There is a particular kind of frustration that comes from watching something work — watching it clearly, measurably, repeatedly work — and then trying to explain why the system built around it treats it as a footnote.
I have lived with that frustration for five years. The research for this book has not reduced it.
EECP should be more developed in the United States than anywhere else. It was refined here. The contemporary pneumatic, EKG-synchronized form of the therapy was developed in American research institutions. American clinical trials established its evidence base. The FDA cleared it. Medicare covered it. The ACC and AHA put it in their guidelines.
And then, slowly, it contracted.
Not because it failed. Not because the evidence weakened. But because it could not find a durable home in the economic architecture of American medicine.
The Reimbursement Funnel and the Interventional Boom
To understand EECP’s current position in American cardiology, you have to understand what happened to American cardiology in the 1990s and early 2000s. Drug-eluting stents, approved by the FDA in 2003, transformed the cath lab. Stent placement became faster, safer, and more reliably durable. Cardiology’s identity reorganized itself around procedures — fast, visible, reimbursable. A blocked artery opened in an afternoon has a clarity that a seven-week course of external compression does not.
The economic logic followed. A single coronary angioplasty generates revenue in a matter of hours. A full course of EECP occupies a room, a machine, and staff time for thirty-five hours spread across seven weeks. The reimbursement for a full EECP course — roughly $7,000 when Medicare coverage was established — was a fraction of what a stent procedure generated. In a specialty organized around throughput, anything that required that much time per patient struggled for institutional space.
EECP also suffered from how Medicare defined its coverage. The national coverage decision restricted reimbursement to patients with disabling angina who were not suitable for further revascularization — patients who had already exhausted the interventional options. This produced a cultural effect that proved nearly impossible to reverse: EECP became, institutionally, the last resort. The consolation prize for patients the system could no longer help.
Once that positioning was established, it was self-reinforcing across generations of training. Cardiologists learned to think of EECP as a niche therapy for a narrow population. Residents were rarely taught to consider it earlier. Patients who might have benefited never heard the word.
The Where’s Waldo Problem
There are currently fewer than five hundred providers offering EECP treatment anywhere in the United States. In a country of 335 million people, that is approximately one provider per 670,000 people. To put that in context: there are more Michelin-starred restaurants in the United States than there are EECP providers.
When I searched for EECP in Florida — the third most populous state in the country, with a disproportionately elderly and cardiovascular population — I found roughly fifteen providers. Of those, only one was willing to offer it as a primary treatment strategy rather than a last resort following failed revascularization.
A standard course of EECP is thirty-five sessions, typically five days per week over seven consecutive weeks. That is thirty-five round trips to the provider. For someone who lives two hours away, it is one hundred and forty hours of travel — nearly four full work weeks — just to complete a single standard course.
Access to EECP in the United States is not theoretical. It is a logistical ordeal, and for many patients with the most to gain, it is an ordeal that defeats them before they begin.
The Patients Being Turned Away
Even patients who can solve the geographic problem frequently encounter a second one: most providers who have an EECP machine are willing to use it for almost nothing beyond refractory angina. And yet the range of conditions for which EECP is physiologically relevant is far broader.
The person with vascular cognitive impairment — early memory decline with a documented vascular component — who understands that the brain is a high-flow organ and that every month of better perfusion is a month of better function.
The long COVID patient who never got their vascular system back. Persistent fatigue. Brain fog that has not lifted in two years. Exercise intolerance so severe that a flight of stairs represents an exertion event. We know COVID injures the endothelium. We know EECP conditions the endothelium. The mechanistic bridge between those two facts is not a stretch. It is a straight line.
The diabetic patient with peripheral neuropathy, burning feet, and the slow creep of numbness. Nerves do not heal well in low-perfusion environments. Improve microvascular circulation and sometimes the progression slows. Not universally. But often enough that a patient facing irreversible neurological decline deserves to know the option exists.
For a patient arriving at a U.S. EECP center with any of these conditions — or simply arriving as someone who wants proactive vascular conditioning before they become a cardiac patient — the answer is almost universally the same: we don’t treat that here.
What It Would Take
The path forward is not mysterious. It requires coverage expansion — broader indications that reflect what the evidence actually supports. It requires training — residency programs that teach EECP as a first-line consideration rather than a last resort. It requires patient awareness at a scale that creates demand the system can no longer ignore.
That last point is the one most immediately actionable. Physicians respond to patients who ask about specific therapies. Coverage decisions respond to utilization data. Utilization data responds to patients who show up and request treatment. The cycle begins with information — with patients who have read the evidence and arrived at their physician’s office prepared to have a different conversation.
This book is intended to produce exactly those patients.