Is EECP Really Quackery As the WSJ Implies?

Why Your Cardiologist Isn't Telling You About EECP

A more traditional form of quackery. Buyenlarge/Archive pictures/Getty images

A front-page story in the June 10, 2014, edition of the Wall Street Journal featured EECP (enhanced extracorporeal counterpulsation) as a prototype of the kind of useless and wasteful medical procedures commonly favored by unscrupulous doctors. (Here's the link - subscription required.)

EECP is a noninvasive treatment for angina. And to be sure, as cardiac therapy goes, EECP certainly is an oddity.

In EECP, long inflatable cuffs (like blood pressure cuffs) are wrapped around the patient’s legs, and the cuffs are inflated and deflated synchronously with each heart beat. By inflating when the heart is finished beating (that is, during diastole), the cuffs help to “pump” blood to the coronary arteries. And by suddenly deflating just before the next heartbeat (that is, just before systole), the cuffs reduce the vascular pressure against which the heart has to work. These actions have a salutary effect on the function of the heart.

And, when administered according to the recommended protocol (five one-hour treatments per week for seven weeks, for a total of 35 treatments), clinical studies show that EECP can have a long-lasting effect on significantly reducing symptoms, and increasing exercise time, in people who have stable angina from coronary artery disease (CAD).

According To The WSJ

The WSJ article features one Dr. Ronald S.

Weaver of Los Angeles, who allegedly has parlayed his EECP clinic into a gigantic money-maker. Dr. Weaver has billed Medicare for EECP procedures 16,619 times (which adds up to 692.5 days of actual pump time), and in 2012 received $2.27 million from Medicare for EECP.

It should be obvious that you can only be as successful as Dr. Weaver if you combine creative thinking with an emphasis on productivity.

Accordingly, Dr. Weaver’s clinic apparently engages in extensive community outreach, allegedly representing to prospective clients that EECP provides various unproven, perhaps made-up, benefits (for instance, that it is a general preventive measure against cardiac disease). And Dr. Weaver’s employees are strongly encouraged, at least according to email messages the Journal has obtained, to spend whatever time it may take to get clients to complete all of their 35 covered treatments. (“Please make sure everyone is on the phone all day long,” urged one email sent to employees). This kind of productivity is clearly needed in order to achieve the clinic’s stated target of performing at least 90 EECP treatments a day.

The WSJ strongly implies that Dr. Weaver’s practice is, at the least, unsavory, and more likely, quackery. As an objective reader of the WSJ, I must say that I tend to be sympathetic to this conclusion, and if it is true I for one would hope that Medicare will find a way to stop sending Dr. Weaver all of our tax money. (Note: See the addendum at the end of this article.)

But at the same time, the WSJ implies that EECP is itself rarely useful, citing as its main evidence the fact that cardiologists almost never use EECP in treating their patients.

(“The 141 cardiologists at the Cleveland Clinic…performed it on only six patients last year.”) Indeed, the Journal implies that its major problem with Dr. Weaver is not so much that he preys on church groups where the elderly and disabled congregate, but rather, that he is not a cardiologist. Only a cardiologist would recognize that extremely rare circumstance where EECP might be of use, so only a cardiologist should determine when or whether to use it.

Why Cardiologists Ignore EECP

The clinical evidence in support of EECP as a treatment for angina is actually reasonably strong. The American College of Cardiology (ACC), in their guidelines for treating stable angina, did an extensive review of that clinical evidence, and their summary statement is as follows: "These studies [on EECP] found the treatment to be generally well tolerated and efficacious; anginal symptoms were improved in approximately 75% to 80% of patients.”

The ACC guideline writers went on, however, in the very next sentence, to decline recommending EECP to treat angina, in anybody. This is because the guideline writers judged that even more clinical evidence was necessary to convince them. The guideline writers, for the most part, were cardiologists - and when it comes to EECP, cardiologists are going to take a heck of a lot of convincing.

As a cardiologist myself, I assert that the large majority of cardiologists are congenitally incapable of embracing an outlandish therapy like EECP. It is not within our natures to do so. Since at least 1980, cardiology has been a highly invasive specialty - attracting people who, like surgeons, desire to identify cardiac problems by the most expedient means available - and then get in there and fix it. We want to catheterize, cauterize, angioplasty, valvuloplasty, ablate and stent. It’s what we spend years of training learning to do; it’s why we chose that kind of training in the first place. We live to take a patient who has a cardiac problem, place that patient on a procedural table, do a procedure and have the patient get off that table cured, or at least greatly improved. I leave it to the psychiatrists (the wusses) to identify the pathology that makes us this way. But whatever the underlying cause, it’s in our natures.

And you expect us to embrace EECP?

To the intellectuals among us cardiologists (such as there may be), there’s no reason at all that anyone should have thought EECP would work in the first place – that temporarily providing counterpulsation would have lasting effects. And the fact that it apparently does work is merely blind luck and leaves proponents of EECP scrambling ridiculously to explain why it does. This is a less than satisfying way to advance science, and obviously (to us) diminishes the importance of the clinical trials showing that EECP works.

To most cardiologists, incorporating EECP into our practices would be logistically difficult, not to mention expensive. To accommodate patients for EECP, we would not only have to purchase costly equipment and space but also we would have to radically change the organization and procedures within our offices and among our staff.

And for what? EECP, in the final analysis, has absolutely nothing in common with what we cardiologists do. We treat the heart, for goodness sake. We stress it, image it, measure it, pace it, shock it, stent it, ablate it, revascularize it, and bathe it in drugs. What we do takes years of specialized training and expertise, millions of dollars of high-tech equipment, and great manual dexterity, and it brings us tremendous prestige, even among our peers within the medical community.

And we’re supposed to drop all that? In order to attach fancy balloons to peoples’ legs, throw a switch, watch them bounce around for an hour, then say, “See you tomorrow?” That’s not cardiology. That’s glorified physical therapy.

This is the real reason your average cardiologist is completely ignoring EECP as if it doesn’t even exist. We simply can’t believe anyone really expects us to do this.

And, if any doctor is going to adopt EECP as a part of their medical practice - whether legitimately or as an industrialized form of quackery - it’s not particularly surprising (to me, at least, if not to the WSJ), that it would turn out to be a non-cardiologist.


EECP is, in fact, a legitimate form of therapy for stable angina. However, if you have angina that has proved difficult to treat with medication and would like to consider EECP, then you are probably going to have to bring it up yourself. Don’t expect your cardiologist to suggest it. And if you do manage to get referred for EECP therapy, don’t be too surprised if a non-cardiologist ends up providing it.

Addendum: June 20, 2014. After this article was published, I was contacted by Dr. Ronald Weaver. Dr. Weaver provided me with a letter he had sent to the authors of the WSJ story before that story was published, disputing many of the allegations about his practice that subsequently appeared in the WSJ. Dr. Weaver’s statements, if accurate, would tend to place his activities regarding EECP in a much more benign light than the WSJ story implies. So: There are still two sides to every story, including this one.


Carreyrou J, Stewart AS, Barry R. Taxpayers foot big bills from a handful of doctors. The Wall Street Journal; June 10, 2014.HTTP://ONLINE.WSJ.COM/ARTICLES/TAXPAYERS-FACE-BIG-MEDICARE-TAB-FOR-UNUSUAL-DOCTOR-BILLINGS–1402364264

Soran O, Kennard ED, Kfoury AG, et al. Two-year clinical outcomes after enhanced external counterpulsation (EECP) therapy in patients with refractory angina pectoris and left ventricular dysfunction (report from The International EECP Patient Registry). Am J Cardiol 2006; 97:17.

Committee on the Management of Patients with Chronic Stable Angina. ACC/AHA 2002 Guidelines Update for the Management of Patients with Chronic Stable Angina - Summary Article. Circulation, 2003;107:149–158.