Modern Treatment For Cardiac Patients

External Counter Pulsation is touted as the next big thing in cardiology. However, only a few centres in India are practising it, Shardul Nautiyal discovers

Dr Pratiksha Namjoshi treating a patient with ECP

Being diagnosed with five major blocks, one of which had 100 per cent severity, it was time for Ganesh Mangeshkar (50) to undergo bypass surgery. Mangeshkar got busy arranging money for the surgery. But as luck would have it, the surgery got postponed for a month due to a doctors' strike and Mangeshkar opted for External Counter Pulsation (ECP) at the Institute of Preventive Care (IPC), Thane. “Today, I lead a healthy life,” smiles Mangeshkar.

For his good health, he credits the first woman preventive cardiologist and Director of IPC, Pratiksha Namjoshi. “She introduced to me to life-saving ECP, which has brought about this transformation, after four long years of suffering from chest pain, breathlessness and mental stress,” he says.

What Is ECP?

ECP is a microprocessor-controlled system, which increases coronary perfusion pressure and blood flow, thereby reducing heart workload and improving cardiac output. “It is absolutely painless, safe treatment, which requires no hospitalisation,” informs Dr Namjoshi.

"Each doctor tries to convince the patient that his ECP is better as each brand name suggests some type of superiority" - Dr SS Sibia Director, Sibia Medical Centre, Ludhiana

According to Dr SS Sibia, Director, Sibia Medical Centre (SMC), Ludhiana, “The US FDA has defined ECP as a generic term.” Specific product names such as SM-III, AECP, ASECP, SECP WFB-V, EECP and ECPT refer to brand names. “Each manufacturer tries to be fool the buyers (doctors) by taking advantage of this confusion. Each doctor tries to convince the patient that his ECP is better as each brand name suggests some type of superiority. ECP is the name of the treatment whereas EECP is one of the brand names,” reveals Dr Sibia.

What Does ECP Treatment Involve?

ECP treatment helps in the development of collateral circulation, which is a gradual process. Not everyone has the same ability to develop this network at a rate that will relieve angina. During the procedure, the patient has to lie down on a padded table in the treatment room. Three sets of rubber cuffs more than four inches wide, are tied around three points of the body- the calves, thighs, legs and hips. These connect to air hoses, which in turn are connected to valves. When the heart contracts the cuffs are deflated and when it relaxes the cuffs are inflated with a predetermined amount of pressure, which pushes the blood from the lower extremities in a timed and sequential manner, towards the heart. Normally, a patient has to undergo the procedure several times, usually 35 days of treatment, six days a week for six weeks. The minute blood vessels or the dormant collaterals open up and that portion of the heart which has been starved of blood because of a blocked artery or arteries, starts receiving blood again.

Paradigm Shift

Prior to 2000, the options for treating patients who experienced chest pain were limited to vasodilator drugs and mechanical revascularisation procedures, notably bypass surgery and somewhat less invasive such as angioplasty or drug-eluting stents to get symptomatic relief from chest pain.

Since then there has been a paradigm shift in the treatment of cardiovascular disease from invasive to less invasive methods. In the US, one is bound by law to offer alternative treatment modalities to patients going for bypass. An increase in demand for ECP in India is expected, as the populace here suffer from multiple blockages, narrow blood vessels and recurrence after bypass.

ECP has an edge over angioplasty and bypass because it doesn't require any admission and can be given to patients with low Ejection Fraction (pumping capacity of the heart), where surgeries are high risk, says Dr Namjoshi. However, according to Dr Sanjay Mittal, Clinical Cardiologist, EHIRC, “There is no data that suggests that ECP increases life expectancy in critical CAD, or for patients who are candidates for CABG or PTCA.”

Benefits Of ECP

Despite therapeutic advances, certain problems persist in the treatment of angina. Drugs do not always provide relief and invasive procedures have their own associated risks such as death, strokes, serious hospital-induced infections, changes in memory and blood clots in the legs and lungs.

ECP is recommended for patients who do not qualify for surgery or for patients who have already undergone surgery, but still have symptoms and for patients of congestive heart failure. It is also helpful for patients with renal hypertension, cerebral arteriosclerosis/ thrombosis/emboli or chronic fatigue syndrome.

The search for effective treatment which can increase the blood flow to the ischemic myocardium, decrease the angina symptoms and improve the quality of life without complicated invasive procedures, has brought ECP to the forefront.

The treatment can help patients in resuming asymptomatic routine activities. Patients for ECP have to be chosen according to a protocol, considering contra-indications like aortic valve leakage, peripheral vascular disease (PVD), thrombosis and heart failure.

Studies

Clinical studies over the past few years have shown that about 75 to 80 per cent of patients treated with a single course of ECP experience a reduction in angina and are able to return to a more active lifestyle.

IPC has so far treated more than 100 patients. All the patients who underwent the treatment at IPC have reported improvement in the heart function, exercise capacity and quality of life.

SMC has also treated about 400 patients with ECP. “Many of these patients had recurrence after bypass surgery or angioplasty, “ says Dr Sibia. Over 350 patients have been treated at Escorts Heart Institute and Research Centre (EHIRC) over a period of four years.

Availability

Currently more than 1000 centres practise ECP, globally. The impact of ECP is not felt in India though, as hospitals with ECP often give it a backseat. Why? After getting used to bypass surgery, now it is difficult for cardiologists to accept that there can be such a simple, safe, non-invasive and economical solution to Coronary Artery Disease (CAD), say experts. There are only around 15 centres in India practising ECP.

ECP was introduced in India at EHIRC, Delhi in August 2001. “SMC is the only centre having three ECP systems. We aim to have five in the next two years,” informs Dr Sibia.

“Major hospitals don't practice it as there is no comparative study done between groups of patients requiring angioplasty or bypass surgery,” says Dr Mittal.

Most doctors dump ECP without knowing about it. “In a capitalistic country, the thought process favours bypass surgery. ECP is highly popular in China, but not as much in the US. Political will has a big role to play. The communist thinking is to keep the patient as active and productive as possible, with as little expense and as little hospitalisation as possible. On the other hand, the capitalist thinking is to make as much money as possible whenever an opportunity comes,” claims Dr Sibia. According to Dr Sudhir Vaishnav, Interventional Cardiologist, Asian Heart Institute, Mumbai, “It will take time for the technology to become popular.”

A Word Of Caution

In this age when commercial reasons sometimes surpass professional reasons for treatment, as witnessed in bypass surgery, one needs to be careful of recommending the wrong patients for ECP for commercial benefits, cautions Dr Sibia.

Cost And Indigenisation

Treatment cost varies depending on the features. At present, ECP equipment cost varies between Rs 35 lakh and Rs 80 lakh. The good news is that the SMC has acquired the technical knowledge from companies in China and also obtained the requisite permission to manufacture the equipment in India. The equipment will now be developed under the name of Spectramed with added features. “We prefer developing the equipment ourselves due to limitations in the available ECPs. The equipment from the East have poor workmanship and life, while those from the West are expensive and may not be suitable for the tropical climate,” informs Dr Sibia.

Another manufacturer of ECP technology, Vaso-Meditech, is a distributor of the technology under the brand name EECP in India. The company has so far installed 17 ECP systems in India.

What Does The Future Hold?

Experts predict that ECP will dominate the medical field in communist countries and bypass surgery in capitalistic countries, as is the scenario today. “If patient welfare is to be kept foremost, then the future of cardiology is in ECP. If commercial decisions prevail, then like many excellent Indian remedies, ECP will also become history,” Dr Sibia says.

shardulnautiyal@rediffmail.com