Enhanced External Counterpulsation Although EECP was carefully reviewed in the 2012 SIHD comments received after the guideline s publication prompted a re-examination of the existing literature, even though no truly new data have become available. EECP is a technique that uses inflatable cuffs wrapped around the lower extremities to increase venous return and augment diastolic blood pressure.47 The cuffs are inflated sequentially from the calves to the thigh muscles during diastole and are deflated instantaneously during systole. The resultant diastolic augmentation increases coronary perfusion pressure, and the systolic cuff depression decreases peripheral resistance. Treatment is associated with improved left ventricular diastolic filling, peripheral flow-mediated dila- tion, and endothelial function. Other putative mechanisms for improvement in symptoms include recruitment of collaterals, attenuation of oxidative stress and proinflammatory cytokines, promotion of angiogenesis and vasculogenesis, and a periph- eral training effect.48 51 EECP was approved by the US Food and Drug Administration in 1995 for the treatment of patients with CAD and refractory angina pectoris who fail to respond to standard revascularization procedures and aggressive pharma- cotherapy. A treatment course typically consists of 35 sessions of 1 hour each, given 5 days a week. Contraindications include decompensated heart failure, severe peripheral artery disease, and severe aortic regurgitation. The efficacy of EECP in treating stable angina pectoris has been evaluated in 2 RCTs and several observational regis- try studies. 