External Counterpulsation For Acute Ischaemic Stroke: A Systematic Review

Background Based mainly on experimental data which indicatesimprovement to the hemodynamics, hemorrheology, and endothelial function,external counterpulsation (ECP), a form of noninvasive circulatory assist, iswidely used in the treatment of acute ischaemic stroke in China. However,the effectiveness and safety of this therapy are not definite. We aimed toassess the evidences from randomized and quasi-randomized controlled trialson the use of ECP in acute ischaemic stroke.Objective Primary objective: to assess the effectiveness and adverse effectsof ECP and its ability to increase disability free survival in patients with acuteischaemic stroke; Secondary objectives: to assess the effects of ECP onneurological impairment and quality of life.Methods We searched the Cochrane Central Register of Controlled Trials(Issue 4, 2006), MEDLINE (Ovid)( 1950 to Dec. 2006),EMBASE (1984 toDec. 2006), the China Biological Medicine Database (1979-2006.12), theCNKI Database (1979-2005.12), the Chinese Stroke Clinical Trials Database(2003-2006.12), the PapersFirst (OCLC) Database (1993-2006.12), theChina Doctor & Master Dissertation Full-text Database (1999-2006.12) andthe reference lists of related articles, and selected randomized controlled trialsor quasi-randomized controlled clinical trials comparing ECP plus routinetreatment with the same routine treatment in patients with acute ischaemic stroke. Two reviewers independently selected studies, assessed quality ofstudies and extracted data. The RevMan 4.2 software was used for statisticalanalysis.Results We included 5 randomized or quasi-randomized controlled trialsinvolving 414 patients. The methodology quality of all the trials was poor.None of these trials reported the numbers of deaths and dependent patients atthe end of follow-up of at least 3 months and adverse events. All these trailsused the improvement of neurological function and/or disability degree asthe outcome measurements at the end of treatment or observing period(13～66 days). One trial performed t test on the neurological functionimprovement (NFI) as continuous data, which showed a better effectivenessof ECP therapy than control with statistical significance (t=9.81, P＜0.01).Meta-analysis of the other four trials showed that the improvement ofneurological deficit between the two groups was significantly increased withECP [OR=5.83, 95%CI (3.84, 10.17)]. No death was reported within thetreatment or observing period and none of these trails conducted long termfollow-up (at least 3 months). The trials did not include any assessment ofquality of life.Conclusions With relatively poor quality of most included trials,insufficient evidence is obtained to support the conclusion that the ECPtherapy is safe or effective in the treatment of acute ischaemic stroke. Furtherhigh quality randomized controlled trials should be carried out.