 percent compared to baseline. Addition of the upper thigh (buttock) cuffs increases the flow to 26 percent over the baseline.<sup>4</sup>

EECP increases cardiac output by a combination of the increased preload and the decreased afterload during the EECP session. Inflation of the cuffs during diastole compresses the venous system in the legs, causing increased venous return to the heart, thereby increasing left ventricular preload. This increased filling of the left ventricle increases cardiac output. Deflation of the cuffs in systole decrease afterload (the pressure the left ventricle has to overcome in order to eject blood), also increasing the cardiac output.

There are long term hemodynamic effects of EECP, which are presumably due to the decreased ischemic burden noted in individuals after completing an EECP regimen. These include a decrease in the left ventricular end diastolic pressure (LVEDP), and subsequently a decreased in [[brain natriuretic peptide]] (BNP) levels, and improved diastolic performance of the left ventricle.<sup>2</sup>

==Contraindications==
Similar to the intra-aortic balloon pump, contraindications to EECP include severe [[peripheral vascular disease]] and significant [[aortic insufficiency]]. Other contraindications include:
* Significant unprotected [[coronary anatomy|left main]] disease
* [[Atrial fibrillation]]
* Overt [[congestive heart failure]]
* Any severe valvular heart disease
* Uncontrolled [[hypertension]] ([[blood pressure]] > 180/100 while on medications)
* [[Phlebitis]]
* [[Deep vein thrombosis]]
* Lower extremity stasis ulcers
* Bleeding diathesis (including [[International normalized ratio|INR]] > 2.0)
* Pregnant or potentially pregnant women

Atrial fibrillation is a relative contraindication, because the varying heart rate makes it impossible to time the inflation and deflation of the cuffs. In the subset of individuals with atrial fibrillation, high degree [[heart block]], and a [[artificial pacemaker|permanent pacemaker]] who are pacemaker dependant, it may still be possible to perform EECP.

==See also==
* [[Cardiomyopathy]]
** [[Ischemic cardiomyopathy]]
* [[Coronary circulation]]
* [[Intra-aortic balloon pump]]


==References==
==References==
{{reflist}}
1. Zheng ZS, Li TM, Kambic H, Chen GH, Yu LQ, Cai SR, Zhan CY, Chen YC, Wo SX, Chen GW, et al. Sequential external counterpulsation (SECP) in China. Trans Am Soc Artif Intern Organs. 1983;29:599-603. ([http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=6673295&query_hl=40&itool=pubmed_docsum Medline abstract])
'''USFDA Approved''' [https://chandanhospital.com EECP Treatment Center] | Dr. Chandandeep Sandhu, MBBS FCGP FIPM FAM PGC (Cardiology) (11 March 2022)

2. Arora RR, Chou TM, Jain D, Fleishman B, Crawford L, McKiernan T, Nesto RW. 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 Jun;33(7):1833-40. ([http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10362181&query_hl=49&itool=pubmed_DocSum Medline reference])

3. Lawson WE, Hui JC, Zheng ZS, Burgen L, Jiang L, Lillis O, Oster Z, Soroff H, Cohn P. Improved exercise tolerance following enhanced external counterpulsation: cardiac or peripheral effect? Cardiology. 1996 Jul-Aug;87(4):271-5. ([http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8793157&query_hl=47&itool=pubmed_docsum Medline abstract])

4. Werner D, Schneider M, Weise M, Nonnast-Daniel B, Daniel WG. Pneumatic external counterpulsation: a new noninvasive method to improve organ perfusion. Am J Cardiol. 1999 Oct 15;84(8):950-2, A7-8. ([http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10532522&query_hl=36&itool=pubmed_docsum Medline reference])

5. Feldman AM, Silver MA, Francis GS, De Lame PA, Parmley WW. Treating heart failure with enhanced external counterpulsation (EECP): design of the Prospective Evaluation of EECP in Heart Failure (PEECH) trial. J Card Fail. 2005 Apr;11(3):240-5. ([http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15812754&query_hl=32&itool=pubmed_docsum Medline abstract])

6. Soran O, Crawford LE, Schneider VM, Feldman AM. Enhanced external counterpulsation in the management of patients with cardiovascular disease. Clin Cardiol. 1999 Mar;22(3):173-8. ([http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10084058&query_hl=28&itool=pubmed_docsum Medline abstract])

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[[Category:Cardiology]]


'''KKM Approved''' [https://blessono.com/eecp-treatment/ EECP Treatment Centre Malaysia] | Dr Wan Faizal Wan MD (Moscow), MRCP (Ireland), Interventional Cardiology Fellowship (MAL), CCDS (USA), EAPCI (Europe), PgDip Preventive Cardiovascular Medicine (NSW)
==External Links==


*[http://www.surgeryencyclopedia.com/Ce-Fi/Enhanced-External-Counterpulsation.html Enhanced external counterpulsation at SurgeryEncyclopedia.com]
{{DEFAULTSORT:Enhanced External Counterpulsation}}
⚫
[[Category:Cardiac procedures]]

Latest revision as of 09:13, 9 January 2024

External counterpulsation
Illustration showing cardiac external counterpulsation
Other namesEnhanced external counterpulsation (EECP)

External counterpulsation therapy (ECP) is a procedure that may be performed on individuals with angina, heart failure, or cardiomyopathy.

Medical uses[edit]

The FDA approved the CardiAssistTM ECP system for the treatment of angina, acute myocardial infarction and cardiogenic shock under a 510(k) submission in 1980[1] Since then, additional ECP devices have been cleared by the FDA for use in treating stable or unstable angina pectoris, acute myocardial infarction, cardiogenic shock, and congestive heart failure.[2]

Studies have found EECP to be beneficial for patients with erectile dysfunction and some COPD patients. Additionally, improvements in exercise endurance in the non-diseased patient has been found in research studies.[3][4]

Some reviews did not find sufficient evidence that it was useful for either angina or heart failure.[5][6] Other reviews found tentative benefit in those with angina that does not improve with medications.[7][8]

For stroke due to lack of blood flow a 2012 Cochrane review found insufficient evidence to make conclusions.[9]

Significantly improved the exercise endurance of normal adults, low endurance adults, and COPD patients.[3]

Method[edit]

While an individual is undergoing ECP, they have pneumatic cuffs on their legs and is connected to telemetry monitors that monitor heart rate and rhythm. The most common type in use involves three cuffs placed on each leg (on the calves, the lower thighs, and the upper thighs (or buttocks)). The cuffs are timed to inflate and deflate based on the individual's electrocardiogram. The cuffs should ideally inflate at the beginning of diastole and deflate at the beginning of systole. During the inflation portion of the cycle, the calf cuffs inflate first, then the lower thigh cuffs, and finally the upper thigh cuffs. Inflation is controlled by a pressure monitor, and the cuffs are inflated to about 200 mmHg.[citation needed]

Of note, therapies are tailored on an individual basis but beginning regimens tend to include daily one-hour treatments that occur 5 days of the week and last 6–8 weeks with an average overall of 35 hours.[10]

Physiological considerations[edit]

One theory is that ECP exposes the coronary circulation to increased shear stress, and that this results in the production of a cascade of growth factors that result in new blood vessel formation in the heart (arteriogenesis and angiogenesis).[11][12]

To best understand the pathophysiology of the therapy it is easiest to understand what each step does. To begin with, as the cuffs on each leg inflate, starting at the calf and working up to the upper thighs, blood is propelled back to the heart thereby increasing the venous return or preload. This increase in preload occurs simultaneously with diastole which happens to be the time during the cardiac cycle in which coronary perfusion occurs. So, by increasing the coronary perfusion, you allow more oxygen to perfuse the heart and ultimately generate more collateral circulation without actually increasing the work of the heart. Additionally, cardiac output is increased via the Frank-Starling mechanism secondary to the increased venous return. As the cardiac cycle progresses to systole, the cuffs on the extremities deflate, allowing for the increased cardiac output to adequately perfuse all tissues including the extremities.[13]

References[edit]

  1. ^ "510(k) Premarket Notification". FDA. Retrieved March 13, 2006.
  2. ^ "Decision Memo for External Counterpulsation (ECP) Therapy (CAG-00002R2)".
  3. ^ a b Zhao M, Huang Y, Li L, Zhou L, Wu Z, Liu Y, Zhang H, Hu C (7 January 2020). "Enhanced External Counterpulsation Efficacy on Exercise Endurance in COPD Patients and Healthy Subjects: A Pilot Randomized Clinical Trial". International Journal of Chronic Obstructive Pulmonary Disease. 15: 25–31. doi:10.2147/COPD.S225566. PMC 6954827. PMID 32021141.
  4. ^ Raeissadat SA, Javadi A, Allameh F (3 December 2018). "Enhanced external counterpulsation in rehabilitation of erectile dysfunction: a narrative literature review". Vascular Health and Risk Management. 14: 393–399. doi:10.2147/VHRM.S181708. PMC 6284534. PMID 30584313. S2CID 56836301.
  5. ^ McKenna C, McDaid C, Suekarran S, Hawkins N, Claxton K, Light K, et al. (April 2009). "Enhanced external counterpulsation for the treatment of stable angina and heart failure: a systematic review and economic analysis". Health Technology Assessment. 13 (24): iii–iv, ix–xi, 1–90. doi:10.3310/hta13240. PMID 19409154.
  6. ^ Amin F, Al Hajeri A, Civelek B, Fedorowicz Z, Manzer BM (17 February 2010). "Enhanced external counterpulsation for chronic angina pectoris". The Cochrane Database of Systematic Reviews. 2010 (2): CD007219. doi:10.1002/14651858.CD007219.pub2. PMC 7180079. PMID 20166092.
  7. ^ Soran O (August 2014). "Alternative therapy for medically refractory angina: enhanced external counterpulsation and transmyocardial laser revascularization". Cardiology Clinics. 32 (3): 429–38. doi:10.1016/j.ccl.2014.04.009. PMID 25091968.
  8. ^ Qin X, Deng Y, Wu D, Yu L, Huang R (2016). "Does Enhanced External Counterpulsation (EECP) Significantly Affect Myocardial Perfusion?: A Systematic Review & Meta-Analysis". PLOS ONE. 11 (4): e0151822. Bibcode:2016PLoSO..1151822Q. doi:10.1371/journal.pone.0151822. PMC 4821484. PMID 27045935.
  9. ^ Lin S, Liu M, Wu B, Hao Z, Yang J, Tao W (18 January 2012). "External counterpulsation for acute ischaemic stroke". The Cochrane Database of Systematic Reviews. 1: CD009264. doi:10.1002/14651858.CD009264.pub2. PMID 22259001.
  10. ^ El-Sakka A, Morsy A, Fagih B (May 2007). "Enhanced External Counterpulsation in Patients with Coronary Artery Disease-Associated Erectile Dysfunction. Part I: Effects of Risk Factors". The Journal of Sexual Medicine. 4 (3): 771–779. doi:10.1111/j.1743-6109.2007.00458.x. PMID 17433083.
  11. ^ Soran O, Crawford LE, Schneider VM, Feldman AM (March 1999). "Enhanced external counterpulsation in the management of patients with cardiovascular disease". Clin Cardiol. 22 (3): 173–8. doi:10.1002/clc.4960220304. PMC 6655819. PMID 10084058.
    Manchanda A, Soran O (October 2007). "Enhanced external counterpulsation and future directions: step beyond medical management for patients with angina and heart failure". J. Am. Coll. Cardiol. 50 (16): 1523–31. doi:10.1016/j.jacc.2007.07.024. PMID 17936150.
  12. ^ https://epub.ub.uni-muenchen.de/12337/1/Deindl_Schaper_12337.pdf [bare URL PDF]
  13. ^ Conti, C. R. (June 1999). "EECP-Enhanced External Counterpulsation*" (PDF). Journal of the American College of Cardiology. 33 (7): 1841–1842. doi:10.1016/s0735-1097(99)00136-9. PMID 10362182.

USFDA Approved EECP Treatment Center | Dr. Chandandeep Sandhu, MBBS FCGP FIPM FAM PGC (Cardiology) (11 March 2022)

KKM Approved EECP Treatment Centre Malaysia | Dr Wan Faizal Wan MD (Moscow), MRCP (Ireland), Interventional Cardiology Fellowship (MAL), CCDS (USA), EAPCI (Europe), PgDip Preventive Cardiovascular Medicine (NSW)

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