The treatment of refractory chronic angina pectoris presents an increasing problem for all physicians caring for patients with coronary artery disease because of the large number of individuals who have either failed multiple revascularization procedures or are not appropriate candidates for such procedures. The aim of this study was to review the safety, efficacy, and clinical applicability of a noninvasive technique (external counterpulsation) for the treatment of angina pectoris. A MEDLINE search for all English language abstracts, meeting presentations, journal articles, and reviews from 1960 through December 2005 was conducted. Of the 194 citations in the literature, 60 appeared before 1983 when the enhanced version of the technique (the one that is presently used) was first reported. Criteria for further evaluation of the 134 post-1983 citations were either (1) randomized trial, (2) observational study of at least 10 patients, or (3) investigations into possible mechanisms. Of the 134 citations, 45 were used for data extraction. Observational studies from the United States, Asia, and Europe have demonstrated improvement in symptoms, reduction in anginal episodes, better quality of life, and improved exercise performance in over 5000 patients. The only randomized study (Multicenter Study of Enhanced External Counterpulsation) confirmed these findings as well as the continuation of clinical benefits at least 1 year posttreatment. Although the mechanisms by which diastolic augmentation achieves these beneficial results are still under investigation, this is a promising noninvasive therapy in a group of patients with limited treatment options.