Knowledge Base

EECP Interview

Indian medical system takes longer time to accept newer technology

Thursday, July 4, 2013

Dr S Ramasamy, an EECP (Enhanced External Counter Pulsation) specialist, is director and chief executive officer of Vaso-Meditech and medical director of Chennai Heart Care Centre (EECP training centre for India and Middle East countries).

He has with him several years of working experience with US-based Vasomedical in research and development of EECP therapy. Pioneered in starting refractory angina and heart failure clinic based on EECP therapy in many cardiac hospitals as well as teaching institutes in India, he was recently appointed as international medical director for the US-based International EECP Therapist Association.

In an exclusive interview with AalaTimes, Dr Ramasamy talks about the EECP therapy and his journey so far.

Tell us something about your journey so far as a researcher as well as a physician?

Journey of my medical academic carrier started from JJM (Jagadguru Jayadeva Murugarajendra) Medical College in Davanagere, Karnataka. After completing my MBBS there I went to USA to pursue my higher studies. I worked as a volunteer research associate under Dr John Tartaglia in New York United Hospital Medical Centre. This medical centre was the first to start commercial Enhanced External Counter Pulsation (EECP) programme in USA. My interest in this new therapy started from here. With my experience as a physician and EECP provider, I joined as the non-invasive clinical research fellow with the United Hospital and subsequently in Stony Brook University's non-invasive cardiology department.

My first research work is to show this new (EECP) therapy can improve the blood flow to the heart muscle without any medication or invasive procedure using nuclear imaging. Simultaneously, I worked on another research work to show EECP, if started after angioplasty, can reduce the chance of the stent getting close again. Both these research work was published and got favorable review by experts. Our paper showing EECP can improve the blood supply beyond the blocked artery without mechanical manipulation of arteries as in bypass surgery and angioplasty is one of the widely cited papers in clinical research.

The EECP manufacturer Vasomedical Inc in New York, which has a team of cardiologist experts to develop the technology to be available to clinical settings across USA, recruited me as one of the research fellow for EECP programme.

Our next larger study on 175 patients' pre and post EECP assessed by nuclear perfusion imaging paved way for EECP as one of the clinically tested and proven treatment in cardiology.

I returned to India in 2004 to promote EECP and did many clinical presentations in cardiology forums nationally and internationally and continued my research on the benefit of EECP to cardiac patients. I am also currently specializing in providing EECP to a sub-group of patients who are in heart failure such that heart function is inadequate to meet the body requirements.

My primary interest is to bring EECP as not only a treatment for patients with cardiovascular disease but also as a preventive treatment. Recognizing my work in India in creating a training programme for EECP therapists and physicians, I was elected as an honorary International Medical Director for the International EECP Therapist Association based in USA.

What kind of therapy EECP is? Is it better than other form of treatments like bypass?

The treatment for vascular disease advances as technology improves. The treatment for heart disease has evolved from a simple drug called nitrates which can dilate the vessels and improve the heart blood supply and then to highly invasive interventional procedure bypass surgery and then less invasive interventional procedures like angioplasty and stent to achieve increased blood flow. The future for treating cardiac disease is now focused on achieving the increased blood flow, which is common for all the above treatment modalities but the challenge is to achieve it in a non-invasive, cost-effective and safer ways.

The only emerging new therapy, which is non-surgical, non-drug therapy and which has already been approved by the US FDA (Food and Drug Administration) and has shown improvement in blood flow to heart muscle can be achieved non-invasively is the Enhanced External Counter Pulsation (EECP) therapy. EECP is the only treatment, which is completely non-invasive, effective in majority of the patients and less expensive, as it's provided as out-patient treatment and needs no hospitalization.

The EECP device applies and releases external pressure in synchronization with the patient's cardiac cycle. When the heart is in the relaxed state, air pressure is applied sequentially from the lower legs up to the thighs to force a wave of blood pressure back to the heart, thus increasing coronary blood flow. When the heart is ejecting blood into the aorta, air is quickly released from the cuffs to remove external pressure, thus reducing the workload of the heart. The EECP therapy is for 35 days — one hour a day session for six days a week for six weeks. The treatment can also be given as twice a day treatment for three weeks.

EECP Treatment Cost in Chennai, India
How much does it costs to a patient?

The treatment cost for 35 days is currently between Rs 85,000 and Rs 1,00,000. Initially, the treatment was provided only in cardiology super specialty hospitals but now due to the growing acceptance of the treatment, it is now offered in smaller hospitals and physician's office. As the treatment is moving from major urban cities to rural areas there will be considerable cost reduction as the operational cost can be brought down due to the positioning of EECP as a standalone treatment centre. Also, our company Vaso-Meditech Pvt Ltd provides EECP physician training programme where doctors are educated in providing EECP under the guidance of cardiologist and how to adhere to the strict protocols of treating cardiac patients safely. Moreover, as the treatment is out-patient, there will not be additional cost factor involved as in other in-patient treatments and hospitals have also started charging the treatment on multiple installments basis rather than upfront full payment to reduce the cost burden on the patients.

How has been the response of EECP therapy in India?

Currently, there are more than 120 EECP centres operational across India. There is growing interest among cardiac patients in EECP therapy. The full course of the EECP treatment has resulted in resumption of many activities the patients were not able to do due to their cardiovascular disease. As the treatment is non-invasive they don't lose their wages and they can do their job while undergoing the treatment to improve their cardiac health by improving the blood supply to the heart muscles.

The overall benefit of EECP is improving the quality of life, exercise tolerance; reducing the repeat hospitalization, and significantly reducing the medication cost. Due to the high response from patients and treating cardiologists and general physicians the number of centres will double by 2013-end. We are working with government agencies and insurance companies to frame policies to regulate the centres so that proper certification and training is provided to the treating physician through our organization to optimize the maximum benefit to the patients.

Recently, you incorporated the EECP therapy with an Ayurvedic programme. Throw some light on it.

Ayurvedic medicine is traditional Indian alternative medicine with origin and whose practice started within the Indian subcontinent. Ayurvedic programme is primarily focused on traditional treatment, which includes natural herbal preparation, diet, Yoga and meditation. Based on available clinical studies, there is no strong evidence to support the Ayurvedic programme as a treatment for cardiovascular disease rather, if you closely observe their programme, it's not designed for the treatment of disease but it explains and teaches the way of healthy living, so the body can heal itself.

Allopathy traditionally delivered, what we obsessively call evidence-based medicine, on disease management. It is in contrast to Ayurveda, which relies upon traditional literatures. EECP, as an Allopathy treatment is the first which is natural and adapts a holistic approach than reductionist and does not involve medicine or surgery.

Would you call it a revolution in the treatment of cardiovascular disease?

Cardiovascular disease currently has become one of the major health threats of our nation. The burden it causes in society is increasing in alarming rate. Cardiovascular disease management has progressed from simple medical management to complicated surgery and simple ECG to advanced computer tomography (CT) scan. Still these advances in treatment and diagnosis have not reduced the incidence of cardiovascular disease. Increased expenditure on healthcare is slowly eroding the wealth of individual families in rural, semi-urban and even in urban areas. The impact of high-end invasive and expensive cardiovascular technology negates productivity in the family, in society and in all spheres of life.

Now the question is whether the technology advancement in cardiovascular healthcare is moving towards the right direction in controlling the major epidemic of cardiovascular disease in our country. Simple and systemic approach will greatly reduce the healthcare cost and simultaneously reduce the cardiovascular burden on the society, the government and the insurance companies.

In this scenario, newer advance in cardiology has shown that the cardiovascular disease be treated holistically as the disease of the entire vascular system of the human body, rather than focused only in coronary arteries for which bypass surgery and angioplasty is currently advised. The EECP therapy provides increased blood flow not only to the heart muscles but also improves the endothelial function of the entire vascular system. So, EECP can be definitely called as a revolution in the field of cardiology.

What sort of challenges have you faced while introducing this non-invasive (EECP) treatment in the Indian medical system?

The Indian medical system takes longer time to accept any newer technology and assimilate it into its vast system. EECP was first introduced in India by the People's Group in Bhopal and the Fortis Hospitals in Delhi in 2002. The initial hesitation among cardiologists is due to lack of awareness about the clinical studies done in this area. The challenge is to bring the clinical knowledge on EECP across India. In spite of the EECP treatment's proven benefit to patients comparable to bypass surgery and angioplasty, initially doctors preferred to ignore the treatment. We created an Indian EECP patient registry, which collected the clinical data of the patients who had undergone the EECP treatment and patient improvement from all major cardiac centres are published in Indian and international journals. The enormous success of this strategy has slowly led cardiologists to start accepting EECP as one of the arsenal in their fight against cardiovascular disease. We are now planning to launch our online EECP data registry, which will collect data from 80 centres across India and the patient benefit will be given to government policy makers and insurance companies to reimburse EECP treatment.

As far as the general public is concerned their perception of cardiovascular disease is always related to removal of block or treatment like bypass surgery which is highly invasive or relatively less invasive procedures like angioplasty. They couldn't practically believe a simple non-invasive solution through EECP could be able to get their life back to normal. Now patients' experience on EECP has been growing phenomenally in the past two years as more and more patients are asking their cardiologists and physicians for EECP treatment for their cardiac alignments.

EECP has wide application in the field of cardiology and in my opinion is well suited for Indian patients who, when compared to the western population, have smaller coronary artery; who are invariably diabetic and whose blood sugar is not well controlled due to lack of compliance with medication. This leads to diffuse and multiple obstructions in the coronary vessels, which appears prematurely in the younger age group. These clinical presentations are difficult to treat by bypass surgery or stent and lead to recurrent symptoms even after intervention. EECP plays a very important role in these patients to improve the blood flow beyond the occluded graft of closed stent thereby improving the quality of life.

Heart related problems being the major problems faced by Indians, what are the practices that need to be brought in to revolutionize the cardiac treatment in India?

The WHO (World Health Organization) estimates that over the next 10 years India will lose 237 billion US dollars due to heart disease, stroke and diabetes. In 2005, the number of CVD (cardiovascular disease) patients was 30 million; 14 million in the urban area and 16 million in rural areas. This is expected to double to 60.4 million in 2015. Hence the low cost, risk free, productive, out-patient treatment is the urgent call of the day; such therapy alone would heal the heart, reduce mortality burden and increase the national health parameters. The vast outreach of the new therapy paradigm will multiply access to quality health along with big numbers. This issue has to be addressed now itself.

The new integrated EECP therapy, which is heart friendly in the sense that it is not heart invasive unlike CABG ( coronary artery bypass graft) and PTCA ( percutaneous transluminal coronary angioplasty), and produces angiogenesis as the sheet anchor of alleviating cardiovascular disease burden. This is the panacea, in our view, rather than attempting to set up vastly costly, risk laden, complicated invasive infrastructure of treatment. The poor and the middle class, whether covered by insurance or not, can be catered to only through this new primary and preventive method, if at all the projected 60 million CVD patients have to be treated by 2015.

The nation can no longer afford to be a bystander when cost-effective, risk-free, non-invasive and productivity promoting EECP therapy is allowed to remain unavailable to the millions of needy CVD patients spread across India. It may be kept in mind that not more than 7 per cent of the reduction in CVD has been attributed in the USA due to PTCA and CABG, the rest are supported and healed by non-invasive and life style changing methods.

What message would you like to give to our readers?

The world is now looking at a paradigm shift in the understanding and treatment of heart disease, even after advancements are made in interventional cardiology and medical management. Patients who have symptoms in spite of this advancement are increasing in alarming proposition. This may be attributed to improved survival and prolongation of life even after suffering major heart attack and also due to prevalence of diabetes and diffuse coronary vessel disease in our country.

Unless the treatment strategy is changed towards focusing on the entire cardiovascular system rather than focusing on heart or coronary segments only, the patient's treatment goals such as good quality of life, improve survival and reduce hospitalization will not be met. The name for cardiac disease has changed from ischemic heart disease to coronary artery disease to a correct terminology cardiovascular disease. This reflects that the treatment should be focused not only on the heart and coronary circulation but on the entire vascular system along with coronary and should improve blood flow to the myocardium.

EECP is a new FDA approved treatment, which has been shown not only to improve myocardial blood flow but also enhances the vascular health thereby correctly addressing cardiovascular disease. Due to its non-invasive, cost-effective and simplicity approach, the EECP therapy can be made available to millions of patients whose quality of life can be improved with reduced chest pain, improved walking distance and decreased dependence on medication.

by Vidhi Rathee

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