What Is External Counterpulsation (ECP)

External Counterpulsation (ECP) is a noninvasive circulatory therapy designed to enhance blood flow to the heart and support cardiac function. During treatment, pneumatic cuffs are wrapped around the legs (calves, thighs, and buttocks) and inflate/deflate in a synchronized sequence following the heart’s rhythm (via ECG gating). The goal is to increase perfusion to the coronary arteries during diastole and reduce the heart’s workload during contraction (systole).

How ECP Works (Mechanism)

• Inflation during Diastole
  As the heart relaxes (diastole), the cuffs inflate sequentially from the lower legs upward, propelling blood toward the central circulation. This increases venous return and augments coronary perfusion pressure.¹ ²

• Rapid Deflation before Systole
  Just before the heart contracts (systole), the cuffs deflate rapidly, reducing arterial resistance (afterload) and making it easier for the heart to eject blood.²

• Long-Term Effects / Biological Response
  Over repeated sessions, the increased shear stress on blood vessel walls may stimulate arteriogenesis / collateral vessel growth in ischemic myocardium, improving blood supply to underperfused heart tissues.¹ ³ The therapy may also enhance endothelial function and vascular health.⁴

Typical Treatment Schedule

Most protocols involve daily one-hour sessions, typically 5 days per week over a period of 6–8 weeks (approximately 35 total sessions) to complete a full course.² ⁵

Patients remain awake and comfortable during treatment; many read, relax, or nap.²

Clinical Uses & Considerations

ECP is often considered for patients who:

• Have chronic stable angina not fully controlled by medication

• Are not good candidates for further invasive procedures (such as bypass or stent)

• Seek symptom relief and improved functional capacity through a noninvasive approach

However, the evidence has limitations. A Cochrane review noted a lack of robust, conclusive evidence in randomized trials for angina symptom improvement.⁶ Nonetheless, observational studies and registries suggest some patients derive benefit.⁷

Safety Profile & Limitations

ECP is generally well tolerated. Potential side effects are mild and may include skin irritation, bruising, leg discomfort, or fatigue from compression.⁶ Contraindications should be strictly evaluated (e.g. peripheral vascular disease, severe valvular disease, arrhythmias interfering with ECG gating).⁸