Patients with refractory angina often suffer from erectile dysfunction. Enhanced external counterpulsation (EECP) decreases symptoms of angina, and increases nitric oxide release. This study evaluated the effect of EECP on sexual function in men with severe angina. The International Index of Erectile Function (IIEF) was used to assess erectile function of severe angina patients enroled in the International EECP Patient Registry. Their symptom status, medication use, adverse clinical events and quality of life were also recorded before and after completing a course of EECP. A cohort of 120 men (mean age 65.0+/-9.7) was enroled. The men had severe coronary disease with 69% having a prior myocardial infarction, 90% prior coronary artery bypass graft or percutaneous coronary intervention, 49% with three vessel coronary artery disease, 86% were not candidates for further revascularisation, 71% hypertensive, 83% dyslipidaemia, 42% diabetes mellitus, 75% smoking and 68% using nitrates. Functional status was low with a mean Duke Activity Status Inventory score of 16.6+/-14.8. After 35 h of EECP anginal status improved in 89%, and functional status in 63%. A comparison of the IIEF scores pre- and post-EECP therapy demonstrated a significant improvement in erectile function from 10.0+/-1.0 to 11.8+/-1.0 (p=0.003), intercourse satisfaction (4.2+/-0.5 to 5.0+/-0.5, p=0.009) and overall satisfaction (4.7+/-0.3 to 5.3+/-0.3, p=0.001). However, there were no significant changes in orgasmic function (4.2+/-0.4 to 4.6+/-0.4, p=0.19) or sexual desire (5.3+/-0.2 to 5.5+/-0.2). The findings suggest that EECP therapy is associated with improvement in erectile function in men with refractory angina.

Objectives We evaluated the association of baseline body mass index (BMI) on the outcomes of enhanced external counterpulsation (EECP) therapy for chronic stable angina.Background We are in the midst of a pandemic of obesity, which is complicating the care of patients with coronary artery disease (CAD).Methods We examined 2730 patients enrolled from 2002 to 2004 in the IEPR-2. Baseline and outcome variables were stratified by the entry BMI in kilograms per meter squared.Results Obesity (BMI > 30 kg/m(2)) was common (40.6%) among patients with severe CAD referred for EECP. Within the total cohort, 2.6% was underweight (BMI <= 20 kg/m(2)) and 4.5% was morbidly obese (BMI > 40 kg/m(2)). Prevalence of /0 diabetes, hypertension, dyslipidemia, and heart failure (HF) was higher in obese patients. However, the rates of baseline angina and prior revascularization were similar among the groups. The peak diastolic augmentation ratio was similar between groups during the first (0.7 +/- 0.4 for lowest and highest BMI) and lost hours of treatment (0.9 +/- 0.5 and 0.8 +/- 0.5). The cumulative hours of treatment, the change in angina class, and the Duke Activity Status Index were similar for all BMI groups. There was a greater reduction in weekly anginal episodes from baseline across ascending levels of BMI (-6.3 +/- 13.6 to -9.7 +/- 15.8, P =.03). The rates of discontinuation for clinical events were highest (14.3%) with skin breakdown being the most frequent cause (10.1%) in the underweight. The rates of clinical events including myocardial infarction, HF, and death trended higher across ascending levels of BMI (P =.52). Multivariate analysis found that older age, history of stroke, history of HF, and diabetes, but not BMI, were predictors of clinical events.Conclusions More than 40% of patients with severe CAD referred for EECP were obese. Underweight patients had higher rates of discontinuation of treatment mainly because of skin breakdown. Symptomatic benefit of EECP was similar among all BMI groups. However, despite symptomatic improvement, there was a nonsignificant trend for higher rates of myocardial infarction, HF, and death as BMI increased.

OBJECTIVES The purpose of this study was to determine the prevalence and severity of paravalvular regurgitation (PVR) in the Artificial Valve Endocarditis Reduction Trial (AVERT) cohort.BACKGROUND The initial AVERT cohort consisted of 807 patients randomized to receive either a Silzone-coated prosthetic valve or a conventional prosthetic valve; early clinical reports showed higher rates of valve explant caused by PVR for Silzone-coated prosthetic valve.METHODS Of the 678 eligible patients, 575 (85%) underwent postoperative transthoracic echocardiograms. The presence and severity of PVR were identified by color flow Doppler. Reviewers were blinded to the type of prosthetic valve and the demographic and clinical variables.RESULTS Among those who underwent echocardiography (Silzone-coated prosthetic valve, n = 285 and conventional prosthetic valve, n = 290), 59% had prosthetic aortic valves, 32% prosthetic mitral valves, and 9% had both; demographic and clinical findings (i.e., prosthetic valve endocarditis, thromboembolism, bleeding, and all-cause death) were similar for the two groups. Echocardiographically determined PVR was present in 50 valves: Silzone-coated prosthetic valve, 29 of 285 (10%) and conventional prosthetic valve, 21 of 290 (7%, p = NS); the severity of PVR was similar in both groups. Kaplan-Meier analysis showed no significant differences in PVR at 24 months from valve implantation between the two groups (24-month event-free rate: 93% Silzone-coated prosthetic valve vs. 94% conventional prosthetic valve, p = NS).CONCLUSIONS Excluding those patients who had initial prosthetic valve explant, the two-year echocardiographic follow-up of the AVERT cohort shows no statistically significant differences in the prevalence or severity of PVR in the Silzone-coated prosthetic valve compared with the conventional prosthetic valve. Further monitoring is warranted to determine whether these clinical outcomes remain similar on long-term follow-up. (J Am Con Cardiol 2004;44:1467-72) (C) 2004 by the American College of Cardiology Foundation.

Background Enhanced external counterpulsation (EECP) is an effective noninvasive treatment for refractory angina which is mainly used for patients (pts) who are not candidates for further invasive revascularization. This report examines whether pts who have the option of further invasive revascularization (CR) demonstrate a comparable initial and sustained 2-year response to EECP as those who are not candidates for revascularization (NCR). Methods Consecutive angina pts enrolled in the International EECP Patient Registry were grouped by potential for further revascularization. Baseline demographics were recorded and outcomes were tracked for 2 years post EECP. Statistical analysis was by chi-square test, t test and Kaplan-Meier survival methods. Significance was defined as p<0.05. Results There were 1,335 NCR pts and 204 CR pts. CR were significantly younger (64.3 ± 11.3 vs. 66.7 ± 10.7 years), with more recently diagnosed CAD (10.8 ± 9.1 vs. 11.6 ± 8.2 years) and had less severe angina (CCS class III/IV 83.3% vs. 91.8%). They were less likely to have prior CABG (55.2% vs 74%), CHF (16.9% vs 35.1%), LVEF<35% (10.9% vs 21%), multivessel disease (64.8% vs 80.7%), or DM (32.8% vs 44.2%). The two groups received the same course of EECP treatment and responded comparably. Immediately post EECP, only 23.6% of CR and 25.2% of NCR remained in CCS class III/IV, with 73.5% of CR and 77.6% of NCR improving one or more CCS angina class. At 2 years both CR and NCR demonstrated preserved and comparable reductions in angina class (16.3% vs 22.7% remained in class III/IV; with 48.2% vs 48.3% in class I or with no angina). Frequency of angina episodes per week and nitroglycerin use were reduced similarly in both groups post EECP and at 2-year follow-up. The NCR group had higher major adverse cardiovascular events (31.3% vs 25.7%) due to a significantly higher mortality (11.0% vs 6.2%) and myocardial infarction (9.3% vs. 5.4%). Exacerbation of CHF (10.1% vs 2.5%) was also significantly more frequent in NCR pts. Conclusions EECP effectively provided comparable sustained relief from angina in CAD pts regardless of their candidacy for further revascularization. However NCR patients presented with a more severe clinical profile at baseline, which was reflected in increased mortality and episodes of CHF in follow-up.

We assessed the frequency, efficacy, predictors, and long-term success of repeat enhanced external counterpulsation (EECP) therapy in relieving angina in a large cohort of patients who had chronic angina pectoris and had undergone a full course of EECP. Within 2 years of the initial course of EECP, the rate of repeat EECP was 18%, which occurred at a mean interval of 378 days after initial EECP. Of those who underwent repeat EECP, 70% had a decrease of >/=1 angina class at the end of repeat EECP with similar decreases in nitroglycerin use.

Background: Enhanced external counterpulsation (EECP) is effective in treating angina in coronary artery disease patients. Whether EECP produces similar immediate and sustained benefits and freedom from adverse events (MACE) at I year in patients with severe systolic dysftinction versus diastolic dysfunction is unknown.Methods and Results: Data of 746 angina patients with a history of heart failure enrolled in the International EECP Registry were divided into 2 groups: left ventricular ejection fraction (LVEF) less than or equal to35% (S) and LVEF >35% (D). Mean LVEF was 51.0 +/- 10.2% in diastolic dysfunction (n = 391) versus 26.3 +/- 6.9% in systolic dysfunction (n = 355). At baseline, 92.0% of diastolic dysfunction and 90.9% of systolic had Canadian Cardiovascular Society Class III/IV angina with similar number of anginal episodes and nitroglycerin use. After 32 hours of EECP, angina was reduced by greater than or equal to1 class in 71.9% of diastolic versus 72.2% of systolic with similar decreases in anginal episodes and nitroglycerin use. At 1-year 78.1% of diastolic and 75.8% of systolic have less angina than pre-EECP. MACE at I year was also comparable (24.4 versus 23.8%).Conclusions: The benefits of EECP in heart failure patients were similar regardless of diastolic or systolic dysfunction. The improvement was sustained at I year with similar MACE.

Background Enhanced external counterpulsation (EECP) treatment has been shown to improve systemic endovascular and neurohumoral effects. Since diabetic patients (pts) with angina have increased CABG morbidity, more PCI restenosis, more cardiovascular death, and increased mortality in those pts with heart failure (HF), EECP may be a beneficial treatment of angina for diabetic pts with HF. Purpose Initial and 1-year effects of EECP on angina status, quality of life (QoL), and MACE (death, MI, CABG/PCI) were compared in angina pts with HF vs angina with heart failure and diabetes. Methods Consecutive angina pts with HF in the International EECP Pt Registry were divided by their diabetic status and prospectively followed for 1 year after EECP. Measures included Canadian Cardiovascular Society (CCS) angina class, nitroglycerin use, QoL, and MACE. Statistical analysis was by chi-square tests, Wilcoxon signed rank tests, and Kaplan Meier survival methods. Significance; p<0.05. Results There were 779 angina pts with HF, 413 (53%) were diabetic. Diabetic pts were younger (66.3 ± 10.7 vs. 68.9 ± 10.8 years), with more recently diagnosed CAD (11.6 ± 8.5 vs. 13.4 ± 8.8 years), more likely to be female (33.7% vs. 22%), hypertensive (80.0% versus 71.2%), and with less smoking history (70.7% vs. 83%). At baseline, there were no differences in CCS class III and IV, mean LVEF, multivessel CAD, and revascularization candidacy between the two groups. Health-related QoL was significantly worse in the diabetics. Both groups underwent a comparable EECP course, with similar MACE during therapy. Post EECP, diabetic pts had a comparable reduction in angina (72.3% vs. 71.1% achieved one or more CCS class reduction), Ntg use and angina episodes/week. Angina reduction was sustained at 1 year; with no significant differences in Ntg use. Diabetic pts demonstrated significantly greater improvements in health, satisfaction, and quality of life at 12 months. Comparable MACE was noted at 1 year (25.6% vs. 21.8%). Conclusions EECP effectively relieves angina in HF patients with or without diabetes. Diabetic pts demonstrate comparable sustained improvements in angina class, decreases in anginal episodes and nitroglycerin use, with more improvement in their quality of life. EECP may be a unique therapy in improving endovascular function in patients with atherothrombosis and neurohumoral activation such as the diabetic with HF and angina.

Enhanced external counterpulsation (EECP) has been shown to reduce Canadian Cardiovascular Society angina class. This study examines the factors that affect the reduction at 1 year, especially in patients who do not demonstrate an initial response. The data of 2,007 consecutive patients enrolled in the International EECP Patient Registry were analyzed. After 36.6 ± 4.9 h of EECP, angina was reduced by at least one class in 82.7%. At 1 year, 35.4% of initial nonresponders and 70.6% of responders remained improved by at least one angina class and free of major adverse cardiovascular events. Multivariate predictors of 1-year benefit are initial response to treatment (odds ratio 4.5, 95% CI 3.5–5.8), baseline angina class compared with class IV (odds ratios: class I 2.1, CI 0.93–4.81; class II 0.62, CI 0.43–0.87; class III 0.80, CI 0.62–1.01) and no history of congestive heart failure (odds ratio 1.41, CI 1.14–1.74).

Introduction: Enhanced external counterpulsation (EECP) is a non-invasive circulatory assist device, which has recently emerged as a treatment option for angina in left ventricular dysfunction. The effectiveness of treatment on reduction of angina depends on the level of diastolic augmentation ratio (DAR). However, there is limited data on the impact of DAR on clinical outcomes, event free survival rates and incidence of repeat EECP. Methods: We compared the clinical outcomes, major cardiovascular event (MACE: Death/CABG/PCI/MI) free survival rates and repeat EECP rates of patients with good DAR (GDAR >= 0.4) and low DAR (LDAR<0.4). DA by finger plethysmography measured the ratio of diastolic to systolic pressure at the first hour of treatment. Comparisons between groups were analyzed using Chi-square or Wilcoxon signed rank tests as appropriate. Rates of follow-up events were analyzed using Kaplan Meier survival methods. Results: 625 (81 %) had GDAR and 151 (19 %) patients had LDAR. GDAR were younger (66 years vs. 69, p<0.05), more likely to be male (82% vs. 72%, p<0.01), less likely to have diabetes (p<0.001) and non –cardiac vascular disease (p<0.001). There were no significant differences regarding smoking, prior revascularization, hypertension, hyperlipidemia, family history, duration of CAD, current medications, mean EF (32%), baseline angina class, multivessel disease, or nitroglycerin usage. GDAR had better treatment compliance (p<0.05) and lower rate of treatment discontinuation due to a clinical event. MACE during the treatment period was low in both groups (<4%). After the treatment course a reduction in angina by at least one class was obtained in 73% of GDAR vs. 69% of LDAR. Discontinuation of nitro usage was 50% in GDAR and 42% in LDAR. At 15 months follow up angina reduction was maintained in 79 % of GDAR and 73% of LDAR. MACE free survival (78% vs. 73%) and repeat EECP rates (15% vs. 16%) were similar in both groups. Conclusion: Good diastolic augmentation is significantly associated with treatment completion. Patients with GDAR tend to have better reduction in angina, lower repeat EECP and higher MACE free survival rates. Special attention should be made to female patients, and those with diabetes or non- cardiac vascular disease to ensure that they achieve good GDAR.