Enhanced external counterpulsation for stable angina or heart failure: a systematic review and economic evaluation


Stable angina is managed primarily through education and lifestyle advice, drug therapy and vascular surgery. Some patients exhibit symptoms that are not optimally controlled with the (apparently) optimal medication and surgical options available (termed refractory angina). Enhanced external counterpulsation (EECP) is a technique that can be used to improve symptoms in chronic stable angina. However, the role of EECP has not yet been well defined; its use in patients with mild heart failure has also been investigated following positive outcomes in patients with both angina and heart failure in two medium-sized multicentre studies.

The primary objectives of this project are to to determine the clinical effectiveness and cost-effectiveness of EECP compared with usual care and placebo for refractory stable angina and heart failure and to undertake analyses of the expected value of information (EVI) to assess the potential value of future research on EECP.


The results from a single RCT do not provide firm evidence of the clinical effectiveness of EECP in refractory stable angina. Further, higher quality RCTs are required to investigate the benefit of EECP in terms of time to ST segment depression, exercise duration, angina frequency and patients' requirements for nitroglycerin, and whether these outweigh the common adverse effects associated with this intervention.

Similarly, the results from a single RCT in heart failure do not provide firm evidence of the clinical effectiveness of EECP. Statistically significant modest benefits were seen in terms of exercise duration and New York Heart Association classification; however, their clinical significance is unclear. These effects need to be investigated in further RCTs.

To date, the impact of EECP on mortality or major adverse cardiovascular events has not been investigated in angina or heart failure.

EECP is cost-effective if the observed quality of life benefits are assumed to continue throughout a patient's lifetime. However, there remain uncertainties around the longer-term effects of the intervention.

Conducted by: C McKenna2, C McDaid1, S Suekarran1, N Hawkins2, K Claxton2, K Light1, M Chester2, J Cleland2, N Woolacott1, M Sculpher2

1. Centre for Reviews and Dissemination; 2. Centre for Health Economics

Further details

Project page on NIHR HTA Programme website


McKenna C, Hawkins N, Claxton K, McDaid C, Suekarran S, Light K, Chester M, Cleland JG, Woolacott N, Sculpher M. Cost-effectiveness of enhanced external counterpulsation (EECP) for the treatment of stable angina in the United Kingdom. Int J Technol Assess Health Care. 2010; 26(2): 175-82

McKenna C, McDaid C, Suekarran S, Hawkins N, Claxton K, Light K, Chester M, Cleland J, Woolacott N, Sculpher M. Enhanced External Counterpulsation (EECP) for the treatment of stable angina and heart failure: a systematic review and economic analysis. Health Technol Assess. 2009; 13(24): 1-112


Commissioned by the NIHR HTA Programme as part of the Technology Assessment Report (TAR) process