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EECP for Heart Failure: Is the Juice Worth the Squeeze?

For now, the PEECH appears not to be juicy enough.

Enhanced external counterpulsation (EECP) is a noninvasive technique used to treat refractory angina. On the legs and buttocks, patients wear cuffs that inflate each time the heart relaxes. The EECP "squeeze" generates both systolic unloading and increased coronary perfusion pressure, much like the hemodynamic effects of intra-aortic balloon counterpulsation. Might EECP benefit patients with heart failure (HF)?

The Prospective Evaluation of Enhanced External Counterpulsation in Congestive Heart Failure (PEECH) investigators randomized 187 optimally treated patients with NYHA class II–III HF (70% ischemic) and left-ventricular ejection fractions 35% to EECP (35 one-hour sessions over 8 weeks) or to ongoing medical HF therapy alone. The study, conducted at 29 U.S. and U.K. centers, involved blinding for investigators, but not patients, and no sham EECP arm. An EECP device manufacturer funded the study.

By 6-month follow-up, significantly more EECP-treated patients than controls achieved at least a 60-second increase in exercise time (35% vs. 25%) and an improvement in NYHA class (31% vs. 14%). However, the two groups did not differ significantly in peak oxygen consumption at 6 months or in quality-of-life improvement. More EECP-treated patients than controls discontinued therapy due to adverse events; one EECP recipient experienced a pulmonary embolism during the treatment period.

Comment: EECP’s relatively modest enhancement of exercise tolerance in PEECH is not a ringing endorsement for its use in HF patients, even discounting problems with the study design. Although the authors explain their rationale for the lack of a placebo (sham EECP) arm, they concede that they cannot exclude a placebo effect and greater intensity of care with EECP as explanations for EECP’s advantage over ongoing medical therapy alone. Editorialists suggest that both explanations are likely and that we need to know much more about EECP in HF before it is used (and reimbursed) for HF care.

— Frederick A. Masoudi, MD, MSPH

Published in Journal Watch Cardiology September 27, 2006

Citation(s):

Feldman AM et al. for the PEECH Investigators. Enhanced external counterpulsation improves exercise tolerance in patients with chronic heart failure. J Am Coll Cardiol 2006 Sep 19; 48:1198-205.

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• Medline abstract (Free)

Gottlieb SS and Piña IL. Enhanced external counterpulsation: What have we learned from the treatment of neurasthenia? J Am Coll Cardiol 2006 Sep 19; 48:1206-7.

• Original article (Subscription may be required)
• Medline abstract (Free)