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About EECP
What is EECP?Clinical EvidenceFAQPatient ReviewsAnginaHeart FailureCoronary Artery DiseaseNon-Obstructive Coronary Artery DiseaseSymptoms of Heart DiseaseEECP and Your Current Treatment PlanWhen Is It Used?
EECP Treatment in Cyprus: How Enhanced External Counterpulsation Works
EECP is a non-invasive, outpatient treatment that uses ECG-timed leg cuffs to support blood flow to the heart. It is mainly used to relieve chronic angina (chest pain) that continues despite medication and, where appropriate, stents or bypass surgery. This guide explains how EECP works, what the research does and does not show, and who may be suitable.
- Cardiologist-led assessment
- No incisions or anaesthesia
- Usually 35 one-hour sessions
- FDA-cleared device type
EECP at a Glance
- What it is
- A series of external counterpulsation sessions: three pairs of air-filled cuffs on the legs inflate and deflate in time with your heartbeat, guided by a continuous ECG.
- Main use
- Relief of symptoms in chronic stable angina, particularly refractory angina that persists despite optimal medication and revascularisation.
- Typical number of sessions
- Usually 35 one-hour sessions, most often five days a week for about seven weeks, as an outpatient.
- Evidence level
- Supported by a sham-controlled trial and observational data for angina symptoms. Guidelines say EECP may be considered in refractory angina (Class 2b).
- What it does not do
- It does not remove or open blockages, and it does not replace stents or bypass surgery when your cardiologist recommends them.
- Who decides
- Suitability is decided after a cardiology assessment of your symptoms, heart condition, previous treatment and leg circulation.
What Is EECP?
EECP stands for enhanced external counterpulsation. It is a non-invasive treatment in which cuffs wrapped around the calves, thighs and upper thighs are inflated and deflated in a precise rhythm that is linked to your heartbeat. The aim is to help blood reach the heart muscle more easily and to reduce the work the heart has to do.
Counterpulsation was first studied in the 1950s and 1960s. The modern, ECG-gated three-cuff form of EECP was tested in a sham-controlled multicentre trial in the late 1990s[1], and it is now used in cardiology centres in many countries, mainly for people with chronic angina.
EECP systems are FDA-cleared medical devices (cleared through the 510(k) pathway). Device clearance relates to the equipment; it is not the same as a clinical guideline recommending EECP for every condition. See clinical evidence for EECP for a wider overview.
EECP in one sentence
A series of sessions of carefully timed pressure on the legs that can improve angina symptoms and exercise tolerance in some people with coronary artery disease, used alongside — not instead of — their usual heart treatment.
At EECP Cyprus
Every patient is assessed before treatment, and all sessions are supervised by our cardiology team led by Prof. Dr. Osman Beton, at our centres in Nicosia and Güzelyurt (Morphou).
How Does EECP Work?
During a session you lie on a padded treatment bed. Three pairs of cuffs are wrapped around your legs and small ECG electrodes are placed on your chest. A computer reads every heartbeat and tells the cuffs exactly when to inflate and when to release. For a step-by-step description of a session, see how an EECP session works.
The cuffs inflate as the heart relaxes and release just before it contracts.
Diastolic augmentation
When the heart relaxes between beats (diastole), the cuffs inflate rapidly in sequence from the calves upwards. This pushes blood in the leg arteries back towards the heart and raises the pressure in the aorta at the moment the coronary arteries fill, which increases the pressure driving blood into the heart muscle.
Systolic unloading
Just before the heart contracts (systole), all the cuffs release at the same time. The sudden drop in pressure in the leg arteries lowers the resistance the heart has to pump against, so it can eject blood with less effort. These two effects on blood pressure are well documented during treatment.
Effects on the blood-vessel lining
The repeated increase in blood flow raises the "shear stress" on the endothelium, the thin layer of cells lining the arteries. In a sham-controlled study, a full series of EECP sessions improved flow-mediated dilation — a standard measure of endothelial function — and lowered some inflammatory markers[4]. This may help explain why symptom benefits can outlast the sessions, but these are measurements of vessel function, not proof of long-term outcomes. Read more about long-term effects on cardiovascular health.
Collateral circulation: what we know
Collaterals are small vessels that can connect around a narrowed artery. Animal research and one small randomised study that measured collateral flow during cardiac catheterisation suggest counterpulsation may encourage these connections[5]. In people, however, the evidence is limited, so it should not be presented as an established fact that EECP "grows new arteries".
What does "natural bypass" mean?
You may see EECP described as a "natural bypass". This is an informal, marketing-style term — not a medical one. EECP does not create a surgical bypass, does not remove blockages, and is not the same procedure as coronary artery bypass grafting (CABG). The phrase loosely refers to the idea of encouraging collateral circulation, which is still being researched.
Who May Benefit from EECP?
EECP is mainly considered for people whose heart-related chest pain continues even though their treatment has been optimised. It is used alongside medication and follow-up with your cardiologist — see EECP and your current treatment plan.
Chronic stable angina
Chest pain on exertion that persists despite medication. Learn more about angina (chest pain).
Refractory angina
Angina that continues when further stents or bypass surgery are not possible or not advised. See refractory angina and EECP.
Coronary artery disease with ongoing symptoms
Symptoms linked to narrowed coronary arteries. Read about coronary artery disease.
Chest pain after a stent or bypass
For persistent symptoms after revascularisation, see chest pain after a stent or bypass and after bypass surgery.
Selected, stable heart failure
Some stable patients may be considered after specialist review; results are mixed. See heart failure.
Angina with non-obstructive arteries
Small studies only so far. Read about non-obstructive coronary artery disease.
Who Should Not Have EECP?
EECP is not suitable for everyone. The conditions below are commonly listed as reasons not to treat, or to treat only after careful specialist assessment. This list is not exhaustive — your cardiologist will review your full history.
Usually not suitable
- Heart rhythm problems that prevent reliable ECG triggering (for example, poorly controlled atrial fibrillation or very frequent extra beats)
- Moderate or severe aortic valve regurgitation
- Aortic aneurysm or aortic dissection
- Decompensated (unstable) heart failure
- Unstable angina or a recent heart attack
- Active thrombophlebitis, or current or previous deep vein thrombosis or pulmonary embolism
- Bleeding disorders, or anticoagulation outside a safe range
- Pregnancy
Needs careful assessment
- Severe peripheral arterial disease in the legs
- Very high or uncontrolled blood pressure (above about 180/110 mmHg)
- A recent cardiac catheterisation or femoral artery puncture
- Recent surgery
- Severe lung disease
- Leg wounds, ulcers or fragile skin where the cuffs sit
Our article on safety, side effects and risks explains these in more detail.
What Does the Research Show?
EECP has been studied for more than 25 years, but most studies are small or observational. It helps to separate what is reasonably well supported from what is still uncertain.
- Angina and ischaemia: in the sham-controlled MUST-EECP trial (139 patients), active treatment lengthened the time to exercise-induced ischaemia on ECG, with a trend towards fewer angina episodes[1].
- Angina class: in a meta-analysis of 13 observational studies (949 patients), 86% of patients improved by at least one Canadian Cardiovascular Society angina class[2]. These studies had no control group, so this describes symptom change in those studies — it is not a cure rate or a "success rate".
- Blood-pressure effects during treatment (diastolic augmentation and systolic unloading) are well documented.
- Safety: generally well tolerated in suitable patients; most side effects are minor.
- Heart failure: in the PEECH trial (187 stable patients), more people improved their exercise time by over 60 seconds (35% vs 25%), but peak oxygen uptake did not change[3].
- Vessel function: improved endothelial function in a sham-controlled study[4].
- Collateral flow: one small randomised study[5].
- Durability: registries suggest symptom benefit can last for months to years in many patients, but this is observational data.
- Quality of the evidence: a Cochrane review judged the angina trials to be of limited methodological quality[6].
Small or early studies have looked at angina with non-obstructive coronary arteries[9], erectile dysfunction, ischaemic stroke, blood-sugar control, mood, and some eye and hearing conditions. EECP is not an established treatment for these conditions.
Research interest in neurological conditions such as Alzheimer's and Parkinson's disease is at a very early stage, and EECP is not a treatment for them. See our summaries of scientific research and clinical studies and exercise capacity research.
What do clinical guidelines say?
The 2023 American Heart Association / American College of Cardiology guideline for chronic coronary disease states that EECP may be considered for symptom relief in patients with refractory angina (Class 2b)[7]. The 2019 European Society of Cardiology guideline on chronic coronary syndromes gave a similar Class IIb recommendation for angina that is refractory to optimal medical and revascularisation strategies[8]. In short, EECP is a recognised option for a specific group of patients — not a first-line treatment.
How EECP Has Developed Over Time
EECP is based on counterpulsation, a principle that has been studied for several decades. The overview below is a simplified summary of how the technique and its evidence base have developed, not a complete history.
Early development
Concepts of counterpulsation were developed in the mid-20th century, and external versions were explored in the decades that followed. Research groups, including teams in China, refined systems with sequentially inflating leg cuffs.
Clinical adoption
From the 1990s, EECP began to be used clinically for angina in several countries.
Research expansion
Randomized and registry studies, such as MUST-EECP (1999) and the International EECP Patient Registry, examined outcomes in angina. Later research also looked at heart failure and vascular function.
Modern use
EECP is considered as an option alongside medication and follow-up for selected people with chronic angina, and the 2014 ACC/AHA update lists it as Class IIb. Research on wider vascular questions continues, and further research is needed.
Dates are approximate; sources are listed at the end of this page.
EECP, Stents and Bypass Surgery: How They Differ
EECP, stents and bypass surgery are different tools. They are used in different clinical situations, and one does not automatically replace another. What is appropriate depends on the heart’s anatomy, symptoms, other health conditions and the judgement of the treating cardiology team.
EECP (Enhanced External Counterpulsation)
- What it is
- A non-invasive treatment given in sessions, using cuffs wrapped around the legs.
- How it works
- The cuffs inflate and deflate in time with the heartbeat, which is intended to support blood flow back to the heart.
- Typically considered when
- Angina continues despite optimised medication, or further procedures are not possible or advised — after cardiology assessment.
- Keep in mind
- It is used alongside medication and does not remove or open blockages.
Coronary stent (PCI)
- What it is
- A procedure in which a small mesh tube is placed in a narrowed coronary artery to keep it open.
- How it works
- A catheter is guided to the artery, usually through the wrist or groin, and the narrowed section is widened.
- Typically considered when
- A specific narrowing that can be treated this way, including some urgent situations, as judged by the cardiology team.
- Keep in mind
- It addresses a defined narrowing; medication and regular follow-up are still needed.
Coronary bypass surgery (CABG)
- What it is
- Heart surgery that creates new routes, called grafts, around blocked coronary arteries.
- How it works
- Blood vessels taken from elsewhere in the body are connected so that they bypass the narrowed sections.
- Typically considered when
- Extensive or complex coronary disease, where the heart team considers surgery the better option.
- Keep in mind
- It is major surgery with a hospital stay and recovery period; medication and lifestyle measures remain important.
These options are not interchangeable. Some people have more than one over the years, and not every option suits every person. The right choice depends on your heart’s anatomy, symptoms, other health conditions and the advice of your cardiology team. Never stop or change a treatment on your own.
Your EECP Treatment Sessions, Step by Step
Standard treatment consists of 35 one-hour sessions, usually given five days a week over about seven weeks. You go home after each session and can normally continue your daily routine. Find out more about the EECP treatment process.
Before treatment: assessment
Your symptoms, medication and previous tests and procedures (such as angiography, stents or bypass) are reviewed, and your blood pressure, heart rhythm and leg circulation are checked to confirm whether EECP is appropriate. See preparing for EECP treatment.
During a session
You lie on the treatment bed with the cuffs around your legs and ECG electrodes on your chest. You will feel a firm, rhythmic squeezing in time with your heartbeat. Most people find it comfortable after the first few sessions and can relax, read or listen to music.
Throughout your sessions
Your heart rhythm, blood pressure and the pressure applied are monitored during every session, and settings are adjusted as needed.
After the final session
Your symptoms are reviewed after your final session. Ask for a written summary to share with your own doctor or cardiologist. Healthy habits and regular follow-up help to maintain any benefit — see life after EECP treatment.
How EECP Fits with Medication, Stents and Bypass Surgery
EECP is not an alternative version of a stent or bypass operation. These treatments do different jobs, and many patients have more than one of them over time. Your cardiologist will recommend the right combination for you.
| Medication | Stent (PCI) | Bypass surgery (CABG) | EECP | |
|---|---|---|---|---|
| What it does | Relieves angina and treats risk factors | Opens a narrowed artery from the inside with a balloon and stent | Uses grafts to route blood around blocked arteries | Uses timed external pressure to support blood flow and reduce the heart's workload |
| Effect on the blockage | Does not remove it | Widens the treated segment | Bypasses it | Does not remove or open it |
| How it is given | Tablets or sprays, long term | Catheter procedure, usually under local anaesthetic | Open-heart surgery under general anaesthesia | Non-invasive; no anaesthesia |
| Time commitment | Daily | Short hospital stay; recovery in days | Hospital stay of several days; recovery over weeks | 35 one-hour outpatient sessions over about 7 weeks |
| Main role | Foundation of treatment for everyone with angina | Selected patients, based on symptoms and anatomy | Selected patients, often with more extensive disease | Symptom relief, mainly when angina persists despite other treatment |
For a detailed comparison, read EECP and bypass surgery compared and EECP and other heart treatments.
EECP Treatment at EECP Cyprus
Treatment is planned and supervised by our cardiology team led by Prof. Dr. Osman Beton. We offer EECP at our medical centres in Nicosia and Güzelyurt (Morphou), so you can choose the location that is most convenient for your sessions.
Before treatment is recommended, your full cardiac history is reviewed and realistic goals are discussed with you. You can also read patient reviews.
Nicosia
Gönyeli, Nicosia
Güzelyurt (Morphou)
Güzelyurt
Planning EECP Treatment from Abroad
Because the full series of sessions takes about seven weeks, patients travelling to Cyprus need to plan ahead. We will help you understand whether the treatment is suitable before you make travel arrangements.
Send us your enquiry
Tell us about your symptoms and current treatment through our contact page, by phone or by WhatsApp.
Share your medical records
Useful documents include recent cardiology letters, ECGs, echocardiogram and angiography reports, details of any stents or bypass surgery, and your current medication list.
Cardiology review
Our team reviews the information and discusses with you whether EECP is likely to be appropriate, and what can realistically be expected.
Plan your stay
Allow about seven weeks for all of your sessions. Our team can answer practical questions about scheduling your sessions; please confirm travel details with us directly before booking.
Treatment and follow-up
After your final session, ask for a written summary to share with your own doctor so that your care continues smoothly at home.
Frequently Asked Questions About EECP
Is EECP treatment painful?
EECP is not usually painful. You will feel a firm, rhythmic squeezing in your legs. Some people find the first sessions unusual, and pressure is increased gradually. Mild skin irritation or muscle aches can occur.
How long do EECP sessions take, and how many are needed?
Each session lasts about one hour. Standard treatment is 35 sessions, usually five days a week for around seven weeks.
When might I notice a difference?
It varies. Some people notice fewer or milder angina episodes during their sessions; for others it takes until after the final session or later. Not everyone improves, and results cannot be guaranteed.
Can I have EECP after a stent or bypass surgery?
Yes, many people who are considered for EECP have already had stents or bypass surgery and still have angina. Your cardiologist will check that enough time has passed since any procedure and that there are no reasons not to treat.
Is EECP an alternative to bypass surgery or a stent?
No. EECP does not open or bypass blocked arteries. When a stent or bypass surgery is recommended — for example to improve survival or treat severe disease — EECP is not a substitute. It is mainly used to relieve symptoms when angina persists despite other treatment, or when further procedures are not suitable.
Is EECP the same as a "natural bypass"?
"Natural bypass" is an informal term, not a medical one. It refers loosely to the idea that EECP may encourage collateral circulation — a mechanism with limited evidence in humans. EECP is not the same procedure as coronary artery bypass grafting.
Does EECP replace my heart medication?
No. EECP is used alongside your usual medication. Do not stop or change any medicine unless your doctor advises it.
What are the possible side effects?
Most side effects are mild and temporary, such as skin irritation or chafing under the cuffs, bruising, leg aches and tiredness. EECP is not suitable for some people, which is why a medical assessment is needed first.
Can I travel to Cyprus for EECP treatment?
Yes. International patients should plan for a stay of about seven weeks and share their medical records in advance, so that suitability can be reviewed before travel.
More answers on our frequently asked questions page.
References
- Arora RR, Chou TM, Jain D, et al. The multicenter study of enhanced external counterpulsation (MUST-EECP): effect of EECP on exercise-induced myocardial ischemia and anginal episodes. J Am Coll Cardiol. 1999;33(7):1833–1840. doi:10.1016/S0735-1097(99)00140-0
- Shah SA, Shapiro RJ, Mehta R, Snyder JA. Impact of enhanced external counterpulsation on Canadian Cardiovascular Society angina class in patients with chronic stable angina: a meta-analysis. Pharmacotherapy. 2010;30(7):639–645. PubMed 20575628
- Feldman AM, Silver MA, Francis GS, et al. Enhanced external counterpulsation improves exercise tolerance in patients with chronic heart failure (PEECH). J Am Coll Cardiol. 2006;48(6):1198–1205. ScienceDirect
- Braith RW, Conti CR, Nichols WW, et al. Enhanced external counterpulsation improves peripheral artery flow-mediated dilation in patients with chronic angina: a randomized sham-controlled study. Circulation. 2010;122(16):1612–1620. PubMed 20921442
- Gloekler S, Meier P, de Marchi SF, et al. Coronary collateral growth by external counterpulsation: a randomised controlled trial. Heart. 2010;96(3):202–207. PubMed 19897461
- Amin F, Al Hajeri A, Civelek B, et al. Enhanced external counterpulsation for chronic angina pectoris. Cochrane Database Syst Rev. 2010;(2):CD007219.
- Virani SS, Newby LK, Arnold SV, et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease. Circulation. 2023;148(9):e9–e119. doi:10.1161/CIR.0000000000001168
- Knuuti J, Wijns W, Saraste A, et al. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J. 2020;41(3):407–477. doi:10.1093/eurheartj/ehz425
- Enhanced external counterpulsation for the treatment of angina with nonobstructive coronary artery disease. Am J Cardiol. 2023. Abstract
Find Out Whether EECP Is Right for You
Talk to our team about your symptoms and previous treatment, or take our short eligibility test first.
Or call +90 392 224 00 40