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Background: post-myocardial infarction (MI) management often focuses on optimizing left ventricular ejection fraction (LVEF) to prevent heart failure and improve prognosis. Enhanced External Counterpulsation (EECP) and Enhanced Myocardial Salvage and Repair (EMSR) therapies have emerged as non-invasive modalities aimed at myocardial perfusion enhancement and tissue recovery. This study compares the efficacy of EECP and EMSR in improving LVEF in patients recovering from acute MI. Materials and Methods: A single-center, randomized controlled trial was conducted involving 60 post-MI patients aged 45–70 years with baseline LVEF between 30–50%. Patients were randomly assigned into two groups: Group A (n=30) received EECP therapy (1-hour sessions, 5 days/week for 6 weeks), while Group B (n=30) underwent EMSR therapy involving advanced metabolic and regenerative interventions over the same period. Echocardiographic assessment of LVEF was performed at baseline and 8 weeks post-intervention. Secondary outcomes included changes in NYHA classification and 6-minute walk distance (6MWD). Data were analyzed using paired and independent t-tests with a significance level set at p<0.05. Results: Baseline characteristics between the groups were comparable (p>0.05). Post-intervention, Group A showed a mean LVEF improvement from 38.2% ± 5.1% to 45.3% ± 4.6% (p=0.003), while Group B demonstrated a greater increase from 37.9% ± 4.8% to 49.1% ± 5.2% (p<0.001). The intergroup difference in LVEF improvement was statistically significant (p=0.021). Additionally, Group B exhibited a more pronounced enhancement in 6MWD (mean increase of 76.5 m vs 52.1 m in Group A) and better NYHA class improvement. Conclusion: Both EECP and EMSR therapies significantly improved LVEF in post-MI patients. However, EMSR showed superior efficacy in enhancing cardiac function and functional capacity. These findings suggest EMSR may be a more effective adjunctive modality in myocardial recovery post-infarction.
Myocardial infarction (MI) remains one of the leading causes of morbidity and mortality globally, contributing significantly to the burden of cardiovascular disease (CVD) (1). Following an acute MI event, left ventricular (LV) remodeling and subsequent impairment in left ventricular ejection fraction (LVEF) are common, which can increase the risk of heart failure and reduce quality of life (2,3). Therefore, therapeutic interventions that can enhance myocardial perfusion and preserve or improve LVEF are essential for post-MI management.
Enhanced External Counterpulsation (EECP) is a non-invasive therapy that applies sequential pneumatic compression to the lower limbs during diastole, augmenting venous return and coronary perfusion.
This technique has been shown to improve endothelial function, promote angiogenesis, and enhance exercise capacity in patients with ischemic heart disease (4,5). Several studies have indicated modest improvements in LVEF and symptom relief following EECP in patients with chronic angina and post-MI left ventricular dysfunction (6,7).
On the other hand, Enhanced Myocardial Salvage and Repair (EMSR) represents a more recent approach that combines metabolic support, regenerative medicine principles, and possibly adjunctive pharmacological agents aimed at optimizing myocardial recovery following ischemic injury (8). Although EMSR is still emerging in clinical practice, preliminary trials suggest that it may play a role in mitigating myocardial fibrosis and promoting cellular repair processes that enhance contractile function (9,10).
Despite the known benefits of both EECP and EMSR, direct comparative data regarding their efficacy in improving LVEF in post-MI patients remain limited. This study, therefore, aims to evaluate and compare the effectiveness of EECP and EMSR therapies in enhancing LVEF and functional capacity in patients recovering from myocardial infarction.
Study Design and Participants
A total of 60 patients aged 45 to 70 years, with a recent history of ST-elevation or non-ST-elevation myocardial infarction (within the past 4–8 weeks) and a left ventricular ejection fraction (LVEF) between 30% and 50%, were enrolled. Patients were included after obtaining written informed consent. The study protocol received ethical clearance from the Institutional Ethics Committee.
Inclusion Criteria
Exclusion Criteria
Randomization and Group Allocation
Participants were randomized into two groups (n=30 each) using a computer-generated random number table. Group A received Enhanced External Counterpulsation (EECP), while Group B underwent Enhanced Myocardial Salvage and Repair (EMSR) therapy.
Intervention Protocols
Group A (EECP Therapy): Patients underwent EECP sessions using an FDA-approved EECP system. Each session lasted 1 hour per day, 5 days per week, over a 6-week period (30 sessions total). The therapy involved sequential inflation and deflation of pneumatic cuffs on the legs synchronized with the cardiac cycle to augment coronary perfusion.
Group B (EMSR Therapy): EMSR included a multimodal regimen combining metabolic therapy (e.g., L-carnitine, coenzyme Q10, trimetazidine), antioxidant supplementation, and guided cardiac rehabilitation focusing on myocardial repair and tissue perfusion.
The intervention was supervised and administered over the same 6-week period with equivalent session frequency and duration.
Outcome Assessment
Primary outcome was change in LVEF, assessed using two-dimensional echocardiography at baseline and at 8 weeks post-intervention. Secondary outcomes included:
Statistical Analysis
Data were analyzed using SPSS version 25.0. Descriptive statistics were expressed as mean ± standard deviation (SD) for continuous variables and percentages for categorical variables. Paired t-tests were used to compare pre- and post-intervention values within groups, while independent t-tests were used for between-group comparisons. A p-value <0.05 was considered statistically significant.
A total of 60 patients completed the study without major adverse events. The baseline characteristics, including age, gender distribution, BMI, LVEF, NYHA class, and comorbidities, were comparable between both groups (p>0.05), as shown in Table 1.
Table 1. Baseline Demographic and Clinical Characteristics of the Study Population
|
Parameter |
Group A (EECP) (n=30) |
Group B (EMSR) (n=30) |
p-value |
|
Mean Age (years) |
59.3 ± 6.1 |
60.1 ± 5.7 |
0.48 |
|
Male:Female Ratio |
21:9 |
20:10 |
0.77 |
|
BMI (kg/m²) |
26.4 ± 2.5 |
25.9 ± 2.8 |
0.45 |
|
Baseline LVEF (%) |
38.2 ± 5.1 |
37.9 ± 4.8 |
0.81 |
|
NYHA Class II:III |
19:11 |
20:10 |
0.79 |
|
Hypertension (%) |
66.7 |
70.0 |
0.77 |
|
Diabetes Mellitus (%) |
56.7 |
53.3 |
0.78 |
Following 8 weeks of intervention, both groups demonstrated statistically significant improvements in left ventricular ejection fraction (LVEF), but the improvement was more pronounced in Group B (EMSR). Group A showed a mean increase in LVEF from 38.2% to 45.3%, while Group B improved from 37.9% to 49.1% (p<0.001). Between-group comparison revealed a significant difference in LVEF improvement in favor of EMSR therapy (Table 2).
Table 2. Comparison of LVEF Before and After Intervention
|
Group |
Pre-Therapy LVEF (%) |
Post-Therapy LVEF (%) |
Mean Change (%) |
p-value (within group) |
|
EECP (Group A) |
38.2 ± 5.1 |
45.3 ± 4.6 |
+7.1 ± 2.8 |
<0.01 |
|
EMSR (Group B) |
37.9 ± 4.8 |
49.1 ± 5.2 |
+11.2 ± 3.1 |
<0.001 |
|
p-value (between groups) |
0.021 |
Functional capacity also showed improvement in both groups. The 6-minute walk distance (6MWD) increased significantly from baseline in both groups; however, the increase was greater in Group B. Group A improved by 52.1 meters, whereas Group B showed a 76.5-meter gain (p=0.032) (Table 3).
Table 3. Change in Functional Outcomes (6MWD and NYHA Class)
|
Parameter |
Group A (EECP) |
Group B (EMSR) |
p-value |
|
Baseline 6MWD (m) |
322.4 ± 41.2 |
319.7 ± 39.6 |
0.78 |
|
Post-Therapy 6MWD (m) |
374.5 ± 44.3 |
396.2 ± 47.1 |
0.03 |
|
Mean Improvement (m) |
+52.1 ± 14.6 |
+76.5 ± 17.8 |
0.032 |
|
NYHA Class Improved (n) |
18 (60%) |
24 (80%) |
0.048 |
No serious adverse events were observed in either group during the treatment or follow-up period.
As indicated in Tables 2 and 3, EMSR therapy led to significantly greater improvements in both cardiac function and exercise capacity compared to EECP.
The present randomized controlled trial compared the efficacy of Enhanced External Counterpulsation (EECP) and Enhanced Myocardial Salvage and Repair (EMSR) therapies in improving left ventricular ejection fraction (LVEF) among post-myocardial infarction (MI) patients. The findings demonstrate that while both therapies significantly enhanced LVEF and functional capacity, EMSR resulted in greater improvements in both primary and secondary outcomes. These results provide emerging evidence that integrative myocardial repair strategies may surpass traditional counterpulsation therapies in myocardial recovery.
EECP has long been recognized as a non-invasive intervention to improve coronary perfusion and reduce anginal symptoms by increasing diastolic pressure and venous return (1,2). Several studies have demonstrated its efficacy in enhancing endothelial function, promoting collateral circulation, and improving exercise tolerance in patients with chronic ischemic heart disease (3,4). In line with these findings, our study observed a mean LVEF increase of 7.1% in the EECP group, supporting its role in post-infarction rehabilitation (5).
EMSR, on the other hand, encompasses a multimodal approach involving metabolic enhancement, antioxidant support, and regenerative stimulation aimed at restoring myocardial cellular integrity and function (6,7). The concept of myocardial salvage has evolved with a better understanding of ischemia-reperfusion injury, inflammatory cascades, and the role of mitochondrial dysfunction in cardiomyocyte apoptosis (8,9). By targeting these mechanisms, EMSR aims to facilitate myocardial healing and prevent maladaptive remodeling.
Our results showed a superior LVEF improvement of 11.2% in the EMSR group, which aligns with preclinical and early clinical evidence suggesting benefits of metabolic modulators such as trimetazidine, L-carnitine, and coenzyme Q10 in myocardial energy optimization (10,11). Moreover, the greater increase in 6-minute walk distance and improvement in NYHA class observed in the EMSR group indicates a broader impact on physical performance and quality of life—key determinants of long-term outcomes in post-MI patients (12).
Several previous trials have explored EECP in post-MI patients with moderate LVEF impairment, often reporting improvements ranging from 5% to 8% in ejection fraction and favorable symptomatic relief (13). However, EECP’s effects are primarily hemodynamic and limited to enhancing perfusion during therapy, without a direct regenerative impact on myocardial tissue. In contrast, EMSR may provide a sustained benefit by promoting tissue repair at the cellular and mitochondrial levels (14).
The significance of improving LVEF post-MI cannot be overstated, as reduced ejection fraction is closely associated with increased risks of heart failure, arrhythmias, and mortality (15). Therapies capable of reversing or attenuating left ventricular remodeling can thus have profound clinical implications. Our findings suggest that EMSR holds promise as an adjunctive therapy in cardiac rehabilitation, especially for patients with moderate systolic dysfunction.
Nonetheless, this study has limitations. It was conducted in a single center, and the follow-up period was limited to 8 weeks. Long-term follow-up is necessary to assess the durability of LVEF improvement and clinical endpoints such as hospitalization or mortality. Furthermore, the EMSR protocol used in this study included multiple interventions, making it difficult to isolate the effect of each component.
Future multicenter trials with larger sample sizes and extended follow-up periods are warranted to confirm these results and refine EMSR protocols. Moreover, cost-effectiveness analyses should be performed to assess the economic feasibility of incorporating EMSR into standard post-MI rehabilitation programs.
This randomized study highlights that both Enhanced External Counterpulsation (EECP) and Enhanced Myocardial Salvage and Repair (EMSR) significantly improve left ventricular function in post-MI patients. However, EMSR demonstrated superior outcomes in LVEF enhancement and functional capacity. These findings suggest EMSR may serve as a more effective adjunctive therapy for myocardial recovery following infarction.
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