MESSAGES to the DOCTORS

Dear Colleague,

As has been summarized with its basic features in this web site, ECP treatment which is used in patients with coronary artery disease and heart failure because of its favorable effects, is a safe, highly effective, non-invasive, outpatient treatment modality. In comparison with the other treatment modalities used in these disease states, ECP treatment unit can be established with a quite low cost, application of the procedure is quite easy and free of serious side effects and risks, thus, training of the users is easy and does not take much time.

A great range of population, including cardiac as well as non-cardiac patients and even persons with high risk without any developed atherosclerotic heart disease can get benefit from this treatment modality as it increases blood perfusion and improoves function not only in the heart but also in almost all organs in the body.

Even though ECP applications was initiated in China about 30 years ago and now widely used in many countries all over the world, with more than 1000 units in USA, it did not receive much acceptance in our country in ten years time since its introduction firstly in the year 2000 by cardiac surgeon Prof. Coşkun İkizler in his own center and secondly in 2001 at Memorial Hospital in Istanbul.

I explain this with the successful applications of bypass operations and invasive interventions in many centers in our country thereby taking the priority of these procedures in the treatment of patients with coronary artery disease and the prejudice of experts on these procedures that such an important disease which is habitually managed by high technological and high cost procedures may not be treated with a simple-look and low-cost modality such as ECP. With this prejudice many of my colleagues even do not review the literature to get information about ECP. Whereas, in all the published clinical and experimental studies which have been done in many countries all over the world but mainly in China and USA, it has been clearly documented that ECP is a safe and highy effective treatment modality.

Another prejudice about the ECP not gaining much acceptence in our country is the consideration of this treatment as a modality which can be used in only those patients with advanced stage coronary artery disease which can not be treated with any other interventional procedures. The reason for this is that when ECP therapy was approved by FDA in 1995 in USA for the use of the patients with coronary artery disease, it was used mainly in patients with very advanced stage disease, namely in those who have the history of myocardial infarction, PTCA and bypass surgery, once or many times, but still having angina and other symptoms even though having many medications and impossible to treat again with the above mentioned interventional procedures. In addition, The USA medical insurance (Medicare) covers the ECP treatment expenses only if ECP is used in patients having these conditions.

Thus, in the conclusion parts of almost all the published clinical studies, the patients who are included in the studies and showed beneficial results are described as “patients with coronary artery disease and angina who have no chance to be treated with any other interventions…”. Accordingly, in the treatment guidelines which guide physicians in their management of patients, it is stated that ECP can be used in patients who have the same features as those included to the clinical studies.  For that reason, ECP treatment comes to mind at the very advanced stages of coronary artery disease.

Whereas, in clinical studies in which above mentioned patients with advanced stage coronary artery disease were included in whom 80% beneficial results were obtained lasting for about 3-5 years, including improvement in anginal symptoms, exercise capacity, myocardial perfusion and quality of life and decrease in drug usage, hospital admissions due to recurrence of symptoms and necessity of interventional procedures and in studies designed to explaine the underlying mechanisms responsible from these beneficial effects, it has been demonstrated that ECP treatment, increasing coronary perfusion pressure leads to enlargement of coronary arteries and opening up collateral vessels, promotes new capillary vessel formation, all together improves blood supply by enrichment of vascularity, in addition to improving endothelial function and exibiting antiatherosclerotic effects.

ECP treatment, with all these underlined effects, holds all the beneficial effects that a physician would desire to provide his patient with coronary artery disease to improve the clinical status and positively effect the progress of the disease. With the comments of the investigators who demonstrated the favorable effects of this treatment, ECP  is now considered a treatment modality which can be useful not only in those with advanced stage disease having no chance to be treated with other interventions but also in secondary prevention of coronary artery disease and even primary prevention in high risk individuals. Especially, in diabetics and in patients with small coronaries and inadequate collaterals, ECP therapy, before or after invasive  interventions such as bypass surgery and balon-stent applications, can improve prognosis by preventing and/or delaying restenosis and occlusions. Everybody who reviews the studies in detail can clearly come to the same conclusion.

In the treatment of coronary artery disease, invasive interventions and ECP should not be considered as rival modalities with each other; instead, they should be considered as complementary modalities.  It is apparent that, ECP therapy after any invasive intervention has the potential to prolong the  “well being period” obtained by these interventions, and thereby has the potential to increase the patients gratitude to the surgeon or the invasive cardiologist who did his invasive treatment.

With my personal experience of over seven years, I have witnessed that, all patients, whatever the stage of their disease, get benefit from ECP treatment, more or less, depending the severity of the disease and become better than the  pre-treatment condition. At the end of the treatment, the patient feels happy, thus the physician who applies ECP also feels happy. Many of my patients who get benefit of ECP, criticize their previous physician for not mentioning before such an effective treatment and insist that I should promote in the country the availability of  such a valuable treatment. In accordance with this demand, I spend great effort to attract the interest of my colleagues who could not have any chance yet to review the literature on ECP and also inform the people about the existence of such alternative and highly effective treatment modality for coronary artery disease, by speaking at cardiology meetings and TV programs, about the results of published studies and my personal experience.

ECP is an attractive treatment especially to those physicians who are interested in non-invasive procedures like myself, as it gives the chance to offer a safe and effective treatment to their patients in addition to drug prescription.

Nowadays, an ECP treatment unit can be set up without much cost, either in a private medical center or in a doctors office and the treatment can be applied  successfully by a trained nurse under the supervision of a cardiologist, as a treatment cure of 35 hours, on one or two hours per day basis. As we consider the presence of about 3 million people with coronary artery disease and more than that with high risks in our country, it is evident that quite a high number of people in the population can have the chance of having such an effective treatment with the increase in the number of ECP units.

Some of my colleagues hesitate that many patients may not be able to accept the ECP treatment as it is not covered yet by state health insurance schemes.

But, it is known that many patients who have to have bypass surgery or balloon-stent applications usually make some extra payment themselves in addition to insurance coverage. Also, the amount of this additional payment even for the implantation of a single drug eluting stent to dilate a significant narrowing at one location on the coronary artery is usually equal to the cost of the total 35 hours ECP treatment which can provide enlargement in most of the coronaries and increase in the number of vessels. When these facts and the additional benefits of ECP treatment are explained, patients do not hesitate to pay the treatment cost themselves and continue the treatment with pleasure relying on its benefits from the very beginning of the treatment course because of the immediate positive hemodynamic effects on the heart and circulation, and overall performance increase due to rise in perfusion in many organs, thereby, complete their treatment with satisfaction successfully.

I wittnessed prominent recovery in some of my patients with advanced coronary artery disease and low ejection fraction after 35 hours ECP treatment without any need of hospital admission for two-three years. But, especially in patients with diabetes, ECP treatment may need to be repeated at certain intervals for the maintenance of the recovery.

Also, I should state that as ECP is a new and non-invasive treatment, it provides a credit and privilege to the physician who applies it and to the center that has this facility. In addition, patients who complete the treatment and observe the benefits of it, usually inquire why no one has mentioned this treatment before.

The beneficial effects of ECP in other diseases rather then coronary artery disease should not be disregarded; especially hypertension resistant to treatment,  small vessel disease known as Syndrome X, brain, eye and ear diseases of vascular origin and sexual incontinance due to vascular causes, restless leg syndrome.

I believe, whoever starts to get involved in ECP will work with great pleasure as me, therefore I wanted to share my knowledge and experience with you. When you have had an opportunity to review the ECP literature in detail, I am sure you will share the same thoughts as I have.

If you need  further information about ECP treatment, please don’t hesitate to contact me. If you plan to apply yourself or to supervise your team who will apply it, either at your private office or in a hospital, I can help you with pleasure in  selecting the ECP unit, in the training of the nurse who will apply it, and in other issues.

I wish you continue your successful studies in good health and happiness.

Prof.Dr. Günsel Şurdum Avcı