Rehab facility provides new type of therapy to cardiac patients

EECP is growing in popularity

Certain cardiac patients have medical problems and pain from angina that prevent them from receiving the full benefits of rehabilitation therapy. Until recently, there was not a whole lot that a rehab facility could do for these people.

That situation has changed for Bacharach Institute for Rehabilitation of Pomona, NJ, which recently began to offer a new service, called Enhanced External Counter Pulsation (EECP), to cardiac patients with angina who lacked good surgery alternatives.

"We have patients who, after 12 weeks of rehab, still have angina, and we thought EECP would be another alternative for them," says Ronald Franceschini, MEd, CSCS, clinical coordinator of cardiopulmonary rehab.

These are patients who are no longer suitable candidates for bypass surgery or angioplasty, Franceschini adds.

The EECP machine, marketed by Vasomedical Inc. of Westbury, NY, was first introduced in the United States a decade ago, but it was not well received. Several years later, the Japanese company that developed it reintroduced it in California and obtained a patent on the machine. The EECP machine has approval from the Food and Drug Administration (FDA) for treatment of unstable angina, and it’s used at more than 300 U.S. sites, most of which are research universities, medical universities, acute care facilities, and cardiology practices.

Franceschini first learned about the device while attending a conference of the American Association for Cardiovascular and Pulmonary Rehabilitation.

"I came upon the machine being demonstrated, and it looked unusual," Franceschini recalls. "There’s a person on the table with inflatable pants, which are inflated and deflated, and after further research I found that the machine had quite a bit of studies backing it up."

Franceschini brought information back to the rehab facility’s administrator, who agreed that it looked like an interesting device. However, there was a problem with its price, which ranged from $150,000 to $200,000.

"I decided with the marketing director to solicit funds from a heart and lung foundation from the area," Franceschini says. "I made a presentation to the foundation’s board and asked them for a four-year commitment, and they agreed to donate $40,000 a year for four years to help us pay off the equipment."

Here’s how the rehab service works:

Sessions: Patients are seen five days a week for seven weeks, for a total of 35 visits. Bacharach Institute for Rehabilitation began to see the first EECP patients in March, and all were covered for the service by Medicare, Franceschini says.

The sessions, including preparation and post-treatment time, last about 1.5 hours.

"From last year to this year, Medicare increased reimbursement for EECP," he adds.

Machine makes its own natural bypass

Machine: Patients apply inflatable trousers that are similar to the military anti-shock trousers used by emergency medical services for patients who are in severe shock. The trousers have Velcro and are pulled over skin-like tights, which help prevent skin breakdown. The inflatable trousers fit over a patient’s calves, thighs, and hips.

The machine then provides 260 mmHg of therapeutic pressure to the patient’s lower extremities. The inflation begins with the calves and works its way up, Franceschini explains.

"It pulsates with your heart beat, so there’s an ECG telemetry reading, and during diastole the blood is shunted to the coronary arteries," he says.

Like exercise, the machine’s activity creates a sheering pressure along the coronary arteries, and it makes its own natural bypass through the creation of tiny arteries, Franceschini says.

"What the machine can do for you and what exercise can do are very similar in terms of trying to improve heart function and the angina threshold," he says. "Of course, the difference is that these patients can’t even walk 100 feet without getting some kind of angina, so they need some treatment that is passive initially."

There was on-site training on using the machine, and if Franceschini encounters any problems he can call a clinician and fax results to the machine’s distributor.

Therapy: The machine measures its activity according to the patient’s heartbeat, so if a patient has a heartbeat of 60 beats per minute, then there will be a continuous inflation/deflation rhythm according to that beat.

"We do pre- and post-vital signs, and during therapy I am looking at telemetry, making sure they are not in tachycardia or dysrhythmia," Franceschini says. "I measure the pulse wave every 10 or 15 minutes."

The measurements show whether the patient is receiving the therapeutic pulsation and gives the therapist an opportunity to adjust the pulse pressure as needed.

Depending on their comfort level, patients may take a nap or simply relax during the session. Franceschini dims the lights and puts on relaxing music to help patients feel more comfortable.

Benefits: After weeks of treatment, patients begin to feel better and their angina decreases during their daily activity, Franceschini says.

"The less angina they feel, the more activity they do, and that lowers their blood pressure," Franceschini explains. "Ultimately, it will make an excellent transition to therapy for those patients who couldn’t come to us initially in rehab."

Another benefit is that the patient’s body will begin to produce nitric oxide, a basal dilator, which also has a positive effect on reducing angina.

Current EECP research is investigating the use of the machine in heart failure patients to see whether these patients can improve their rating on the New York Heart Failure Classification scale.

Risks: The most prevalent adverse effect is skin breakdown, which occurs very rarely. Because patients undergo therapy while lying on a table, they are stable, and therapists can easily discontinue treatment should a problem arise, Franceschini says.

"If things go wrong, you push a button, stop the machine, and treat the patient," he explains.

Currently, the treatment is recommended for patients who are suffering from severe peripheral vascular disease, aortic valve insufficiency, stenosis, or who have heart failure, Franceschini adds.

One of Franceschini’s patients reports feeling pressure in her thighs and a soreness afterward, but another patient reports no discomfort after the therapy session.

Treatment might increase exercise tolerance

Patients: Franceschini treats a patient who has vessel disease, with blockage ranging from 70% to 90%, and who is a noninsulin diabetic with renal insufficiency.

Because of his renal problems, the patient is not eligible for heart surgery, and although he has already gone through a cardiac rehab program, he still has angina when he’s out walking his dog.

Traditional therapy has included teaching him a different strategy for walking his dog: Instead of following the dog uphill on one route, he can take a more level route. However, Franceschini says he hopes the EECP treatment will alleviate the man’s angina and enable him to increase his exercise tolerance.

A five-year study that tracked major adverse cardiovascular events (MACE) among 33 patients with coronary artery disease who were treated with EECP found that 64% or 21 of the 33 patients remained alive and without MACE or the need for revascularization five years post-EECP treatment, suggesting that EECP is an effective long-term therapy.1

Other published research found that EECP treatment improves exercise tolerance, reduces angina, and extends time to exercise-induced ischemia in patients with symptomatic coronary artery disease.2,3

Referring clinicians: Cardiologists are the main referring clinicians for the treatment.

To introduce EECP to local cardiologists, Franceschini met with the doctors to discuss the procedure, and the rehab institute has plans to hold a dinner meeting presentation on EECP.

There also has been a symposium held for area case managers, and the institute has advertised the service on local television shows with health update spots.

"So far, we’ve gotten a lot of phone calls, but it’s new so people are a little timid," Franceschini says. "Within four weeks, I have four patients, which will keep me busy."

References

1. Lawson WE, Hui JC, Cohn PF. Long-term prognosis of patients with angina treated with enhanced external counterpulsation: Five-year follow-up study. Clin Cardiol 2000; 23:254-258.

2. Urano H, Ikeda H, Ueno T, et al. Enhanced external counterpulsation improves exercise tolerance, reduces exercise-induced myocardial ischemia and improves left ventricular diastolic filling in patients with coronary artery disease. J Am Coll Cardiol 2001; 37:93-99.

3. Arora RR, Chou TM, Jain D, et al. 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; 33:1833-1840.

Need More Information?

  • Ronald Franceschini, MEd, CSCS, Clinical Coordinator of Cardiopulmonary Rehab, Bacharach Institute for Rehabilitation, 61 W. Jim Leeds Road, Pomona, NJ 08240. Telephone: (609) 748-2091.
  • Vasomedical Inc., 180 Linden Ave., Westbury, NY 11590. Telephone: (800) 455-3327 or (516) 997-4600. Fax: (516) 997-2299. E-mail: CustomerService@vasomedical.com.