ABCs of Modern Management of Chronic Stable Angina

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ABCs of Modern Management of Chronic Stable Angina

• A Aspirin(anti platelet), Anti-Angina,ACEI,ARBS
  Angioplasty/stent
• B Beta Blockers, Blood Pressure control
• C Cholesterol,Calcium antagonists,Cigarette
  smoking cessation,Clopidogrel(PCI),Cord(spina
  l) stimulation CABG
• D Diet for weight control,Diabetes control,
  Depression
• E Education, Exercise, EECP
• F Fattly acid oxidation inhibition(pFox I),
  Family
• G Glycerol Trinitrate
• H Happiness(antidepressant)
• I Isosorbide Dinitrate

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Enhanced External Counterpulsation (EECP)

• EECP is a noninvasive therapy for patients with
  Ischemic heart disease.
• A full course of EECP is 30-35 hours, 1-2 hour(s)
  daily for 3-7 weeks.

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• During Diastole
• Diastolic Pressure is raised
• Increases Aorto-Coronary Perfusion Pressure
• Venous Return is Increased
• Increases Cardiac Output by the Starling
  Mechanism

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• During Systole
• Rapid drop in Diastolic Pressure
• Unloads the Left Ventricle
• Decreases the work of the ventricle thus
  decreasing Myocardial Oxygen Consumption

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Baseline
100mmHg
150mmHg
200mmHg
250mmHg
300mmHg
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Hemodynamic Effects of EECP
Intracoronary Ultrasound Coronary Blood Flow
Control
EECP
Andrew Michaels, Circulation 20021061237-1242
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Increase Coronary Artery Blood Flow
Doppler Flow Velocities obtained with FloWire in
the LAD
Michaels AD, et al. Circulation 2002 106
1237-42.
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Summary of basic and clinical effectiveness

• Mechanisms of action demonstrated
• Increase blood flow to all organs during EECP
  treatment
• Improve endothelial functions
• Clinical evidence on the safety and effectiveness
  in treating patients with angina pectoris and
  heart failure
• Improve exercise capacity
• 70-80 of patients improved their cardiovascular
  functional class
• Improve perfusion to ischemic regions of the
  myocardium
• Improve quality of life by at least 60-70
• Reduction in nitroglycerin usage

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ANALYSIS OF THE AORTIC PRESSURE WAVE
Measured Wave Incident Wave Reflected Wave
Incident wave
Measured Pressure Wave
Incident wave related to aortic stiffness
Measured Flow Wave
Reflected Pressure Wave
Reflected wave related to stiffness of entire
arterial tree
Reflected Flow Wave
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Pulse Wave Velocity and Arterial Stiffness
Travel Time of Reflected Wave
Decreased PWV ? Increased ? tp/ 2
p0.001
Travel Time (msec )
74 ? 6.6
68 ? 8.0
Pre-EECP
Post-EECP
Pulse Pressure ( Pi Pd ) Augmentation Index
(Ps Pi) / (Ps Pd) Time for pressure wave to
travel from aortic root and back ?tp Wasted LV
pressure energy 2.09 X ?tp (Ps Pi) LV
Workload Tension Time Index area under
systolic wave
J Am Coll Cardiol 2006481208-1214
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Effects of EECP on Arterial Function

• Randomized, sham-controlled study
• 35 hours/sessions of therapy (EECP vs. SHAM)
• CAD pts. with refractory angina
• Optimal Anti-Hypertensive Medication
• Preliminary Data
• 30 Subjects
• 20 EECP
• 10 SHAM

Braith et al. NIH HLBI R01-HL077571-01
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Patient Demographics
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Applanation Tonometry
? Central Hemodynamics
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Wave Reflection
Augmentation Index (AIa)
Round Trip Travel Time


?tp (msec)
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Wave Reflection
Reflected Aortic Pressure
Wasted LV Energy

Duration of Reflected Wave
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Central Pulse Wave Velocity
Carotid-to-Femoral PWV
p ? 0.05

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Peripheral Pulse Wave Velocity
Carotid-to-Radial
Femoral-to-Foot
p ? 0.07
p ? 0.06


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Flow-Mediated Dilation (FMD) of Brachial and
Femoral Arteries
Brachial or Femoral Artery
? Diameter
Tourniquet
Ultrasound Probe
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Brachial FMD
Change
Absolute Dilation (mm)


p lt 0.05
Normalized for Shear Rate
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Femoral FMD
Absolute Dilation (mm)
Change


p lt 0.05
Normalized for Shear Rate
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Venous Occlusion Plethysmograph
220 mmHg
50 mmHg
? Circumference
for 5 seconds
Peak Calf and Forearm Blood Flow
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Limb Blood Flow
Peak Forearm BF
Peak Calf BF


p ? 0.01 vs. baseline
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Anginal Class
Improvement Following EECP
Canadian Cardiovascular Society Angina
Classification
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Conclusions

• EECP improves wave reflection characteristics,
  decreases LV afterload and MVO2.
• EECP reduces central and peripheral arterial
  stiffness.
• EECP improves endothelial function in peripheral
  conduit and resistance vessels.

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Conclusions

• EECP reduces anginal episodes in CAD patients.
• EECP improves exercise tolerance, time to angina,
  and VO2 peak.
• EECP improves peripheral and central blood
  pressures.

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• EECP May be Considered Adjunctive
• to Conventional Revascularization,
• Instead of Being Used After These
• Procedures are Performed or Have
• Failed

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Where are we going?
Enhanced External Counterpulsation (EECP)
Risk Factors
Increases blood flow / shear stress
Endothelial dysfunction
Improves Endothelial function
Initiation of atherosclerotic process
Prevent Progression of Cardiovascular Disease
Progression of Cardiovascular Disease
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Symptomatic Coronary Artery DiseaseTreatment
Evolution
Eventual?
Next step?
Current
Aggressive Medical Therapy
Aggressive Medical Therapy
Aggressive Medical Therapy
CABG, PCI
EECP
CABG, PCI
EECP
EECP/Other
CABG, PCI