Treatment of Hypertension
- In patients with baseline hypertension, EECP has been proven to reduce systolic and diastolic blood pressure, while having no significant impact on heart rate.
- Perhaps even more remarkably, sustained benefits of the treatment have been demonstrated following a single session of EECP and indeed well after a full six-week therapeutic course, wherein a significant drop in blood pressure was observed after the first treatment, and more modest reductions were recorded across the remaining 34 sessions.
- In patients with coronary artery disease with left ventricular (LV) dysfunction, EECP’s improvement of LV function is believed to be responsible for lower brachial systolic pressures.
J Clin Diagn Res. 2016;10(10):OC 30-OC34.
Treatment of Ischemic Stroke
- An ischemic stroke occurs when the blood supply to part of the brain is blocked or reduced. This prevents brain tissue from getting oxygen and nutrients, leading to damage or death of brain cells. 87% of all strokes are ischemic.
- EECP has shown appreciable effects on ischemic stroke patients, by increasing blood pressure and cerebral blood flow.
- This improvement of cerebral perfusion and collateral supply is thought to result from significant increases in mean blood pressure produced by EECP treatment.
- While undergoing EECP treatment, patients have been known to experience mean blood flow velocity increases in both the ipsilateral and contralateral sides over baseline.
- Blood pressure and flow velocity then return to baseline when EECP treatment concludes.
Stroke, 2012 Nov ;43(11):3007-11. Int. J of Stroke, 2022;ijac.13839.
Treatment of Chronic Kidney Disease (CKD)
- Chronic Kidney Disease (CKD) is a progressive condition characterized by a decline in renal function, often associated with cardiovascular comorbidities such as hypertension, atherosclerosis, and heart failure. As vascular health deteriorates, so does renal perfusion, exacerbating the decline in glomerular filtration rate (GFR).
- EECP improves systemic vascular resistance and augments renal blood flow through:
► Improved endothelial function: EECP enhances nitric oxide
production and reduces inflammatory cytokines, which may
protect renal microvasculature.
► Increased renal perfusion pressure: Through elevated diastolic
pressure, EECP may support glomerular perfusion.
► Reduction in sympathetic tone: By improving baroreceptor
sensitivity, EECP may reduce renal vasoconstriction.
- Studies indicate adjunctive EECP decreases urinary protein excretion, stabilizes GFR, and improves creatinine clearance -suggesting a direct protective effect on residual nephrons.
- Pilot studies and case reports have demonstrated that patients with Stage 3–4 CKD, particularly those with comorbid congestive heart failure or ischemic heart disease, may benefit from EECP.
- By improving endothelial function, reducing arterial stiffness, and enhancing renal perfusion, EECP could play a supportive role in slowing CKD progression.
Chinese Journal of Cardiology. 2012;40(10):874-877.
Treatment of Cognitive Impairment
- Cognitive impairment often results from reduced cerebral perfusion, endothelial dysfunction, and microvascular disease—factors also common in cardiovascular disorders. As EECP improves systemic and cerebral hemodynamics, it is being explored as a non-pharmacologic treatment option to mitigate cognitive decline.
- Key mechanisms by which EECP may influence brain function include:
► Improved cerebral blood flow (CBF): Studies show that
EECP increases perfusion in the frontal and temporal
lobes—areas critical for memory, attention, and
executive function.
► Endothelial function restoration: EECP upregulates nitric
oxide and reduces inflammation, potentially reversing
microvascular dysfunction in the brain.
► Reduction of arterial stiffness and pulse wave velocity:
This helps improve blood delivery to the brain’s delicate
capillary beds, especially in elderly patients with atherosclerosis
or hypertension.
- A study by Zhang et al. evaluated 30 patients with coronary artery disease (CAD) and mild cognitive impairment (MCI). After 35 sessions of EECP, patients demonstrated significant improvements in Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) scores, correlating with increased cerebral perfusion on SPECT imaging.
- No large-scale randomized controlled trials (RCTs) have yet established EECP as a standard cognitive intervention. As research advances, EECP could become an important part of multimodal cognitive care strategies.
J Geriatr Cardiol. 2015;12(6):488–494.
Treatment of Vascular Dementia
- Vascular dementia is the second most common cause of dementia after Alzheimer’s disease and results from impaired cerebral blood flow due to stroke, microvascular disease, or chronic cerebral hypoperfusion. Symptoms include memory loss, slowed thinking, mood changes, and poor executive function.
- EECP improves perfusion not only to the heart but also to the brain—offering a novel therapeutic approach for vascular cognitive decline.
- EECP increases blood flow to the brain, especially to frontal and parietal lobes—regions involved in attention, planning, and decision-making.
- EECP stimulates the release of nitric oxide, improves endothelial function, and reduces systemic vascular resistance.
- By lowering pulse wave velocity and improving arterial compliance, EECP supports better cerebral blood delivery and protects the small vessels of the brain.
- Indirectly, EECP may reduce oxidative stress and inflammation—key contributors to the progression of vascular cognitive impairment.
- In a pilot study of patients with coronary artery disease and mild cognitive impairment. after 35 EECP sessions, participants showed significant improvements in cognitive scores (MMSE and MoCA), which correlated with increased cerebral blood flow on SPECT imaging.
- EECP may be considered for: 1) Patients with confirmed or suspected vascular dementia, especially those with cardiac comorbidities; 2) Elderly individuals with cerebral small vessel disease or chronic cerebral hypoperfusion; and 3) Those not responding to or intolerant of standard pharmacologic treatments.
- Continued research may solidify EECP as a complementary therapy in the multidisciplinary care of vascular dementia and mixed dementia (Vascular dementia and Alzheimer’s disease).
Chinese Journal of Geriatrics. 2016;35(7):724–728.
Treatment of Diabetic Neuropathy
- Diabetic neuropathy is a common and debilitating complication of long-standing diabetes mellitus, characterized by damage to peripheral nerves due to chronic hyperglycemia, ischemia, and inflammation. Patients typically experience numbness, tingling, burning pain, and, in severe cases, foot ulcers or gait instability.
- Emerging research suggests EECP may offer benefits for diabetic peripheral neuropathy (DPN) by improving peripheral circulation, reducing oxidative stress, and enhancing nerve regeneration.
- In DPN, reduced microvascular blood flow contributes to nerve ischemia. EECP enhances capillary perfusion in the lower limbs, helping restore oxygen and nutrient delivery to damaged nerves.
- EECP stimulates nitric oxide (NO) production and reduces endothelin-1 levels, leading to vasodilation and reduced vascular resistance—key factors in reversing diabetic microvascular dysfunction.
- By lowering systemic inflammation and oxidative stress, EECP may help mitigate one of the central mechanisms driving nerve injury in diabetes.
- Some studies suggest EECP may increase the expression of vascular endothelial growth factor (VEGF), which supports both angiogenesis and neurogenesis, potentially aiding nerve repair.
- In a clinical trial, 60 patients with painful diabetic neuropathy were divided into an EECP treatment group and a control group. After 35 sessions, the EECP group demonstrated significant improvements in pain scores (VAS), vibration perception thresholds, and nerve conduction velocity compared to baseline.
- EECP may benefit: Patients with painful diabetic neuropathy not responding to medications; individuals with peripheral arterial disease (PAD) and diabetic foot symptoms; and diabetic patients with microvascular complications and limited exercise capacity.
Diabetes Res Clin Pract. 2018;140:278–285.
Treatment of Diabetic Kidney Disease (DKD)
- Diabetic kidney disease (DKD), also known as diabetic nephropathy, is a leading cause of end-stage renal disease (ESRD) worldwide. It results from chronic hyperglycemia-induced damage to the glomerular microvasculature, leading to proteinuria, reduced glomerular filtration rate (GFR), and eventual kidney failure. The pathophysiology involves hemodynamic stress, oxidative stress, endothelial dysfunction, and microvascular inflammation.
- EECP enhances diastolic pressure and cardiac output, which can lead to increased renal perfusion and improved glomerular filtration in patients with compromised kidney function.
- EECP promotes endothelial nitric oxide synthase (eNOS) activity, increasing nitric oxide availability. This vasodilatory effect improves microvascular circulation in the kidneys and reduces glomerular hypertension—a key factor in DKD progression.
- EECP has been shown to decrease inflammatory markers like C-reactive protein (CRP) and interleukin-6 (IL-6), both implicated in the pathogenesis of diabetic nephropathy.
- By improving oxygen delivery and reducing oxidative stress, EECP may help limit tubulointerstitial fibrosis and podocyte injury, thereby slowing DKD progression.
- Clinical studies suggest that EECP may slow kidney function decline and improve metabolic parameters when used as an adjunct to conventional therapies in patients with diabetic nephropathy.
- EECP may be considered for patients with diabetic nephropathy and coexisting cardiovascular disease; diabetic patients with declining eGFR not yet on dialysis; and individuals with difficult-to-control hypertension contributing to kidney disease progression.
- EECP has the potential to stabilize kidney function and improve outcomes in patients with diabetic nephropathy—especially those with overlapping cardiovascular conditions.
J Clin Nephrol. 2016;16(3):145–149.
Treatment of Diabetic Retinopathy (DR)
- Diabetic retinopathy (DR) is a microvascular complication of diabetes and the leading cause of vision loss in adults aged 20–74 years. Chronic hyperglycemia damages retinal capillaries, leading to ischemia, increased vascular permeability, microaneurysms, hemorrhages, and in advanced cases, neovascularization, and retinal detachment. Although glycemic and blood pressure control remain the cornerstone of prevention, novel therapies that improve retinal perfusion and microvascular health are being explored.
- EECP increases diastolic blood pressure and cardiac output, thereby improving perfusion in ischemic retinal tissue. Studies have shown improved ocular blood flow and central retinal artery perfusion following EECP sessions.
- EECP promotes the release of nitric oxide (NO) and reduces endothelin-1, restoring endothelial balance. In diabetic retinopathy, endothelial dysfunction plays a major role in capillary leakage and non-perfusion.
- Chronic inflammation and oxidative damage are key drivers of microvascular injury in DR. EECP has been shown to lower pro-inflammatory cytokines and oxidative markers, potentially slowing retinal damage.
- By improving oxygen delivery to ischemic retinal areas, EECP may reduce the hypoxia-driven upregulation of vascular endothelial growth factor (VEGF), thereby reducing pathological neovascularization.
- Zhang et al. studied diabetic patients with early-stage non-proliferative diabetic retinopathy who underwent EECP therapy. They found improvements in retinal perfusion as assessed by ocular Doppler and fundus photography after 35 sessions. Some patients also reported subjective improvement in visual clarity.
- EECP may be considered for patients with early non-proliferative diabetic retinopathy to improve retinal circulation; diabetic individuals with coexisting ischemic heart disease and retinopathy; and adjunctive treatment for macular edema or reduced visual acuity not responding to anti-VEGF therapy.
- Because EECP is non-invasive, it may be a useful supportive therapy alongside laser photocoagulation, anti-VEGF injections, or corticosteroids.
- EECP may help slow the progression of microvascular damage and improve visual outcomes. Though not yet standard care, EECP warrants further study as part of a holistic strategy to manage diabetic microvascular complications.
Int J Ophthalmol. 2017;10(9):1402–1407.
Treatment in Erectile Dysfunction (ED)
- Erectile dysfunction (ED) affects millions of men worldwide, especially those with diabetes, hypertension, and cardiovascular disease. The pathophysiology of ED often involves endothelial dysfunction and impaired penile blood flow due to atherosclerosis of the pelvic vasculature. While oral phosphodiesterase-5 (PDE5) inhibitors (e.g., sildenafil) are first-line treatments, they are ineffective in 30–40% of patients—particularly those with severe vascular disease.
- EECP is now being investigated for its potential benefits in ED, particularly vasculogenic ED, the most common form in older men.
Mechanisms by Which EECP May Improve Erectile Function:
- Enhanced Pelvic and Penile Blood Flow
- EECP increases diastolic perfusion and shear stress on the vascular endothelium, promoting vasodilation and neovascularization. Studies using Doppler ultrasound have shown improved blood flow in the internal pudendal and cavernosal arteries after EECP.
- Improved Endothelial Function
- EECP boosts nitric oxide (NO) production and reduces oxidative stress, counteracting the endothelial dysfunction seen in ED and enhancing vasorelaxation necessary for penile erection.
- Reduction in Vascular Resistance and Inflammation
- By lowering systemic vascular resistance and reducing inflammatory cytokines, EECP may restore the health of penile vasculature and increase the responsiveness to other ED treatments.
- A pilot study evaluated EECP in patients with refractory vasculogenic ED. After 35 sessions, 75% of patients reported subjective improvement in erectile function, and significant increases were observed in the International Index of Erectile Function (IIEF-5) scores.
- EECP offers a novel, non-invasive approach to improving erectile function, particularly in men with vasculogenic ED and coexisting cardiovascular disease. By enhancing pelvic blood flow and endothelial health, EECP may serve as an adjunct or alternative to medication, especially in non-responders to PDE5 inhibitors.
J Sex Med. 2012;9(12):3487–3494.
Treatment in Peripheral Artery Disease (PAD)
- Peripheral artery disease (PAD) is a common circulatory condition characterized by narrowing or blockage of the peripheral arteries, most often in the legs. It results from atherosclerosis and is associated with reduced blood flow, leg pain during exertion (claudication), poor wound healing, and, in severe cases, critical limb ischemia (CLI).
- PAD shares many risk factors with coronary artery disease (CAD), including diabetes, hypertension, and smoking. Standard therapies include exercise, antiplatelet agents, statins, and revascularization procedures. However, a significant number of patients are either not candidates for or do not respond well to these interventions.
- For PAD patients, the potential mechanisms include:
► Improved Limb Perfusion
EECP increases diastolic blood pressure and venous return,
thereby improving arterial inflow to the ischemic limbs and
reducing symptoms of claudication.
► Collateral Vessel Development
The repetitive shear stress from EECP is believed to stimulate
angiogenesis and arteriogenesis, leading to the formation of
collateral vessels in the lower extremities.
► Endothelial Function Enhancement
EECP promotes the release of nitric oxide and reduces levels of
inflammatory cytokines, enhancing vasodilation and
microvascular circulation in patients with PAD.
► Reduced Inflammation and Oxidative Stress
Chronic inflammation plays a key role in PAD progression. EECP
has been shown to reduce markers of systemic inflammation
and oxidative stress, potentially slowing disease progression.
- In a study, patients with PAD who underwent EECP showed significant improvements in walking distance, claudication onset time, and peak oxygen uptake, suggesting improved exercise tolerance and limb perfusion.
- EECP may be helpful for patients with intermittent claudication unresponsive to exercise or pharmacotherapy; individuals with critical limb ischemia not eligible for revascularization; diabetic patients with combined PAD and neuropathy, and PAD patients with concurrent CAD or heart failure who are already undergoing EECP.
- By enhancing lower extremity perfusion, promoting collateral circulation, and improving endothelial function, EECP can alleviate symptoms of claudication, improve mobility, and support limb salvage. It holds particular promise for high-risk and no-option patients and may become a valuable component of comprehensive PAD management.
Vasc Med. 2011;16(5):345–349.
Treatment of Restless Legs Syndrome (RLS)
- Restless Legs Syndrome (RLS), also known as Willis-Ekbom Disease, is a neurologic sensorimotor disorder characterized by an uncontrollable urge to move the legs, often accompanied by uncomfortable sensations. Symptoms typically worsen during rest or at night and are temporarily relieved by movement.
- Although the precise cause of RLS is not fully understood, emerging research highlights roles for dopaminergic dysfunction, iron metabolism abnormalities, and peripheral vascular insufficiency. This has led to the exploration of EECP as a novel, non-pharmacologic therapy that may address vascular and circulatory dysfunction in RLS.
- Mechanism of Action Relevant to RLS:
- Improved Peripheral Circulation
Many RLS patients—especially those with diabetes or PAD—have poor lower limb perfusion. EECP enhances oxygen delivery and nutrient transport to muscles and nerves, potentially relieving the dysesthesia sensations of RLS. - Reduction of Leg Hypoxia and Metabolic Waste
Hypoxia and accumulation of metabolic by-products may contribute to the discomfort of RLS. EECP promotes microvascular flow and clearance of metabolites, which may relieve symptoms. - Enhanced Endothelial Function
EECP increases nitric oxide production and reduces oxidative stress, improving vascular tone and function, which may play a role in reducing RLS symptom severity. - Improved Sleep and Autonomic Regulation
By improving circulation and reducing sympathetic overactivity, EECP may indirectly enhance sleep quality—commonly impaired in RLS—and normalize dopaminergic activity. - EECP may be considered in patients with moderate-to-severe RLS associated with vascular comorbidities (e.g., PAD, diabetes, CKD); individuals who are intolerant or unresponsive to dopaminergic medications; and patients already undergoing EECP for cardiovascular indications who report RLS symptoms.
- EECP offers a promising adjunctive therapy for patients with RLS, particularly those with underlying vascular dysfunction. Although not yet standard of care, its use in select patients with RLS and cardiovascular disease may offer meaningful symptom relief and improved quality of life.
Korean J Pain. 2019;32(2):110–114.
Treatment of Chronic Fatigue Syndrome (CFS)
- Chronic Fatigue Syndrome (CFS) is a complex and debilitating condition characterized by profound, unexplained fatigue lasting more than six months, often accompanied by post-exertional malaise, cognitive dysfunction, unrefreshing sleep, and orthostatic intolerance. The exact cause remains unclear, but proposed mechanisms include autonomic dysfunction, impaired circulation, mitochondrial dysfunction, and neuroinflammation.
- The hemodynamic and vascular effects of EECP may benefit CFS through the following pathways:
- Enhanced Systemic Perfusion
Many CFS patients exhibit reduced cardiac output and impaired oxygen delivery to tissues, particularly during exertion. EECP increases diastolic pressure and venous return, improving overall perfusion and potentially reducing exercise-induced fatigue. - Improved Endothelial Function
EECP stimulates nitric oxide production and reduces markers of vascular inflammation. Since endothelial dysfunction and reduced blood vessel responsiveness are observed in CFS, EECP may restore better vascular tone and capillary perfusion. - Autonomic Nervous System Regulation
CFS is frequently associated with dysautonomia, including postural orthostatic tachycardia syndrome (POTS). EECP improves baroreflex sensitivity and may help stabilize autonomic function, reducing symptoms like lightheadedness and palpitations. - Reduction in Inflammatory and Oxidative Stress
Systemic inflammation and oxidative stress are implicated in the pathophysiology of CFS. EECP has been shown to decrease C-reactive protein and pro-inflammatory cytokines, which may lead to symptom improvement in affected patients. - EECP may be beneficial for CFS patients with orthostatic intolerance or POTS; individuals with fatigue and concurrent cardiovascular or microvascular dysfunction; and patients seeking non-pharmacologic, adjunctive treatments for energy restoration.
- EECP may offer a novel, non-drug intervention for patients with Chronic Fatigue Syndrome by enhancing circulation, reducing inflammation, and stabilizing autonomic function. Though not yet a standard treatment, it holds promise for those with vascular or autonomic components contributing to their fatigue.
J Clin Med. 2020Aug 14;9(8)2616.
Treatment of Long COVID Syndrome
- Long COVID syndrome—also known as post-acute sequelae of SARS-CoV-2 infection (PASC)—refers to a complex, multi-system condition in which symptoms persist or emerge four or more weeks after the acute phase of COVID-19. Common symptoms include chronic fatigue, shortness of breath, chest pain, palpitations, brain fog, exercise intolerance, and dysautonomia.
- While the pathophysiology is still under investigation, hypotheses include endothelial dysfunction, microvascular damage, autonomic imbalance, chronic inflammation, and mitochondrial dysregulation.
- Potential mechanisms by which EECP may benefit Long COVID patients include:
- Improved Microvascular Circulation
Long COVID may involve microvascular clotting and endothelial injury. EECP enhances shear stress and nitric oxide production, helping to restore endothelial function and improve tissue perfusion—particularly in the brain, lungs, and skeletal muscles. - Autonomic Nervous System Rebalancing
Many Long COVID patients report orthostatic intolerance, tachycardia, or symptoms of POTS. EECP has been shown to improve baroreceptor sensitivity and reduce sympathetic overactivity, supporting autonomic recovery. - Reduction of Inflammation and Oxidative Stress
Systemic inflammation and oxidative stress are elevated in Long COVID. EECP decreases inflammatory markers like C-reactive protein (CRP) and improves antioxidant defenses, possibly reducing symptom severity. - Enhanced Oxygen Delivery and Energy Metabolism
By improving cardiac output and tissue oxygenation, EECP may alleviate fatigue, exercise intolerance, and brain fog, commonly reported in post-COVID patients. - Ali et al. reported symptom improvement in Long COVID patients with fatigue, brain fog, and chest tightness after a full course of EECP. Patients experienced increased energy, better concentration, and reduced cardiovascular symptoms.
- An observational case series presented by Zhou et al. described Long COVID patients with autonomic dysfunction who underwent EECP therapy and reported improvements in orthostatic symptoms, heart rate variability, and sleep quality.
- EECP may benefit (1) Long COVID patients with persistent fatigue, cognitive dysfunction, or shortness of breath; (2) Individuals with dysautonomia, POTS-like symptoms, or orthostatic intolerance; and (3) Patients with underlying cardiovascular risk factors or microvascular complications exacerbated by COVID-19.
- EECP offers a promising, non-pharmacologic treatment option for Long COVID syndrome, particularly in patients with fatigue, cognitive impairment, and autonomic dysfunction. While further research is needed, EECP holds potential as part of a multimodal recovery strategy for post-COVID patients.
J Clin Transl Res. 2022;8(1):104–110.
1. Int J Cardiol Heart Vasc. 2023;40:101085.