In January 2021, Jack Clifford left a hospital in Florida against medical advice. He was forty-seven years old. His left anterior descending artery — the one cardiologists call the widow maker — was one hundred percent blocked. His left circumflex was ninety-five percent blocked. His right coronary artery was eighty percent blocked. His doctors told him they were all unstentable. After being presented with his surgical options, he went a different direction.
His cardiologist’s parting words: “If you live that long.”
He had refused triple bypass surgery. Not out of recklessness, but out of a conviction that one more option existed — one that almost no one had told him about. He went looking for it, bought a machine, and over the next five years accumulated more hours on an EECP device than perhaps anyone in the United States.
He is still here. And he is running faster now than he did at forty.
About the Book
EECP — Enhanced External Counterpulsation — is FDA-cleared, Medicare-covered, and guideline-acknowledged by both the American College of Cardiology and the American Heart Association. It has been studied in peer-reviewed trials. Major academic medical centers have offered it. The evidence for its effectiveness in reducing angina, improving heart failure symptoms, and conditioning the vascular system is substantial.
And yet most Americans with coronary artery disease have never heard of it. In the entire state of Florida — home to 22 million people — Clifford could find roughly fifteen providers when he needed the therapy most. He had to buy the machine himself.
EECP: The Most Underutilized Therapy in Medicine is the story of one man’s survival — and a rigorously sourced investigation into why a therapy that demonstrably helps people remains so hard to find.
What EECP Does
EECP works by inflating compression cuffs around the lower body in precise synchrony with the heartbeat — augmenting blood flow to the heart during diastole (the phase when the heart muscle receives its own blood supply) and reducing the heart’s workload at systole. Across dozens of sessions, this mechanical stimulus does something that no drug and no surgical procedure can replicate: it trains the vascular system to build new circulation.
The mechanism is shear stress — the physical force of blood moving across the endothelium (the cellular lining of every blood vessel). Shear stress triggers nitric oxide production, reduces arterial stiffness, suppresses vascular inflammation, and stimulates arteriogenesis: the growth of collateral vessels that route blood around obstructions.
In a randomized controlled study, thirty-six hours of EECP raised nitric oxide levels by sixty-two percent and reduced endothelin-1 — a vasoconstrictor elevated in heart disease — by thirty-six percent. Both remained improved three months after treatment ended.
The endothelium is not a cardiac structure. It lines every blood vessel in the body — coronary, cerebral, renal, peripheral, pelvic. Condition it in one place and you influence it everywhere.
Which is why EECP’s benefits, as Clifford discovered over six hundred hours of treatment, extend well beyond the heart — touching cognitive clarity, sleep architecture, sensory acuity, and physical capacity in ways documented with the precision of someone who treated himself as both patient and observer.
The Scope of the Book
The book is organized in six parts. Click each to expand.
Part I follows Clifford’s personal journey — from the hospital bed to the machine in his office to more than six hundred hours of treatment that transformed his cardiac function, cognitive clarity, sleep, sensory experience, and physical capacity. The Christmas hospitalization. The consent forms that bundled the diagnostic cath and bypass surgery into a single authorization. The decision to decline and leave against medical advice. The desperate weekend of research on a hospital phone during COVID. The drive to find a physician willing to use EECP first-line. The $22,000 machine financed on credit.
It also tells the story of his wife Jennifer — who navigated traumatic brain injury, scleroderma, and lymphoma across two decades — and whose own quiet, measurable improvements on the same machine transformed a personal discovery into something he felt obligated to share.
The history of counterpulsation from Harvard in the 1950s to Sun Yat-sen University in the 1970s; the physiology of shear stress, nitric oxide, and arteriogenesis; an honest accounting of what EECP can and cannot do; and the evidence base for applications ranging from refractory angina and heart failure to long COVID, vascular cognitive impairment, and erectile dysfunction. The clinical trials are examined directly: the MUST-EECP trial, the PEECH trial, the International EECP Patient Registry, and the 2024 long COVID controlled study. The section includes a frank discussion of genuine contraindications and the limits of the current literature.
Why a therapy invented in American research institutions and refined in China is used broadly in Beijing and Mumbai but has fewer than 500 providers in the entire United States. The answer is structural — a function of reimbursement economics, procedural identity, and a coverage framework that positioned EECP as a last resort rather than a first consideration. China’s system rewards functional outcomes. India’s cost constraints make a non-invasive, reusable device economically attractive. America’s system rewards procedures. Three countries, three incentive structures, three completely different levels of patient access to the same evidence.
A practical guide to finding and completing EECP treatment: how to identify a serious provider, what questions to ask, how to raise the conversation with a cardiologist who may never have offered it, how Medicare coverage actually works, what a standard 35-session course looks like, and what responsible self-administration looks like for the growing number of patients who pursue the therapy independently. The central argument: patients will not be handed EECP by the system. Patient activation — arriving with specific questions, genuine preparation, and the willingness to advocate clearly — is the mechanism by which this therapy reaches the people who need it.
EECP’s emerging role in long COVID treatment, vascular dementia research, and the broader shift toward understanding aging as primarily a vascular phenomenon. The economics of neglect: why a cost-effective therapy with a strong evidence base stays starved of research funding and clinical infrastructure in a system that rewards procedures over outcomes. And the case for what it would take for this therapy to finally find the place in American medicine that the evidence has long supported.
What patients, physicians, researchers, and advocates each need to do to move this forward. The book closes on the idea that lies at its heart: circulation is not static. It is trainable. That idea, taken seriously, changes how we think about heart disease, cognitive decline, long COVID, and healthy aging.
Who This Book Is For
EECP: The Most Underutilized Therapy in Medicine is written for the patient who has been told their options are medication, stents, or bypass — and who suspects that isn’t the complete picture. For the caregiver reading at midnight. For the physician curious about a therapy they were rarely taught. For the researcher studying endothelial function, vascular aging, or long COVID. And for the person who is not yet a cardiac patient but who understands that vascular aging begins decades before the diagnosis arrives.
It is not an anti-medicine book. It is a pro-information book. The cardiologists who practice within the current framework are not the villains of this story. The system that created the framework is — and systems can be changed when patients are educated and partnered with providers who are ready to make a difference.
All clinical and scientific claims are sourced in endnotes drawn from peer-reviewed literature, including the MUST-EECP trial (JACC, 1999), the PEECH heart failure trial (JACC, 2006), the 2024 long COVID controlled study (COVID, MDPI), and decades of cardiovascular physiology research.