External counterpulsation therapy was first developed over half a century ago as a resuscitative tool to support the failing heart and was based on hemodynamic principles of the intraaortic balloon pump. Over the course of last few decades, it has evolved into the modern enhanced external counterpulsation (EECP) therapy, which has proven to be a safe, effective, and low-cost noninvasive treatment for patients with debilitating angina and chronic heart failure who are poor candidates for revascularization procedures and have suboptimal results from other therapies. Numerous studies have shown EECP to be efficacious in patients with chronic angina, with its effects lasting for several years after completion of therapy. Besides being safe in patients with coexisting left ventricular dysfunction, there is emerging evidence that EECP therapy may result in improvement in exercise capacity and oxygen consumption in heart failure patients. Several mechanisms have been postulated to explain the therapeutic effects of EECP, including improvement in endothelial function, promotion of angiogenesis and new collaterals, reduction in atherosclerotic burden, improvement in ventricular function, and peripheral training effects analogous to that of exercise. With greater understanding of these complex mechanisms, possible applications of EECP have broadened in recent years, with its use being studied in conditions like hepatorenal syndrome, erectile dysfunction, and restless leg syndrome. This review article offers a historical perspective on the origins of EECP, an overview of our current understanding of its physiological effects, and a glimpse at its future utilization in clinical practice.