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Specialized Circulations in Susceptible Tissues
Published in Wilmer W Nichols, Michael F O'Rourke, Elazer R Edelman, Charalambos Vlachopoulos, McDonald's Blood Flow in Arteries, 2022
Numerous efforts, both pharmacological and mechanical, have been oriented at improving coronary flow to the ischemic myocardium. The advent of intra-aortic balloon counterpulsation and enhanced external counterpulsation (EECP) originated from experiments that produced a delay in the arterial pressure pulse perfusing the coronary arteries (Kantrowitz and Kantrowitz, 1953). As discussed in Chapters 8 and 12, ideal timing of wave reflection occurs in young adults so that the reflected wave returns to the ascending aorta and coronary ostia as contraction ceases, thus boosting coronary perfusion pressure of the coronary system in diastole as the LV relaxes. Such optimal timing is usually lost by middle to late adulthood because of aortic degeneration. In persons with symptomatic coronary atherosclerosis, this optimal timing is usually lost. Optimal aortic pressure waveforms can be established mechanically by inflating and deflating a sausage-sized balloon in the descending aorta, at the heart rate of the patient, and with such phase (timing) that proximal aortic pressure is boosted in diastole and reduced in systole, as the left ventricle contracts (Thiele et al., 2018). A significant increase in coronary blood flow can be produced by modifying the coronary arterial pressure pulse so that it occurs during ventricular diastole (Figure 14.14) (Michaels et al., 2002; Wu et al., 2006). These observations form the basis of the intra-aortic balloon pump and EECP.
Angina pectoris in the elderly
Published in Wilbert S. Aronow, Jerome L. Fleg, Michael W. Rich, Tresch and Aronow’s Cardiovascular Disease in the Elderly, 2019
Wilbert S. Aronow, William H. Frishman
Recent mechanical techniques for the treatment of angina include transmyocardial laser revascularization (TMLR), enhanced external counter pulsation (EECP), and spinal cord stimulation. These approaches have been used in patients with severe angina who are not candidates for PTCA or CABG, usually due to diffuse CAD or extreme comorbidities. Such approaches would appear to be suitable for many elderly CAD patients who may have inoperable CAD and multiple comorbidities plus angina that is difficult to control with medical therapy.
Therapies for chronic chest pain
Published in Peter R Wilson, Paul J Watson, Jennifer A Haythornthwaite, Troels S Jensen, Clinical Pain Management, 2008
Ivan N Ramos-Galvez, Glyn R Towlerton
Acting in the same way as aortic counter pulsation, this technique augments blood flow during diastole. The technique involves cuffs compressed in early diastole for up to 35 × 1-hour sessions. There have been several studies of enhanced external counter pulsation (EECP). A multicenter study (MUST-EECP) of 139 patients decreased anginal episodes by 25 percent (p<0.035) when compared to sham EECP.62 The technique has a number of contraindications and is limited by availability, but has been licensed by the Food and Drug Administration (FDA) for RAP.
Advances in small-molecule therapy for managing angina pectoris in the elderly
Published in Expert Opinion on Pharmacotherapy, 2019
Nida Waheed, Ahmad Mahmoud, Cecil A. Rambarat, Carl J. Pepine
Given current limitations of the available pharmacotherapies, there has been increased interest in other treatment modalities for patients with refractory angina. Enhanced external counterpulsation has shown promising results in patients with severe refractory angina (CCS grade III–IV) in whom conventional treatment modalities failed. Although beyond the scope of this review on ‘small molecules,’ cell-based therapy with autologous CD34+ cells has documented improvement in angina among patients with no revascularization options who had persistent symptoms despite medical optimization. Studies of spinal cord stimulation have demonstrated minimal improvement in anginal symptoms. However, these studies have small sample sizes and differing study designs.