ORIGINAL RESEARCH
published: 03 March 2022
doi: 10.3389/fsurg.2022.851113
Frontiers in Surgery | www.frontiersin.org
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March 2022 | Volume 9 | Article 851113
Edited by:
Songwen Tan,
Central South University, China
Reviewed by:
Xuefeng Yang,
University of South China, China
Wenjun Gu,
Shanghai Jiaotong University School
of Medicine, China
*Correspondence:
Peng Huang
hpp1361@163.com
†These authors share ﬁrst authorship
Specialty section:
This article was submitted to
Visceral Surgery,
a section of the journal
Frontiers in Surgery
Received: 09 January 2022
Accepted: 31 January 2022
Published: 03 March 2022
Citation:
Zhao S, Liu S, Wen Y, Qi Q and
Huang P (2022) Analysis of the Effect
of External Counterpulsation
Combined With High-Intensity Aerobic
Exercise on Cardiopulmonary Function
and Adverse Cardiovascular Events in
Patients With Coronary Heart Disease
After PCI. Front. Surg. 9:851113.
doi: 10.3389/fsurg.2022.851113
Analysis of the Effect of External
Counterpulsation Combined With
High-Intensity Aerobic Exercise on
Cardiopulmonary Function and
Adverse Cardiovascular Events in
Patients With Coronary Heart
Disease After PCI
Shiming Zhao 1†, Shaowen Liu 1†, Yuan Wen 1, Qiuhuan Qi 1 and Peng Huang 2*
1 Department of Cardiology, Wuhan Hankou Hospital, Wuhan, China, 2 Intensive Care Unit, Emergency Medical Department,
Wuhan Hankou Hospital, WuHan, China
Purpose: To explore the intervention effect of external counterpulsation (ECP) combined
with high-intensity aerobic exercise (HIAT) on patients with coronary heart disease (CHD)
after PCI.
Methods: 124 patients with stable CHD after PCI admitted to our hospital from June
2018 to June 2021 were selected, and all patients were divided into control group
and observation group using the random number table method. The control group
received conventional treatment, The observation group received ECP combined with
HIAT based on the control group. The cardiorespiratory function indexes, exercise
endurance indexes, incidence of major cardiovascular adverse events (MACE), Barthel
index of the two groups were observed.
Results: After intervention, METs max, VO2 max, VO2 max/kg, VO2 max/HR, and PP, ED,
AT, and Barthel score in both groups were signiﬁcantly higher than before intervention,
and patients in the observation group were signiﬁcantly higher than those in the control
group (P < 0.05). The incidence of MACE in the observation group (3.23%) was lower
than in the control group (12.90%) (P < 0.05).
Conclusion: ECP combined with HIAT can improve the cardiopulmonary function of
patients with CHD after PCI, and improve exercise endurance, reduce the incidence of
MACE, improve patients’ ability of daily living.
Keywords: coronary heart disease, external counterpulsation, high-intensity aerobic exercise, cardiopulmonary
function, adverse cardiovascular events
Zhao et al.
External Counterpulsation/High-Intensity Aerobic Exercise
INTRODUCTION
Coronary heart disease (CHD), a common disease among
middle-aged and elderly people, has become the leading cause of
hospitalization and death in China. The onset age of this disease
is generally after 60 years old, and in recent years, the prevalence
of CHD has been on a rapid rise (1). With the development
of science and technology and medical treatment, percutaneous
coronary intervention (PCI) is increasingly used in the treatment
of CHD, which is a therapeutic method for patients with coronary
artery stenosis to unblock the narrowed or occluded coronary
artery lumen by transcatheter technique. It has the advantages of
less trauma, quick recovery and high success rate (2, 3). However,
PCI is not the end of treatment for patients with CHD. Although
PCI can save patients’ lives, the incidence of major cardiovascular
adverse events (MACE) after PCI is high and the recovery of
cardiopulmonary function after PCI is poor (4, 5). At present,
only drug or surgical treatment can not completely relieve the
risk factors of patients with CHD, and it is of great clinical
signiﬁcance to eﬀectively stabilize the condition of patients with
CHD, reduce the incidence of coronary complications, and
improve the cardiopulmonary function of patients.
Research has shown that the key to improving the quality
of life and prognosis of patients with CHD is not only
conventional drug therapy, but also somato-psychological and
other integrated rehabilitation measures are equally important
(6). External counterpulsation (ECP) is a non-invasive assisted
circulation device, which sequentially inﬂates the balloon during
the diastolic phase of the heart to promote blood return
to the lower extremity arteries and increase coronary artery
perfusion, and is beneﬁcial to improving myocardial blood
supply and increasing oxygen-carrying capacity, thus aﬀecting
cardiopulmonary function, and has become the main non-drug
treatment for various angina pectoris, heart failure and other
cardiovascular diseases (7, 8). In addition, cardiac rehabilitation
therapy with exercise training as the core content is gradually
recognized and respected by clinical health care professionals and
patients. High-intensity aerobic training (HIAT) can reduce the
body’s inﬂammatory reaction, improve the patient’s endothelial
function, promote the establishment of coronary collateral
circulation and delay coronary stenosis through high-intensity
eﬀective exercise stimulation (9). HIAT not only helps to control
body weight, improve patients’ blood pressure and blood glucose,
but also prevents cardiovascular events, promotes mental health,
and controls risk factors of cardiovascular disease as a whole, thus
improves patients’ exercise function and survival quality, and has
a positive impact on patients’ prognosis (10). The aim of this
study was to investigate the eﬀect of ECP combined with HIAT
on cardiopulmonary function and MACE in patients with CHD
after PCI.
MATERIALS AND METHODS
Object
124 patients with stable CHD after PCI admitted to our hospital
from June 2018 to June 2021 were selected, and all patients
were divided into control group and observation group using the
random number table method, with 62 cases each.
Inclusion Criteria
Met the diagnostic criteria of coronary heart disease (11); PCI
was performed successfully for the ﬁrst time within 3 months;
Hemodynamics was stable after PCI; Have the condition of
basic movement.
Exclusion Criteria
Accompanied by movement restriction diseases such as bone
joints and muscles; Patients with severe arrhythmia and
severe heart failure that aﬀect ECP; Severe cardiopulmonary
dysfunction;
Those
who
were
unable
to
perform
cardiopulmonary exercise test for various reasons; Accompanied
by systemic serious organic diseases; Complicated infectious
diseases; Mental disorder, abnormal cognitive function, Unable
to cooperate with training; Increase or decrease the amount of
exercise if you did not follow the instructions.
Methods
The control group received conventional treatment, including
drug therapy, anti-blocking rehabilitation training, and daily
nursing (1). The medical staﬀ gave the patients anti-platelet
aggregation, nitrates, angiotensin-converting enzyme inhibitors,
and statins (2). Integrated with the guidance of the director
of our rehabilitation department, the patients performed elastic
band exercises with the help of researchers to ensure that the
patients did not feel any discomfort on the day of training,
and instructed the patient to wear a heart rate monitor.
Preparatory activities and relaxation activities were performed
before exercise, relaxation movements and warm-up movements
include shoulder, wrist, ankle, neck, waist, hip, knee joint
activities. The patients’ blood pressure and heart rate were
closely monitored during exercise, and exercise was stopped
immediately if symptoms such as progressive chest pain, pale
complexion, ataxia, dizziness, fatigue, and shortness of breath
occurred. The training forms could simply be arranged and
designed according to the movement of the joint, the resistance
provided by the elastic band at 100% extension was 1.7 kg. In
resistance training, each isometric contraction lasted 10s, rested
for 10 s, repeated 10 times as a set of training, and each training
was done with 10 sets of training (3). Health education was
carried out on quitting smoking and drinking, eating regularly,
exercising properly, and regulating emotions.
The observation group received ECP combined with HIAT
based on the control group. Patients were evaluated by
cardiopulmonary exercise test before the intervention. Patients
were ﬁrst warmed up with a power bike for 5 min with no load
and rested for 3 min with an initial power of 5 W. The power
was increased at a rate of 10 W/min. Patients were kept at a
speed of 50–60 r/min while pedaling training. When patients
had chest pain, weakness, dyspnea and other uncomfortable
symptoms, or when ECG and blood pressure monitoring reached
the indications for test discontinuation, the evaluation was
discontinued and peak power (PP) was recorded (1). ECP: The
intervention was performed with a balloon type ECP device
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External Counterpulsation/High-Intensity Aerobic Exercise
(P-ECP/TM, Pushkang, Chongqing). During the treatment, the
patient was lying ﬂat on the bed, and airbags were pumped on
the patient’s calves and thighs as well as buttocks, which were
connected to the air compressor through an air tube. Under
cardiac monitoring, the balloons were inﬂated and deﬂated
simultaneously with the patient’s cardiac cycle, with sequential
compression of the lower limbs and buttocks during diastole
and rapid deﬂation of the three balloons during systole, with a
counterpulsation balloon inﬂation pressure of 260–340 mmHg
and a ﬁnger pulse wave showing a diastolic/systolic wave ratio
>1.2. 1 time/d, 1 month was a course of treatment (2). HIAT:
After 5 min of warm-up, patients were trained with power
treadmill by bicycle with aerobic exercise intensity of 80% PP,
3 min for each group, with 1 min rest between groups, 10 groups
for each training, a total of 40 min. The initial training could
be carried out with 60% PP as exercise load for 7 days of
adaptive training. The treatment lasted for 3 months, 1 time/d,
and 3 times/week.
Observation Index
(1) Baseline
information
such
as
patient’s
age,
gender,
smoking
history,
alcohol
history,
combined
diseases,
and postoperative course of PCI were recorded.
(2) Before intervention and 3 months after intervention, the
K482
cardiopulmonary
exercise
test
training
system
(COSME,
Italy)
was
used
to
measure
the
patients’
cardiorespiratory function indexes. The patients’ maximal
METs (METs max), maximal oxygen uptake (VO2
max),
maximal oxygen uptake every kilogram (VO2 max/kg) and
maximal oxygen pulse (VO2 max/HR) were recorded.
(3) Before intervention and 3 months after intervention,
the K482 cardiopulmonary exercise test training system
(COSME, Italy) was used to measure the exercise endurance
indexes of the patients. The PP, exercise duration (ED) and
anaerobic threshold (AT) in the patients’ cardiopulmonary
exercise test were recorded.
(4) The incidence of MACE such as angina pectoris, arrhythmia
and heart failure was recorded in both groups within 3
months of intervention.
(5) Before intervention and 3 months after intervention, the
Barthel index was used to evaluate the patients’ ability of
daily living. The scale had 10 items with a total score of
100 points, >60 points: in daily life, patients could basically
take care of themselves; 40–60 points: in daily life, patients
needed the help from others; 20–40 points: life needs a lot
of help; <20 points: in daily life, patients completely needed
the help from others. The higher the score, the stronger the
independence and the smaller the dependence of the patient.
Statistical Methods
SPSS 22.0 software was used for analysis. The measurement data
was (± s), the comparison was made by t-test, the count data
was (%), and the comparison was made by χ2 test. P < 0.05 was
statistically signiﬁcant.
RESULTS
Baseline Information of the Patient
There was no statistical diﬀerence in age, gender, smoking
history, alcohol history, combined diseases, and postoperative
course of PCI between the two groups (P > 0.05). As shown
in Table 1.
Cardiopulmonary Function of Patients
After intervention, METs
max, VO2
max, VO2
max/kg, and
VO2 max/HR in both groups were signiﬁcantly higher than
before intervention, and patients in the observation group were
signiﬁcantly higher than those in the control group (P < 0.05).
As shown in Figure 1.
Exercise Endurance of Patients
After intervention, PP, ED, and AT in both groups were
signiﬁcantly higher than before intervention, and patients in the
observation group were signiﬁcantly higher than those in the
control group (P < 0.05). As shown in Figure 2.
Incidence of MACE in Patients
The incidence of MACE in the observation group (3.23%) was
lower than in the control group (12.90%) (P < 0.05). As shown
in Table 2.
Ability of Daily Living of Patients
After intervention, the Barthel score in both groups were
signiﬁcantly higher than before intervention, and patients in
the observation group was signiﬁcantly higher than that in the
control group (P < 0.05). As shown in Figure 3.
DISCUSSION
PCI is one of the common clinical treatment modalities for
CHD, which can eﬀectively improve myocardial blood perfusion,
promote myocardial cell recovery and improve prognosis (12).
However, after PCI, the myocardial blood supply of patients with
CHD is insuﬃcient, and the oxygen-carrying capacity of the
body is reduced, which leads to the decline of cardiopulmonary
function and exercise endurance, easily triggers MACEs such
as angina pectoris, arrhythmia, heart failure, seriously aﬀecting
the physical and mental health and life safety of patients
(13). At present, the clinic attaches great importance to the
rehabilitation of patients with CHD, and the intervention model
with the ultimate goal of improving cardiopulmonary function,
improving quality of life and returning to society is gradually
applied widely.
ECP is a non-medical, non-invasive physiotherapy method
that increases cardiac perfusion by wrapping the patient’s
buttocks and lower extremities with segmental balloons. During
the diastolic phase of the heart, the balloons are sequentially
inﬂated to promote the return of blood from the arteries of
the lower extremities to the aorta and then to the arteries
at all levels, thereby increasing diastolic pressure, and during
the systolic phase of the heart, the balloons are rapidly
deﬂated to allow rapid ﬂow of blood from the aorta to
the lower extremities to reduce cardiac afterload (14). The
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External Counterpulsation/High-Intensity Aerobic Exercise
TABLE 1 | Baseline information of patients (n, %, ¯x± s).
Group
Number of cases
Age (years)
Gender
Smoking history
Alcohol history
<60
≥60
Male
Female
Control group
62
28 (45.16%)
34 (54.84%)
31 (50.00%)
31 (50.00%)
36 (58.06%)
35 (56.45%)
Observation group
62
30 (48.39%)
32 (51.61%)
27 (43.55%)
35 (56.45%)
37 (59.68%)
39 (62.90%)
χ2 value
0.130
0.518
0.033
0.536
P-value
0.719
0.472
0.855
i0.464
Group
Number of cases
Combined diseases
Postoperative course of PCI (d)
Diabetes
Hypertension
Hyperlipidemia
Control group
62
19 (30.64%)
14 (22.58%)
13 (20.96%)
40.23 ± 8.13
Observation group
62
17 (27.42%)
16 (25.81%)
12 (19.35%)
38.85 ± 8.55
χ2/t value
0.273
0.920
P-value
0.872
0.359
FIGURE 1 | Cardiopulmonary function of patients. Compared with before intervention, *P < 0.05; compared with control group, #P < 0.05.
principles of ECP therapy are mainly: (1) Increase aortic diastolic
pressure, increase coronary blood perfusion and improve
myocardial blood supply. (2) Reduce peripheral resistance,
improve blood ﬂow, and promote the formation of coronary
collateral circulation. (3) Increase the shear stress of blood
ﬂow, improve the shape and function of vascular endothelial
cell, repair damaged vascular endothelium, and inhibit the
development of atherosclerosis. (4) Accelerate blood ﬂow, reduce
blood viscosity, improve microcirculation while increasing the
oxygen uptake capacity of the body. (5) When the balloon is
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External Counterpulsation/High-Intensity Aerobic Exercise
FIGURE 2 | Exercise endurance of patients. Compared with before intervention, *P<0.05; compared with control group, #P < 0.05.
TABLE 2 | Incidence of MACE in patients (n, %).
Group
Number of cases
Angina pectoris
Arrhythmia
Heart Failure
Total incidence
Control group
62
5 (8.06%)
2 (3.23%)
1 (1.61%)
8 (12.90%)
Observation group
62
1 (1.61%)
1 (1.61%)
0 (0.00%)
2 (3.23%)
χ2 value
3.916
P-value
0.048
constantly squeezing the lower limbs, the body’s nervous system
generates micro-electrical stimulation, which is conducive to
relieving muscle tension and relaxing the cerebral cortex (15–17).
ECP is a non-invasive, safe, eﬀective, and inexpensive treatment
device that can reduce the discomfort of patients with CHD,
control the progression of the disease, and change the exercise
endurance of the patient, thereby facilitating adaptation to more
intense or longer exercise (18). Physical inactivity is one of the
risk factors for CHD, and long-term physical inactivity may
lead to a decrease in cardiorespiratory ﬁtness, which in turn
may aﬀect the patient’s quality of life. HIAT can positively
aﬀect the cardiovascular system of patients with CHD after
PCI in many ways: (1) HIAT can promote the formation of
cardiac collateral circulation, improve coronary artery blood
supply and intrinsic myocardial contractility, increase coronary
blood ﬂow and capillary diﬀusion, and improve the circulation
transportation capacity of the coronary artery, thereby reducing
cardiac work and improving left ventricular myocardial function.
(2) HIAT can promote adaptive changes in the structure,
function and regulatory capacity of the cardiovascular system
and skeletal muscle system, which can increase the density of
skeletal muscle capillaries, increase the number of myocardial
capillaries, improve the supply of peripheral blood, increase
the oxygen uptake capacity of skeletal muscle, so as to meet
the body’s demand for oxygen and reducing the load on the
heart. (3) Aerobic exercise can increase the shear stress of
coronary blood ﬂow, stimulate the production and release of
nitric oxide synthase in vascular endothelial cells, improve the
vasodilatory capacity of endothelial intact coronary arteries,
improve the function of peripheral vascular endothelial cells,
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External Counterpulsation/High-Intensity Aerobic Exercise
FIGURE 3 | Ability of daily living of patients. Compared with before
intervention, *P < 0.05; compared with control group, #P < 0.05.
and thus increase myocardial perfusion. (4) HIAT enhances the
oxygen utilization capacity and aerobic metabolism of muscle
groups, improves mitochondrial function of cardiomyocytes,
which in turn increases cardiovascular eﬀects, improves overall
patient function, and reduces the incidence of cardiovascular
events. (5) HIAT reduces coronary stent lumen loss in patients
with CHD after PCI, and this may be closely related to a
reduction in the patient’s systemic inﬂammatory response (19–
21). Villelabeitia-Jaureguizar have found that compared with
moderate-intensity aerobic exercise, although the patients are
more laborious during HIAT, the duration of HIAT is short, and
interval rest can avoid excessive fatigue and discomfort, which
makes the patient’s tolerance higher (22). At the same time, HIAT
brings stronger exercise stimulation to patients, and the higher
the intensity of exercise, the higher the cardiorespiratory ﬁtness
of patients with CHD. METs max can reﬂect the level of cardiac
energy metabolism and exercise capacity; VO2 max indicates the
body’s maximum aerobic metabolic capacity, cardiac output and
cardiac reserve function, and VO2 max is the gold standard for
evaluating cardiopulmonary function; VO2 max/kg corrects the
eﬀect of body weight on oxygen uptake and was a predictor
of cardiovascular events; VO2 max/HR can reﬂect the oxygen
intake capacity of the heart’s stroke volume. PP is the maximum
exercise load that the patient can tolerate in the cardiopulmonary
exercise test; ED is the exercise time that the patient lasted from
the beginning to the end of the cardiopulmonary exercise test
evaluation; AT is the critical value of the transition from aerobic
metabolism to anaerobic metabolism when the body performs
increasing load exercise, which can reﬂect the body’s maximum
aerobic exercise capacity. In this study, METs max, VO2 max,
VO2 max/kg, VO2 max/HR, PP, ED, and AT of patients in the
observation group were signiﬁcantly higher than those in the
control group, suggesting that ECP combined with HIAT can
improve the cardiopulmonary function and exercise endurance
of patients with CHD after PCI.
In addition, we found that patients with CHD after PCI
had a lower incidence of MACE and better daily living ability
after interventions. The traditional single rehabilitation training
model cannot provide suﬃcient training volume to resist the
patient’s physical strength loss and cannot achieve the goal
of motor learning optimization through suﬃcient repetitive
activities, so the therapeutic eﬀect is limited. In contrast, ECP
and HIAT can improve myocardial oxygen supply, enhance
the physical performance of patients, and relieve or even
reduce the occurrence of angina pectoris and arrhythmias. The
combined application of the two methods will eliminate obesity
and bad mood and other risk factors of cardiovascular and
cerebrovascular diseases, help patients gradually recover their
ability to perform activities of daily living and improve the
quality of survival (23, 24). It is worth mentioning that patients
with contraindications to exercise can also be treated with ECP.
Clinicians can give ECP to patients with CHD ﬁrst, and then
start HIAT when the patient’s condition is stable and there
is no discomfort, which is safe and eﬀective in the ﬁeld of
CHD rehabilitation.
CONCLUSION
In conclusion, ECP combined with HIAT can improve the
cardiopulmonary function of patients with CHD after PCI, and
improve exercise endurance, reduce the incidence of MACE,
improve patients’ ability of daily living. This intervention brings
a new model for cardiac rehabilitation. In this study, in
order to ensure the uniformity of aerobic exercise intervention
intensity for patients, we only used one form of exercise to
train patients. In addition, when performing cardiopulmonary
exercise test, due to insuﬃcient exercise cooperation and
subjective exercise eﬀort of patients, this may aﬀect the research
results. At the same time, cardiopulmonary exercise test also
require relatively high operation requirements for professional
technicians. Therefore, this study needs to expand the sample
size, prolong the observation time, and choose the exercise form
according to the patient’s personal interests in the future, so
as to further prove the long-term eﬃcacy of ECP combined
with HIAT.
DATA AVAILABILITY STATEMENT
The original contributions presented in the study are included
in the article/supplementary material, further inquiries can be
directed to the corresponding author/s.
ETHICS STATEMENT
The studies involving human participants were reviewed and
approved by the Ethics Committee of the WuHan HanKou
Hospital. The patients/participants provided their written
informed consent to participate in this study.
AUTHOR CONTRIBUTIONS
PH was the director of the entire study. All authors of this study
made equal contributions, mainly including the design of the
study, the inclusion of cases, the detection of results, the statistics
of the data, and the writing of the paper.
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Conﬂict of Interest: The authors declare that the research was conducted in the
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Frontiers in Surgery | www.frontiersin.org
7
March 2022 | Volume 9 | Article 851113

Analysis of the Effect of External Counterpulsation Combined With High-Intensity Aerobic Exercise on Cardiopulmonary Function and Adverse Cardiovascular Events in Patients With Coronary Heart Disease After PCI.
Zhao, Shiming,Liu, Shaowen,Wen, Yuan,Qi, Qiuhuan,Huang, Peng