The use of EECP (enhanced external counterpulsation,) a non-invasive therapy for angina, has remained a tough sell for cardiologists. (Click here to read a description of EECP and why cardiologists don't like it.) Now, the results of a new randomized trial suggest that EECP may also be useful for patients with heart failure.
The PEECH trial (Prospective Evaluation of EECP in Congestive Heart Failure) randomized 187 patients with heart failure, who remained symptomatic despite optimal medical therapy, to either receive a standard 7-week course of EECP or to remain on medication alone. They were then tested using 2 diagnostic tests - one measuring the patients' maximum exercise duration, and the other measuring the peak amount of oxygen they consumed during exercise. Patients showed a significant improvement in exercise duration after EECP, but not in oxygen consumption (though there was a non-signficant trend toward improvement in this measure). Further, patients reported significant improvements in their quality of life following EECP, and their average functional capacity (i.e., the degree of symptoms they experience during daily living) was improved.
Proponents of EECP interpreted this data as strong evidence that EECP can be useful in heart failure. Critics point out that the only measures that were improved after EECP were subjective - that is, measures that were in control of the patients (i.e., time of exercise and reporting on well-being.) The one objective measure - oxygen consumption - was not significantly improved after EECP. Thus, they point out, the "benefits" of EECP could be explained by a placebo effect - especially since patients who invested 7 weeks of their lives to receiving EECP therapy might be especially prone to the placebo effect.
DrRich Comments:
The PEECH trial showed that patients with stable but still-symptomatic heart failure reported feeling better, and were able to exercise longer, after a course of EECP. They did not significantly improve their oxygen consumption, however, which is an objective measure of functional capacity.
There's something to be said for feeling better and having fewer symptoms - and patients randomized to EECP did experience these gains. Such subjective gains, however, are notoriously common with a placebo effect, and it is possible that's what happened in the PEECH trial. We just don't know for sure.
The bottom line is that the PEECH trial is not going to convince any EECP-critics (a group that includes most practicing cardiologists) to change their minds. At the same time, the PEECH trial offers at least some hope to patients who continue to have symptoms due to heart failure, and who are already on maximal drug therapy. If EECP can improve the quality of life for such patients, it ought to be seriously considered as an option, despite the fact that the scientists cannot yet sort out whether the benefits are due to a placebo or a physiologic effect.
The EECP controversy continues.
