Michael Gratch

Founder & CEO, Flow Therapy. Building the national platform for Counterpulsation Therapy. The physiological category alongside meds and procedures.

[Michael Gratch @mbgratch]

There’s a gap in cardiology that deserves a brighter light.

Millions of symptomatic patients are waiting for a therapy that works alongside their meds and procedures, not after. A real next step, way before the thought of “nothing else.”

This is who we built Flow Therapy for.

[Dr. Filippo Cademartiri @FCademartiri]

🫀⚠️ We fix the arteries.
 But what if the problem isn’t just in the lumen of the main coronary arteries?

This Lancet study goes straight at a blind spot we all know exists—but rarely quantify.

🧠 The setup
1003 real-world patients
undergoing invasive angiography + full physiology (FFR, CFR, IMR)
So not theory.
👉 actual coronary physiology in practice

🔍 The uncomfortable finding
👉 Coronary microvascular dysfunction (CMD) in ~16% of patients
And not just in “normal coronaries”:
- 21.5% WITH obstructive CAD
- 9.3% WITHOUT obstructive CAD

Translation
👉 Microvascular disease is NOT a niche problem
👉 It is embedded within “classic CAD”
📉 Outcomes (this is where it gets real)

At ~2 years:
👉 18.8% events with CMD
👉 10.5% without
👉 HR ~1.9

And here’s the kicker:
In patients WITHOUT obstructive CAD:
👉 HR ~3.45

🧠 Translation (again, because this matters)
You can have:
👉 “normal” coronaries (by FFR)
👉 no revascularization
And still:
👉 a 3x higher risk
⚠️ The paradigm problem
Our entire workflow is built around:
👉 stenosis
👉 FFR
👉 revascularization

But this paper shows:
👉 fixing epicardial disease does NOT normalize risk

🧬 Why?
Because CMD reflects:
- microvascular dysfunction
- endothelial dysfunction
- inflammation
- diffuse myocardial injury
Not a plumbing problem
👉 a biological one

🧠 My take
This paper doesn’t just add information.
It exposes a structural limitation:
👉 we are solving the visible part of the disease
And missing:
👉 the microcirculation
👉 the diffuse component
👉 the residual risk
That is the underlying atherosclerotic/metabolic/inflammatory milieu.

⚡ The real implication
If you only measure:
👉 stenosis
👉 FFR
You are ignoring:
👉 a major determinant of outcomes
🚨 Bottom line
CAD ≠ epicardial stenosis
Ischemia ≠ FFR alone
👉 Coronary disease is multi-level
👉 And the microcirculation is not optional
Final uncomfortable thought
We’ve optimized PCI.
We’ve optimized stents.
We’ve optimized FFR.
But:
👉 we still don’t systematically measure what happens beyond them

#Cardiology #CMD #Microcirculation #FFR #CardiacRisk #PrecisionMedicine

[Michael Gratch @mbgratch]

We say Counterpulsation Therapy now.

Modern delivery. Built to bring it back into the conversation, and within reach of the patients who benefit.

The therapy hasn’t changed. The difference is how well we understand it, and how access is changing.

[Michael Gratch @mbgratch]

A note on language.

For decades, cardiology has known this therapy as EECP. The evidence base was built under that name, and the clinicians who championed it deserve real credit.

But the name carried the confines of an earlier era: limited access, uneven awareness.

[Michael Gratch @mbgratch]

@MTomaniak @PCRonline I wish I could have been in Paris this year! What were the latest thoughts on physiological therapies for this population?

[Michael Gratch @mbgratch]

@CMichaelGibson Enjoyed the part on the evolution of EECP, from the historical confines to how a modern delivery model brings it back in the conversation. Grateful for your perspective on where the field is going.

[Michael Gratch @mbgratch]

Last week, some of the leading voices in cardiology discussed #Counterpulsation Therapy and the patients with persistent symptoms who benefit from a real next step.

Grateful for the conversation w @CMichaelGibson, @potluri70, @TonyDasMD, @ThuyPhamDO, Dr. Mo. More to come. #EECP

[Michael Gratch @mbgratch]

Walking the Gainesville site today. The next clinic is taking shape.

Partnership with Northeast Georgia Health System. Opening this summer.

More patients with a real next step. The build continues.

[Michael Gratch @mbgratch]

If you’re a clinician with patients living in that gap, this account will be a place to follow the work.

If you’re a patient or family member still searching for a real next step, there is one.

And there’s more to come.

[Michael Gratch @mbgratch]

There’s a gap in cardiology that deserves a brighter light.

Millions of symptomatic patients are waiting for a therapy that works alongside their meds and procedures, not after. A real next step, way before the thought of “nothing else.”

This is who we built Flow Therapy for.

[Michael Gratch @mbgratch]

At Flow Therapy, we’re building the national platform to advance that work.

Clinics expanding across Texas, North Carolina, and Georgia. 1,000+ referring cardiologists. A clinical pathway used by service line leaders at major health systems. A patient population being seen.

[Monica Verduzco-Gutierrez, MD @MVGutierrezMD]

Which is why #EECP has been game changing for people with #LongCovid who can access it. (Thankfully me)

[Flow Therapy @FlowTherapyEECP]

Proud to highlight the positive outcomes on patients with microvascular dysfunction at the recent AHA Scientific Session. We appreciate @TCHheart for the great partnership on this project. https://t.co/54OvY0jCLz

[Michael Gratch @mbgratch]

@jbspadoni @AdhirShroff @Babar_Basir @evandrofilhobr @UICcardfellows @spiritus_bah @KhalilIbrahimMD @mividovich @SarojNeupaneMD I am curious about group’s thoughts on EECP in this circumstance.

[Michael Gratch @mbgratch]

@DrRajeshG1 @sobermedico @DavidLBrownMD @AHajduczok @matthew_nudy They do very well. We have some nice data on this cohort.

[Michael Gratch @mbgratch]

@loscharlos @calirunnerdoc Very different