Counter pulsation is a therapy developed from sound physiological principles, widely used in cardiothoracic and interventional centres in the form of intra-aortic balloon pumping (IABP). It has now been developed externally as enhanced external counter pulsation (EECP). EECP is a non-invasive, safe and well tolerated therapy, with very few contraindications.  Currently, EECP is used predominantly in patients with severe angina, who are at high risk and are not suitable for revascularisation. It provides a therapeutic and supportive approach to managing such patients regardless of age and co-morbidity including those with stable heart failure.