Fascination with myocardial infarction and normal coronary arteries.

and brain natriuretic peptide levels. Unlike the Masuda et al. study, atrial natriuretic peptide levels were unchanged, but brain natriuretic peptide levels decreased after enhanced external counterpulsation treatment as they did in the study of Masuda et al. The authors concluded that enhanced external counterpulsation improves myocardial perfusion, exercise performance and left ventricular diastolic filling and decreases cardiac workload, providing yet more data to explain the mechanisms by which enhanced external counterpulsation achieves its antiischaemic benefits. In summary, results from the Stony Book experience and the MUST-EECP trial clearly demonstrate the beneficial haemodynamic myocardial effects of external counterpulsation in patients with chronic refractory angina. Masuda et al. shed light on possible mechanisms responsible for these effects. In my opinion, this procedure should be considered as part of the contemporary clinician’s therapeutic armamentarium in selected patients, as recommended by Conti in his editorial accompanying the initial MUST-EECP report and by Lange and Hillis in their editorial questioning the role of transmyocardial laser revascularization. Lange and Hillis recommend that safer and less invasive therapies (such as enhanced external counterpulsation and neurostimulation) be the procedures of first choice in refractory chronic angina patients, rather than transmyocardial laser revascularization, and this seems an eminently sensible approach, especially in light of the new data provided by Masuda et al.. P. F. COHN SUNY Health Sciences Center, Stony Brook, NY, U.S.A.