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心臟病 EECP體外反搏治療
狹心症及心臟衰竭的另類治療方式- 簡介EECP體外反搏治療 - 文／臺北醫學大學‧附設醫院／心臟內科施俊明主任／第162期／102年9月 心臟疾病治療方式日新月異，這些年在醫療上的新方法─EECP（體外反搏療法），以壓力褲配合下肢擠壓，可以改善心肌功能，成為狹心症、心臟衰竭較安全而另類的治療方式。 心臟醫學進展一直非常迅速，特別是在冠心症、心臟衰竭方面的治療。除了各種藥物發展，更有心導管及血管支架的治療、心臟同步節律器及體內電擊器等發展，外科手術也有長足進步。即使如此，仍有許多做完血管支架或外科繞道手術後，依舊胸悶或喘的病人；過去只能不斷加藥治療，但這些年EECP（Enhanced external counterpulsation）的治療逐漸成熟、療效也獲證實，被廣泛接受作為狹心症及心臟衰竭的替代或另類治療。北醫附設醫院也在去年底引進EECP的服務，頗獲病人好評。 EECP (Enhanced External CounterPulsation)的概念已發展近半世紀，是一種非侵入性的機械輔助循環裝置，以壓力褲配合心跳做下肢擠壓，靠機械作用提高主動脈舒張壓，減低主動脈收縮壓，使心臟冠脈血流量增加，進而改善心肌代謝與功能。長時間EECP治療，能增加心臟的血管新生，進一步改善心肌功能。 近年已有多項研究証實EECP具有增加冠狀動脈血流，提高血流切應力、改善血管內皮細胞結構及功能、防止血栓形成以及促進血管側枝循環形成等優點。有研究指出，臨床上病人對此治療的反應率可可達到70~80%，效果可能可持續長達2-5年之久。因此，目前醫界認為EECP對心絞痛及心臟衰竭病人來說，是一種有效且安全的另類治療選擇。 治療方式 EECP治療時，病患舒服地躺在特製的床上，下肢、臀部裹以特製的氣囊套，以心電圖Ｒ波為觸發信號；在心臟舒張早期，氣囊由遠至近依序加壓，驅動下肢血液向主動脈返流，提高主動脈舒張壓，從而改善心臟、大腦等重要器官的血液供應。在心臟收縮期前，氣囊迅速排氣，受壓的肢體血管開放，使主動脈收縮壓下降，從而減少外週循環阻力，減輕心臟負荷。 目前建議之治療療程為每次1小時, 一週5次, 持續7 週, 共35次。 治療範圍 EECP能明顯地增加心臟及全身各臟器血液的灌注、提升血液供應量，改善缺血的情形；且在壓力的作用下，血液流速增加，降低了血液的粘稠度，抑制動脈粥樣硬化動脈粥樣硬化等病變的發生。主要應用在缺血性疾病，包括：冠心病、心絞痛、心肌缺血、陳舊性心肌梗塞、心肌炎後遺症、腦動脈硬化、腦供血不足、椎基底動脈供血不足，缺血性腎臟病。無法開刀、體內有導管等心臟病人，或是具糖尿病等心血管疾病、小血管疾病的病人，都適合使用EECP治療。 但是嚴重主動脈瓣膜疾病、嚴重血壓控制不佳、嚴重下肢靜脈血栓等病人，不適宜接受EECP治療。 結語 EECP提供患者一項非侵襲性的治療方式，無論短期、長期來看都有顯著療效，而且相關療程可在門診直接安排，省去病人反覆住院的不便及醫療支出。目前美國心臟學會（AHA）及歐洲心臟學會（ESC）在心血管疾病和心臟衰竭的相關治療指引中，已建議在符合相關適應症的患者身上使用EECP。因此對藥物反應不佳、無法接受侵入性治療的病人，可與心臟科醫師討論這項治療。但若要治本，藥物的使用、戒菸、運動等相關生活努力，仍是重要的養生之道。 |
目前建議之EECP治療療程為每次1小時, 一週5次, 持續7 週, 共35次。
Schematic mechanism of EECP - 目前建議之EECP治療療程為每次1小時, 一週5次, 持續7 週, 共35次。
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External Counterpulsation Therapy (ECP)
External counterpulsation therapy (ECP) is a procedure performed on individuals with angina or heart failure or cardiomyopathy in order to diminish symptoms of ischemia, improve functional capacity and quality of life. In various studies, ECP has been shown to relieve angina, and decrease the degree of ischemia in a cardiac stress test. Method While an individual is undergoing ECP, he/she has pneumatic cuffs on his or her legs and is connected to telemetry monitors that monitor heart rate and rhythm. The most common type in use involves three cuffs placed on each leg (on the calves, the lower thighs, and the upper thighs (or buttock)). The cuffs are timed to inflate and deflate based on the individual's electrocardiogram. The cuffs should ideally inflate at the beginning of diastole and deflate at the beginning of systole. During the inflation portion of the cycle, the calf cuffs inflate first, then the lower thigh cuffs and finally the upper thigh cuffs. Inflation is controlled by a pressure monitor, and the cuffs are inflated to about 200 mmHg. When timed correctly, this will decrease the afterload that the heart has to pump against, and increase the preload that fills the heart, increasing the cardiac output. In this way, ECP is similar to the intra-aortic balloon pump (IABP). Since it increases pressure in the aorta while the heart is relaxing (during diastole) ECP also increases blood flow into the coronary arteries, which also occurs during that phase. Physiological considerations One theory is that ECP exposes the coronary circulation to increased shear stress, and that this results in the production of a cascade of growth factors that result in angiogenesis. ECP is a rehabilitation process that provides mechanical external cardiac assistance on a consistent regimen resulting in significant improvement in energy and exercise tolerance much like an exercise program. By restoring oxygenated blood flow, there are abundant benefits to the body. This restoration of nutrient rich blood flow revives tissue in parts of the heart and body that have become 'stunned' or 'hibernated' due to restricted or blocked blood flow. The heart benefits greatly as patients will see an improvement in structure, strength (contracility) and a reduction in afterload (workload) due to the reduction in systemic vascular resistance. Patients will see improvements in symptoms of chest pain, shortness of breath, chronic fatigue (tiredness) as well as a significant improvement in exercise tolerance (energy). Indications and Contraindications Indications: Angina patients who are not relieved by medicine. Patients who don’t want to have bypass surgery. Patients who are contraindicated for bypass or angioplasty like kidney failure, liver failure, severe COPD cases, Diffuse diabetes disease, very old age, patients of Syndrome X, i.e microvessel disease, ischaemic and dilated cardiomyopathy patients all can go for ECP. Contraindications: Severe aortic regurgitation and aortic stenosis Deep vein thrombosis Pregnancy Very high blood pressure Severe peripheral vascular disease. |
Illustration depicting Cardiac External Counterpulsation (EECP)
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Enhanced External counterpulsation (EECP)
Enhanced External counterpulsation (EECP) is a unique FDA approved method doctors such as Dr. Steenblock use to treat circulatory conditions such as angina and a whole lot more. Known as “EECP” treatments are done using a computer-driven device in which three compressive air cuffs (like big blood pressure cuffs) are wrapped out a patient’s wrapped around each leg, one at calf level, another slightly above the knee and the third on the thigh. These are then inflated and deflated in synchronization with his or her cardiac or heart pumping cycle. During diastole or when the heart fills with blood following a contraction the three sets of air cuffs are inflated in sequence (lower body to upper) which sends blood rushing to the heart. This causes an increase in diastolic blood pressure, the generation of arterial blood flow that is the reverse of what normally occurs and an increase in blood return from veins. The cuffs are all deflated just prior to contraction or systole, which (among other things) brings about a a decrease in ventricular workload and increased cardiac output. EECP has the near immediate effect of delivering more oxygen to the heart while simultaneously reducing the demand for oxygen by reducing the heart’s work requirements. Over time it bolsters blood flow through blood vessels that feed the heart. Many doctors refer to this increased blood & oxygen flow as a “natural bypass.” Clinical studies have demonstrated that ECP/EECP reduces the number and severity of angina episodes. According to published data these effects stick around for months to years after a course of therapy is concluded. One review showed that EECP elicited a significant clinical response in 70-80% of treated patients with refractory angina which were sustained for up to 5 years. Enhanced External Counterpulsation (EECP) There are a large, increasing number of patients who have persistent anginal symptoms, who have exhausted the standard treatments for revascularization and remain severely restricted. Enhanced External Counterpulsation (EECP) may stimulate the openings or formation of collaterals (small branches of blood vessels) to create a natural bypass around narrowed or blocked arteries. Who is a candidate for EECP? You may be a candidate if you: Have chronic stable angina Are not receiving adequate relief from angina by taking nitrates Do not qualify as a candidate for invasive procedures (bypass surgery, angioplasty, or stenting) What happens during EECP treatment? EECP is a non-invasive, outpatient therapy. During treatment: Patients lie down on a padded table in a treatment room Three electrodes are applied to the skin of the chest and connected to an electrocardiograph (ECG) machine. The ECG will display the heart’s rhythm during treatment. Blood pressure is also monitored. A set of cuffs is wrapped around the calves, thighs and buttocks. These cuffs attach to air hoses that connect to valves that inflate and deflate the cuffs. Patients experience a sensation of a strong "hug" moving upward from calves to thighs to buttocks during inflation followed by the rapid release of pressure on deflation. Inflation and deflation are electronically synchronized with the heartbeat and blood pressure using the ECG and blood pressure monitors. How does EECP work? The EECP treatment gently but firmly compresses the blood vessels in the lower limbs to increase blood flow to your heart. Each wave of pressure is electronically timed to the heartbeat, so that the increased blood flow is delivered to your heart at the precise moment it is relaxing. When the heart pumps again, pressure is released instantaneously. This lowers resistance in the blood vessels in the legs so that blood may be pumped more easily from your heart. EECP may encourage blood vessels to open small channels that become extra branches. These channels or collaterals may eventually become "natural bypass" vessels to provide blood flow to heart muscle. This contributes to the relief of angina symptoms. How often are patients treated? Patients who are accepted for treatment must undergo 35 hours of EECP therapy. Treatment is administered 1-2 hours a day, five days a week, for 7 weeks. Published studies conducted at numerous medical centers have demonstrated benefits for most patients including: Less need for anti-anginal medication Decrease in symptoms of angina Increased ability to do activities without onset of symptoms Ability to return to enjoyable activities Resources: Coronary Artery Disease Coronary Artery Disease web chat transcripts Center for Advanced Ischemic Heart Disease EECP - Vasomedical Patient Information |