What question did this study set out to answer?

To determine the clinical effectiveness and cost-effectiveness of enhanced external counterpulsation (EECP) compared with usual care or placebo for refractory stable angina and heart failure.

April 1, 2009Health Technology AssessmentOpen Access

Enhanced external counterpulsation for the treatment of stable angina and heart failure: a systematic review and economic analysis

Q: What is the clinical evidence from this study?

Study design: Systematic Review. Population: Refractory stable angina and heart failure. Intervention: Enhanced external counterpulsation (EECP) vs. Usual care or placebo (sham EECP). Primary outcome: Time to ≥1-mm ST segment depression (exercise-induced ischaemia) (MD 41 seconds, 95% CI 9.10-73.90).

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Key result

Enhanced external counterpulsation improved time to exercise-induced ischaemia by a mean of 41 seconds compared to sham treatment, but current evidence is insufficient to confirm its clinical effectiveness for stable angina or heart failure.

Why the study?

Does enhanced external counterpulsation improve clinical outcomes in adults with refractory stable angina and heart failure?

Population

Adults with refractory stable angina and heart failure.

Comparison

Enhanced external counterpulsation (EECP) vs Usual care or sham EECP

Design

Systematic_review

Follow-up

up to 1 year

Authors

CMClaire McKennaEast London NHS Foundation Trust CMCatriona McDaidUniversity of York SSS SuekarranUniversity of York

Discussion

Member takes

Implication

Insufficient evidence precludes routine EECP adoption for stable angina or HF; leaves open whether larger, long-term RCTs will confirm clinical benefit.

Key Points

To determine the clinical effectiveness and cost-effectiveness of enhanced external counterpulsation (EECP) compared with usual care or placebo for refractory stable angina and heart failure.
Systematic literature review searching major electronic databases between November 2007 and March 2008, identifying five studies (two randomized trials and three non-randomized registry comparisons).
Decision modeling to evaluate the incremental cost-effectiveness ratio (ICER) of EECP versus no treatment in adults with chronic stable angina across willingness-to-pay thresholds.
In the MUST-EECP angina trial, EECP significantly improved time to ≥1-mm ST segment depression versus sham (MD 41 seconds, 95% CI 9.10–73.90), but showed no significant differences in total exercise duration, angina episodes, or nitroglycerin use, while doubling adverse events (RR 2.13, 95% CI 1.35–3.38).
In the PEECH heart failure trial, EECP increased the proportion of patients with New York Heart Association functional class improvement (RR 2.25, 95% CI 1.25–4.06), but exercise duration gains (MD 34.6 seconds, 95% CI -4.86 to 74.06) and peak VO2 response did not achieve clear clinical significance.
Economic analysis calculated an ICER of £18,643 per quality-adjusted life-year (QALY), yielding a 0.44 probability of cost-effectiveness at £20,000/QALY and 0.70 at £30,000/QALY, driven largely by assumptions regarding the duration of quality-of-life benefits.

Study Design

Type

Systematic Review

Structured PICO

Does enhanced external counterpulsation improve clinical outcomes in adults with refractory stable angina and heart failure?

Population

A systematic review evaluating the clinical and cost-effectiveness of enhanced external counterpulsation compared with usual care or placebo in patients with refractory stable angina and heart failure.

Intervention

Enhanced external counterpulsation (EECP)

Comparator

Usual care (pharmacotherapy only, elective PCI) or sham EECP

Outcome

Clinical effectiveness (time to exercise-induced ischaemia, exercise duration, angina episodes, peak VO2, NYHA class) and cost-effectiveness (incremental cost-effectiveness ratio)

Main Result

Mean Difference: 41 (95% CI 9.1–73.9)

The available evidence from single RCTs is insufficient to confirm the clinical effectiveness of EECP for refractory stable angina or heart failure, highlighting the need for higher-quality, long-term studies.

Limitations

Lack of data on long-term outcomes
High risk of selection bias in the included non-randomised studies
Limitations in the generalisability of the trial results
Higher rate of withdrawals due to adverse events in the EECP group
High risk of selection bias in non-randomised studies
Limitations in generalisability due to substantial exclusion criteria
Large proportion of participants with Class I or II disease in MUST-EECP

Cite This Study

McKenna et al. (2009) conducted a systematic review in Refractory stable angina and heart failure. Enhanced external counterpulsation (EECP) vs. Usual care or placebo (sham EECP) was evaluated on Time to ≥1-mm ST segment depression (exercise-induced ischaemia) (MD 41 seconds, 95% CI 9.10-73.90). Enhanced external counterpulsation improved time to exercise-induced ischaemia by a mean of 41 seconds compared to sham treatment, but current evidence is insufficient to confirm its clinical effectiveness for stable angina or heart failure.

synapsesocial.com/papers/6a772bf7576efb0ddaf72351 https://doi.org/10.3310/hta13240

Topics

HFrEF treatment Heart failure HFpEF management

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Implication

Insufficient evidence precludes routine EECP adoption for stable angina or HF; leaves open whether larger, long-term RCTs will confirm clinical benefit.

Enhanced external counterpulsation for the treatment of stable angina and heart failure: a systematic review and economic analysis

Discussion

Member takes

Implication

Key Points

Study Design

Structured PICO

Main Result

Limitations

Cite This Study

Topics

Enhanced external counterpulsation for the treatment of stable angina and heart failure: a systematic review and economic analysis

Discussion

Member takes

Implication

Key Points

Study Design

Structured PICO

Main Result

Limitations

Cite This Study

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Topics

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