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The Effectiveness of Enhanced External Counterpulsation (EECP)

Therapy for Heart Disease Patients

Johannes Bastira Ginting

, M. K. M, Okta Jaya

Faculty of Public Health, University Prima Indonesia, Medan, Indonesian

Faculty of Computer Science and Technology, University Prima Indonesia, Medan, Indonesian

Keywords: EECP, angina pectoris 2019.

Abstract: According to the WHO, the estimated number of deaths by 2020 in the world, especially in developing

countries, will be caused by chronic diseases, and 71% due to ischemic heart disease. EECP (Enhanced

External Counterpulsation) is an FDA-approved non-invasive alternative therapy that is particularly beneficial

for patients with heart disease. This study is a qualitative study, conducted at the wellness center of Royal

Prima Hospital, June 2020, the number of samples as many as 15 respondents. Miles and Huberman's data

analysis with the encoding used in the data analysis process is open encoding, axial encoding, and selective

encoding. As a result of the study, the majority of respondents expressed chest pain (angina pectoris)

expressed a decrease of 13 people (86.7%) and stated chest pain was no longer as much as 2 people (13.3%).

In terms of quality of life, all respondents stated an increase in life, with an increase in physical activity that

can be felt by the respondent. Concluded research, that EECP therapy provides effectiveness that reduces

chest pain and improves the quality of life of respondents who have undergone therapy 35 times. In the future,

more and more health facilities are providing EECP therapy facilities, especially in Medan.

1 INTRODUCTION

According to WHO data, the estimated number of

deaths by 2020 worldwide, especially in developing

countries, 75% will be caused by chronic diseases and

71% due to ischemic heart disease, (WHO Technical

Report Series, 2013). The UK states coronary heart

disease (CHD) is the leading cause of death. One in

five men and one in six women die from CHD. Every

year 101,000 people die from CHD, (Colin Tidy, d.

2012). Sudden cardiac death (SCD) events reach

400,000 cases per year in developed countries such as

the United States.

Indonesia as a developing country, but the pattern

of disease is already the same as the pattern of

diseases of developed countries, CHD is still the most

common disease-causing sudden death, (Yuniadi Y,

2019).

From the data of the Indonesian Association of

Cardiovascular Specialists (PERKI) 2019, it is

reported that CHD (which is classified as circulatory

system disease) is the main cause and the first of all

deaths, which is 26.4%, this figure is four times

higher than the death rate caused by cancer (6%). In

other words, approximately one in four people who

died in Indonesia were from CHD (Firdaus. I. 2019).

Sudden death is often caused by dangerous

cardiac arrhythmias triggered by sudden blockages of

the coronary arteries that have been narrowed due to

plaque forming in the atherosclerosis process. The

process of atherosclerosis, which is the main cause of

CHD, begins from young adulthood, and the plaque

that forms increases in age or time (Suherman.J,

2019).

The main cause of plaque formation is an

endothelial injury that lines the inside of the blood

vessels. Factors that play a role in continuous

endothelial injury are LDL (Low-Density

Lipoprotein) levels, high cholesterol, hypertension,

smoking, diabetes mellitus, and others (Insull W Jr,

2009).

There are currently several non-pharmacological

alternative therapies for patients with or without heart

failure, namely: neurostimulation (electrical

stimulation of transcutaneous nerves and spinal

medulla stimulation), EECP (Enhanced External

Counterpulsation), laser revascularization

techniques, gene therapy, and recent interventional

procedures such as percutaneous in situ coronary

artery bypass. However, a non-invasive and FDA-

approved alternative therapy is EECP therapy. Where

the target of EECP therapy is to open the existing

196

Ginting, J. and Okta Jaya, M.

The Effectiveness of Enhanced External Counterpulsation (EECP) Therapy for Heart Disease Patients.

DOI: 10.5220/0010292601960201

In Proceedings of the International Conference on Health Informatics, Medical, Biological Engineering, and Pharmaceutical (HIMBEP 2020), pages 196-201

ISBN: 978-989-758-500-5



coronary artery collateral and form new blood vessels

to provide blood supply to the blood-deficient heart

muscle. EECP benefits more in people with

narrowing of one or two major vessels. Unfortunately

in Indonesia, not many choose this non-invasive

therapy that has proven beneficial. That may be

because there are still few facilities that provide

EECP therapy and information about eecp therapy

methods is still lacking.

This study aims to identify the effectiveness of

EECP therapy against heart disease patients who are

undergoing therapy and who have undergone EECP

therapy. With the higher rate of morbidity and

mortality of coronary heart disease, it is expected that

later with this research, will add insight, public

information about EECP therapy, so that it can be

considered to the public in the treatment of CHD in

addition to the treatment of CABG surgery or less

invasive stent installation.

Several studies have been conducted to look at the

effectiveness of EECP therapy, which is used as

follows:

No Research Title Results

1 Effect of enhanced

external

counterpulsation therapy

on myeloperoxidase in

lowering cardiovascular

events of patients with

chronic heart failure

EECP therapy

lowers the MPO

levels of GJK

patients so that it

can decrease

cardiovascular

events within 6

months of

observation. The

higher the MPO

level correlated

with the higher the

incidence of

cardiovascular

events.

Researcher's name:

Starry H. Rampengan,

etc

Place and Time of

Research: General

Hospital of Prof Dr. R.

D. Kandou, Manado

Siloam Hospital,

Manado Adventist

Hospital, and Manado

Jade Cardiovascular

Clinic, January-

December 2012

(Rampengan, S. H,

2015).

Researcher's name:

Starry H. Rampengan,

etc

Time and Place of

Research: January 2014

and June 2015, Jade

Cardiovascular Clinic,

Manado, North

Sulawesi, Indonesia

(Rampengan, S. H,

2017).

2 Quality of life

improvement of

chronic heart failure

patients after the effect

enhanced external

counterpulsation

(EECP) therap

The WHO-5

questionnaire

resulted in false

before and after

EECP therapy, but in

the EECP group

showed statistically

significant

differences (p<0.05).

The WHO-5

questionnaire

attributes the results

to a significant

increase in feeling

cheerful and in good

spirits (p=0.03) and

waking up feeling

refreshed (p=0.030)

in the EECP group

compared to the fake

group. Conclusion:

EECP therapy is

effective for reducing

depression thus

improving quality of

life in CHF

atients

Researcher's name:

Starry H. Rampengan,

etc

Time and Place of

Research: January 2014

and June 2015, Jade

Cardiovascular Clinic,

Manado, North

Sulawesi, Indonesia

(Rampengan, S. H,

2017).

Nearly a century and a half ago, researchers at

Havard University began experiments with

counterpuIsasi. They have proven that this technique

can meaningfully reduce the workload and oxygen

consumption of the left ventricle. In 1953, Kantrowitz

et al. described diastolic changes as the cause of

increased coronary blood flow. Birtwell et al. in the

USA began the development of this technique, he first

implemented the concept by developing an artery

pulsator counter. Zheng et al. reported for the first

time the advantages of using external

counterpulsation in the 1980s, he used pneumatic

counterpulsation tools.

Lawson et al. at the State University of New York,

Stony Brook, analyzed several open studies of EECP

use between 1989-1998, using objective and

subjective viewpoints. These studies show that,

although open and not random, EECP users

statistically produce progress on exercise tolerance.

This is evidenced by thallium stress tests, which show

partial or total healing from coronary perfusion

defects. In 1999 for the first time, Arora et al. Report

the results of the multicenter Study of Enhanced

External Counterpulsation (MUST-EECP) double-

blind randomized placebo-controlled test. Since then,

EECP therapy has emerged as an effective, non-

invasive, and reliable alternative therapy for patients

with angina, even those with heart failure (Insull W

Jr, 2009). According to Prof. Peter Kabo, in

Indonesia, the first person to promote EECP is Prof.

The Effectiveness of Enhanced External Counterpulsation (EECP) Therapy for Heart Disease Patients

197

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Dr. Syukri Karim. They did a simple study and the

results showed that EECP improved the

manifestations of CHD tested with ECG, treadmill

test, or talcum scintigraphy. In 1997, Indonesia was

the only country in Southeast Asia to have an EECP.

But currently, EECP has been used in Malaysia, Hong

Kong, Taiwan, Philippines, and Singapore as one way

of countermeasures cardiovascular (Suherman.J,

2019).

EECP tools work regulated by computers based

on the patient's electrocardiogram to increase arterial

diastolic blood pressure thereby improving diastolic

blood flow in the coronary, cerebral, and renal

arteries, as well as stimulating diuresis and natriuresis

(Insull W Jr, 2009). In 2002, the FDA approved

EECP therapy for patients with heart failure due to

myocardial ischemic. EECP (Enhanced external

counterpulsation) therapy is a non-invasive therapy

using three sets of pneumatic cuffs wrapped around

the calves, thighs, and hips. Air filling and emptying

in cuffs is regulated according to the heart cycle based

on a computer-controlled ECG.

At the time of diastole onset, three sets of cuffs are

filled with air quickly with adjustable pressure,

sequentially starting from the calf, then the thigh, and

the last in the hip. Thus the blood from the lower

limbs is squeezed back and channeled to the base of

the aorta (counterpulsation). The increased diastolic

pressure increases the perfusion pressure of the

coronary artery, opens the existing collateral vessels

and shear stress that occurs in the coronary artery will

improve endothelial dysfunction.

Patients who will benefit from EECP therapy

include patients with angina attacks that cannot be

overcome by pharmacological therapy (refractory

angina) and limiting their activity to avoid angina

symptoms. Patients with coronary anatomy are not

suitable or at high risk for revascularization therapy.

EECP therapy is also not a great choice for patients

with microvascular angina (cardiac syndrome X) and

diabetic Mellitus patients with coronary heart disease.

The target of EECP therapy is to open the existing

coronary artery collateral and form new blood vessels

to provide blood supply to the blood-deficient heart

muscle. EECP benefits more in people with

narrowing of one or two major vessels. If narrowing

has occurred in the 3 main coronary vessels then

EECP therapy should be done after CABG.

Guidelines for EECP therapy are:

1. Therapy is carried out daily for one hour, a

week 6 times to 36 times.

2. All drugs are consumed as prescribed, except

diuretic drugs should not be taken before

therapy as it will interfere with therapy.

3. Patients do not eat or drink 2 hours before

therapy.

4. The patient empties the bladder before therapy

begins.

5. The patient wears cotton trousers that fit

perfectly.

6. The patient's blood pressure and pulse

frequency are checked before and after therapy.

7. ECG, heart rate frequency, and oxygen

saturation and plethysmograph monitored

during therapy

Figure 1. EECP (Rampengan, S. H, 2017) Therapy Stage

Diagram

Steps 1-3 of air are pumped in succession shortly after

pistol Step 4 air is sucked simultaneously shortly

before pistol.

Figure 2. Mechanism of eecp therapy clinic benefits

2 RESEARCH METHODS

This research was conducted with a qualitative

approach. This means that the data collected is not in

the form of numbers, but rather it comes from

interview scripts, field notes, personal documents,

memo notes, and other official documents, so the

purpose of this qualitative research is to portray the

empirical reality behind the phenomenon in-depth,

detail and complete. This research was conducted at

the Royal Prima Wellness Center Hospital 5th Floor,

in 2019. The population is all coronary heart patients

undergoing therapy at Wellness Center Rs Royal

Prima Medan. From the initial survey, data found that

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the average coronary heart patient undergoing EECP

therapy is 5-7 people per month. Therefore,

researchers determined the number of samples as

many as 15 patients, this is because every one patient

takes about 7 to 8 weeks to complete EECP therapy

following EECP therapy guidelines. So that later this

research can be completed according to the schedule

that has been determined.

The data source in this study was the subject from

which the data was processed, primary data being

direct data from patients using semi-structured

interview techniques and documentation. Secondary

data is data from the patient archives at the Wellness

Center of the Royal Prima Hospital and previous

research literature to strengthen the results of the

research and complete the information that has been

collected through in-person interviews with

informants.

The data analysis techniques used in this study use

Miles and Huberman interactive model data analysis

techniques that include data reduction, data display,

and conclusion drawing/ verification (Saldana. et al,

2014).

Here's an explanation:

a. Data Reduction

At this stage, researchers are sorting through

the results of interviews and documentation

that are still complex and unstructured so that,

researchers obtain data relevant to the study's

problems.

Display Data Display data is the presentation of

data into the corresponding matrix. In

qualitative research, display data or data

presenters can be done in the form of briefs,

charts, and relationships between categories,

flowcharts, and the like. Withdrawal of

Conclusions or Verification In concluding,

researchers begin to look for the meaning of the

data that has been collected (Sugiyono. 2008).

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Figure 3. Miles and Huberman Interactive Data

Analysis Model

The results of the study were conducted to 15

respondents, the majority of patients of the male

gender (>65%), the age of the majority of respondents

over 50 years (80%), in terms of education, the

majority of respondents are highly educated (60%), in

terms of employment, the majority of respondents are

self-employed, namely (46.7%), for more details can

be seen in Table 1.

Table 1. Overview of Research Respondents, by Age,

Gender, Education and Employment Status

Variable

Characteristics

Sum

Percentage

(%)

Age

< 40 years 1 6.7

40 s/d 50

years

2 13.3

> 50 years 12 80.0

Gender

Male 10 66.7

Female 5 33.3

Job

PNS,

BUMN,

TNI,

Government

2 13.3

Private

Employees

6 40.0

Self-

employe

7 46.7

Education

Higher

Education

(S1, S2, S3)

9 60.0

High school 6 40.0

Table 2: Overview of Research Variables

Research Variables Sum

Percentage

(%)

Therapy

EECP

< 35 Times 5 33.3

≥35 Times 10 66.7

Chest

Pain

Reduced

Chest Pain

13 86.7

Chest Pain

Is Gone

2 13.3

Quality

of Life

There Are

rovements

15 100

From table 2, it can be seen by current and current

respondents who have undergone therapy for <35

times as many as 5 (33.3%), who have undergone

therapy ≥35 times as many as 10 (66.7%).

Respondents who expressed chest pain decreased by

13 people (86.7%), and who stated chest pain was no

longer there (never relapsed) as many as 2 people

(13.3%). In terms of quality of life, all respondents

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199

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stated that the quality of life there was an increase of

15 people (100%).

From the results of the study, respondents stated

that the symptoms of chest pain (angina pectoris)

were reduced, and some claimed to have never felt or

experienced chest pain. The researcher's assumption,

that respondents who are and have undergone EECP

therapy have felt the benefits of such therapy.

Whereas we know, the target of EECP therapy is to

open up existing coronary artery collateral and form

new blood vessels to provide blood supply to the

blood-deficient heart muscle. EECP benefits more in

people with narrowing of one or two major vessels.

So it can be concluded EECP therapy has

effectiveness in the treatment of patients who have

coronary heart disorders.

This is in line with research conducted by Darren

PC. Et al, 2008, found that EECP is effective in

reducing plasma levels of alpha tumor necrosis factor

(TNF-α), monocyte protein chemoattractant-1 (MCP-

1), and these changes are in parallel with reducing

chest pain symptoms. Of the quality of life variables,

all respondents stated that this therapy was shown to

improve their quality of life, judging by the patient's

passion and joy to undergo therapy. Because

according to the patient, after undergoing therapy,

their sleep at night is very good, so in the morning the

patient feels very healthy. Also, seen from some

respondents' statements, after EECP therapy, patients

felt the physical improvement was increasing. Where

before undergoing therapy, some respondents can

only walk a few meters, after undergoing therapy,

patients can already increase the intensity of exercise

(walking) more than before undergoing therapy.

There was one respondent, who had previously

been unable to walk again (already in a wheelchair),

after undergoing therapy 35 times, that respondent

had improved, where the respondent was already able

to walk even though he was still bricked up and

helped to walk. This research is in line with the results

of research conducted by Rampengan, S. H, 2015,

wherein his research stated EECP therapy is safe and

effective as well as beneficial on improving quality of

life in patients with chronic heart failure as shown by

the increased walking distance in the six-minute

walking test.

The downside of EECP therapy, there are some

complaints received by researchers from respondents,

namely concerning the problem of the time it takes to

complete the therapy is felt long enough, namely 35

times therapy for 35 days (1 day, therapy 1 hour).

Where if the patient does not live on schedule, then

the therapy should be repeated from the initial count,

to achieve maximum results. And the facilities that

provide EECP therapeutic facilities are still limited.

However, because the respondent immediately felt a

good effect starting from the first therapy, the

respondent felt the weakness of the time was

considered not a big problem. Some statements from

patients who have undergone therapy for 35 times,

continue therapy, with schedule settings 1 therapy

every 1 week, to still be able to maintain their health

condition. According to the respondent's assumption,

with this follow-up therapy, this is done to prevent the

possibility of chest pain as early as possible.

Placebo from the results of this study, according

to respondents who have undergone therapy, said that

although EECP therapy is very helpful to overcome

chest pain but to get the most results, respondents

must also follow the treatment given by the doctor,

consume additional vitamins, and also no less

important, namely the support of the family in the

treatment of their disease.

3 CONCLUSIONS AND

SUGGESTIONS

3.1 Conclusions

In the conclusion of this study, the majority of

patients stated that after undergoing EECP therapy,

chest pain or angina was less than 13 people (86.7%),

even respondents also stated chest pain was no longer

there. In terms of quality of life, all respondents stated

an improvement in the quality of life of 15 people

(100%), characterized by an increase in physical

activity that can be done by respondents after

undergoing therapy. EECP therapy is a non-invasive

for patients with coronary heart disease, whether it

has undergone revascularisation or not. For patients

who experience coronary heart disease because of

complications from DM type2, because with the

presence of EECP therapy then a small probability of

revascularisation action.

This therapy is hilly to improve the quality of life

of the sufferer, visible from the spirit and joy of

patients to undergo such therapy. Since the result of

EECP therapy can make the heart perfusion better and

open the collateral blood vessels that have been and

are thought to form new collateral vessels.

3.2 Suggestions

Because of the limited researchers in the deep dive

into the effectiveness of EECP therapy until

laboratory tests, researchers hoped for the future,

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researchers could continue with the research by

collaborating with more clinical teams. Expected for

the future, more health facilities that provide EECP

therapy facilities, especially in the city of Medan.

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