indian perspective of enhanced external counter pulsation

1. Indian Perspective of Enhanced External Counter Pulsation

2. CARDIAC SCENERIO IN INDIA.

3. Cardiovascular Disease Burden

4. Country 2007 Country 2025 Persons-Millions) (Persons-Millions) India 40.9 India 69.9 China 39.8 China 59.3 United States of America 19.2 United Sates of America 25.4 Russian Federation 9.6 Brazil 17.6 Germany 7.4 Pakistan 11.5 Japan 7.0 Mexico 10.8 Pakistan 6.9 Russian Federation 10.3 Brazil 6.9 Germany 8.1 Mexico 6.1 Egypt 7.6 Egypt 4.4 Bangladesh 7.4 People with diabetes (20 � 79 age group) 2007 and 2025

5. Cardiovascular Disease. According to recent estimates. Cases of CVD may increase from about 20.9 Million in 2000 to as many as 60.4 Million in 2015. Deaths from CVD will also more than double. Most of this increase will occur on account of coronary heart disease �AMI, angina, CHF and inflammatory heart disease. Source:NCMH Background Papers�Burden of Disease in India (New Delhi, India), September 2005

6. Estimates and trends of coronary heart disease (CHD) cases in various age groups in India.

7. INDIAN CORONARY ANATOMY INDIANS HAVE MORE COMMON Involvement at younger age. Small coronary arteries. Diffuse Distal Disease. Multi vessel Disease. Higher incidence in Women.

8. INDIAN RESOURSE FOR EECP DATA

9. To improve the quality of EECP patient care by providing information, knowledge and tools; implementing quality initiatives; and supporting research that improves patient care and outcomes. To create Expert panel to organize and improve the quality of research and publication from IPER data base. Mission of the IPER

10. EECP PATIENT SELECTION

11. INDICATION FOR EECP THERAPY. A. Chronic CAD Primary utilization of EECP to revascularize Anginal Patient refractory to Medical treatment B. Surgery /PTCA not contemplated Patient refused Diffuse distal disease. Target lesion is inaccessible. Co-morbid states create high risk LV dysfunction � High risk CABG. Restenosis after PTCA CABG graft occlusion C. Preparation for Revascularization Severe LV Dysfunction with lot of hibernation to stabilize Heart Function. Waiting due to some other reason. D. Heart Failure Non-Ischemic Cardiomyopathy Ischemic Cardiomyopathy Patient with LV Dysfunction Patient with moderate to severe levels of CHF. E. Cardiac X Syndrome. .

13. SHORT COURSE TREATMENT IS IT EFFECTIVE?

14. A modified course of Enhanced External Counterpulsation improved myocardial perfusion in patients with severe left ventricular dysfunction Pradeep G.Nayar1, S.Ramasamy1,Madhu.N.Sankar1, K.M.Cherian1 ,William E Lawson2 and John CK Hui2

16. INTRA-AORTIC BALLOON PUMP

17. Methods Pre and Post myocardial perfusion study by I.V injection TC99m tetrafosmin . Gated LV function and territorial score was assessed. One day prior to starting EECP. Immediately after completing EECP. Patient received a 10 hour course of EECP treatment prior to Surgery (2 hour/day for 5 Days). Requirement for IABP and post opertaive complication is observed.

18. Demographic Profile of The Patients

19. RESULTS

20. RESULTSN=16 12 Patients underwent CABG after treated with modified short course EECP. ( 75%) IABP was avoided in7 patients in this group (58%) 4 patients were continued on 35 sessions EECP due to patients preference. 2 patients expired post CABG due to complications. ( 12.5%) in IABP group. Reduced hospitalization time in patient who were able to Avoid IABP after EECP.

21. Conclusion Short course of EECP in patient with Severe LV Dysfunction prior to CABG improves myocardial perfusion and LV contractility. Short course EECP can reduce post CABG hospitalization and IABP insertion. Randomized trial is warranted to evaluate whether EECP prior to high risk CABG can avoid emergency IABP insertion and reduce post operative complication and hospitalization time.

22. Is EECP EEFECTIVE IN DIABETIC PATIENT�S?

24. Enhanced External Counter pulsation improves cardiac symptoms and function in severe ischemic cardiomyopathy patients independent of Diabetes. Nishith Chandra,* S.Ramasamy,** C.Arumugam ** *Escrorts Heart Institute and research center New Delhi and **Frontier Lifeline Hospital Chennai.

25. Objective Ischemic Cardiomyopathy patients has shown to improve in exercise tolerance and quality of life when treated with EECP. In the present study we examined the effect of EECP in symptoms, exercise tolerance and ventricular function in patient with diabetic and non-diabetic ischemic Cardiomyopathy.

26. Method Two dimensional Echocardiography and 6min walk test was performed pre and post EECP. Patients were divided in to two group. Diabetes and Non-Diabetes.

27. Results- Demographics

34. Enhanced External Counterpulsation � Perfusion Imaging

36. INTRODUCTION Enhanced external counter pulsation (EECP) is a recently approved treatment modality for selected patients with refractory angina and Heart failure. However, the efficacy of EECP on Myocardial perfusion in severe left ventricular (LV) dysfunction has not been well established. The study was aimed to determine whether EECP leads to an improvement in myocardial perfusion.

37. AIM To evaluate the therapeutic effects of EECP by Technetium-99 single-photon emission computed tomography (99Tc-SPECT) in patients of multi vessel coronary artery disease with left ventricular systolic dysfunction.

38. PATIENTS AND METHODS 56 consecutive patients with CAD who were symptomatic despite conventional medical, interventional or surgical therapies or not eligible for revascularization were enrolled and received EECP therapy for a total of 35 h [1 hour/day]. From Jan 2007 to June 2008. They were subjected to 99Tc SPECT before and after EECP therapy to note the changes in Myocardial Perfusion Imaging. During SPECT, 20 segment myocardial perfusion study and gated ejection fraction were analyzed.

41. Demographic Profile of The Patients

42. Myocardial perfusion pre and Post EECP

43. Global increase in Myocardial perfusion

45. CONCLUSION We concluded that EECP improved LV function, as shown by radionuclide assessment in patients with severe coronary artery disease and left ventricular dysfunction. EECP can be offered as an option for patients with poor quality of life who are not a candidate for standard revascularization procedures.

46. Effect of Enhanced External Counterpulsation on Ejection Fraction in Patients with Ischemic Heart Disease William E Lawson1, Himanshu Padh2, Subramanian Ramasamy3, John CK Hui1

47. Objective Patients with ischemic heart disease often have compromised left ventricular function due to a combination of: prior scarring, persistent severe ischemia, stress induced ischemic dysfunction, adverse remodeling. The present study was conducted to examine whether EECP would effect left ventricular structure and function (ejection fraction and end-diastolic, end-systolic volumes) in patients with ischemic heart disease.

48. Methods 2-Dimensional Echocardiography was performed on 505 patients with ischemic heart disease, 29% with 3 V CAD. Within 1 week prior to starting EECP. Within 1 week of completing course of EECP. Patient received a 35 hour course of EECP treatment (1 hour/weekday for 6 weeks).

49. Methods Patients were divided into a preplanned 2 cohorts for analysis: Baseline Left Ventricular EF >35% Baseline Left Ventricular EF = 35% Comparative analysis of pre and post 2-D Echo results by 2-tailed paired t-test with significance at p<0.05. Analysis of demographic differences by chi squared or t-test as appropriate.

50. Results- Demographics

51. Results- All Patients

52. Results- Cohort = 35% EF

53. Results- Cohort > 35% EF

55. Effect of EECP on LV Ejection Fraction- All Patients

56. Effect of EECP on LV End Systolic Diameter (mm)

57. Effect of EECP on LV End Diastolic Diameter (mm)

58. Effect of EECP on LV Ejection Fraction

59. Effect of EECP on Heart Rate

60. Effect of EECP on Cardiac Output

61. Discussion Potential mechanisms include: Improvement in LV contractility by collateral recruitment or development. Afterload reduction with mitigation of adverse remodeling. �Normalization� of endovascular tone and function improving coronary perfusion and decreasing impedance.

62. Conclusions EECP significantly improved LV ejection fraction, stroke volume, cardiac output in patients with ischemic heart disease and Left ventricular EF > 35% Left ventricular EF = 35% The increase in Left Ventricular EF is mediated predominately by a decrease in end-systolic volumes.

63. EECP scenario in India 52 centers across India. Including University and Major Cardiac center. 2008 its covered by Tamilnadu government Insurance Scheme . Star Insurance BHEL insurance. .