1. Case Study

2. Patient AH 51-year-old male patient family history of hyperlipidemia status post myocardial infarction x 2 (1995,1997) Coronary artery bypass grafting in 1995 x 4 consisting o f a saphenous graft to the posterolateral artery, a saphenous graft to OM1, a lemograph to the first diagfonal, and a renograph into the PDA. 9 bare metal stents placed during 4 separate catheterizations (1995) rotational atherectomy (Rotablator) procedure (1996). 51-year-old male patient family history of hyperlipidemia status post myocardial infarction x 2 (1995,1997) Coronary artery bypass grafting in 1995 x 4 consisting o f a saphenous graft to the posterolateral artery, a saphenous graft to OM1, a lemograph to the first diagfonal, and a renograph into the PDA. 9 bare metal stents placed during 4 separate catheterizations (1995) rotational atherectomy (Rotablator) procedure (1996).

3. Evaluation Severe four vessel coronary artery disease despite surgical interventions in 1994 and 1997. 4 trips to ER and admitted twice from 1996 to 2001 with complaint of chest pain. Patient considered not suitable for further interventional therapy. Severe four vessel coronary artery disease despite surgical interventions in 1994 and 1997. 4 trips to ER and admitted twice from 1996 to 2001 with complaint of chest pain. Patient considered not suitable for further interventional therapy.

4. Evaluation Presented with Class IV angina pectoris Patient cc of chest pain and shortness of breath even at rest. Patient severely limited daily activities to prevent symptoms. Patient scored a 2 on the Duke Activity Index and rated Quality of Life (QOL) of a 1 out of 10. Presented with Class IV angina pectoris Patient cc of chest pain and shortness of breath even at rest. Patient severely limited daily activities to prevent symptoms. Patient scored a 2 on the Duke Activity Index and rated Quality of Life (QOL) of a 1 out of 10.

5. Outcome Following 35 1-hour sessions EECP® (July 2002) -Functional status markedly improved -Patient reported no nitroglycerin use or angina post treatment. (angina =0 and ntg. use =0 after 17 th treatment) -Patient showed increased exercise ability -Duke Activity Index score of 30 -QOL self rated at 8.5 Following 35 1-hour sessions EECP® (July 2002) -Functional status markedly improved -Patient reported no nitroglycerin use or angina post treatment. (angina =0 and ntg. use =0 after 17 th treatment) -Patient showed increased exercise ability -Duke Activity Index score of 30 -QOL self rated at 8.5

6. Positron Emission Tomography -1 month Post-treatment Positron Emission Tomography (PET) revealed marked interval improvement in stress-induced inferolateral basal perfusion defect suggesting REVERSAL of anatomic stenosis of this segment. -Interval development of significant longitudinal base to apex gradient of flow. -Suggests that EECP does, in fact, improve myocardial perfusion. -1 month Post-treatment Positron Emission Tomography (PET) revealed marked interval improvement in stress-induced inferolateral basal perfusion defect suggesting REVERSAL of anatomic stenosis of this segment. -Interval development of significant longitudinal base to apex gradient of flow. -Suggests that EECP does, in fact, improve myocardial perfusion.

8. Conclusion Objective and Subjective markers demonstrate efficacy of External Counterpulsation for CAD patients with refractory angina Nuclear studies offer evidence based explanations for significant subjective improvements. Objective and Subjective markers demonstrate efficacy of External Counterpulsation for CAD patients with refractory angina Nuclear studies offer evidence based explanations for significant subjective improvements.

9. Questions