Microvascular Angina Intervention With Compound Danshen Dripping Pill (MAIDS)
Phase: PHASE4
Conditions: Microvascular Angina
Sponsor: Qilu Hospital of Shandong University

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Microvascular Angina Intervention with Compound
Danshen Dripping Pill (MAIDS)
Pre-experimental research
plan
Project holder : Qilu Hospital of Shandong University
February 18 , 2022

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1.
Research Background
Coronary microvascular disease (MVD)
is a clinical syndrome
refers to laboratory evidence of exertional angina or myocardial ischemia
caused by structural and/or functional abnormalities of precoronary
arterioles and arterioles under the influence of multiple pathogenic
factors.. The main symptoms of patients with coronary microvascular
disease are exertion-related chest pain attacks. It is difficult to distinguish
patients with coronary microvascular disease from patients with severe
coronary stenosis based on symptoms alone. However, the following
clinical characteristics suggest that patients have coronary microvascular
disease. It is more likely. First of all, it is more common in women,
accounting for about 56%-79% of patients with coronary microvascular
disease. However, most female patients with coronary microvascular
disease have their first symptoms after menopause, which is no different
from traditional female coronary heart disease patients. Secondly, most of
the symptoms are induced by exertion, but it is not uncommon to have
patients with silent chest pain. There are fewer patients with coronary
microvascular disease who simply present with silent chest pain.
Impaired coronary dilatation, increased sympathetic stimulation and
sensitivity, and exercise-mediated coronary constriction can lead to the
development of coronary microvascular dysfunction and reduced
coronary flow reserve. Long-term recurrent angina pectoris attacks affect

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the patient's quality of life. Patients with significantly reduced coronary
blood flow reserve or myocardial perfusion reserve, especially female
patients, may have a higher incidence of adverse cardiovascular events.
Regarding drug treatment, traditional anti-ischemic treatment
methods are currently recommended, including β- blockers, calcium ion
antagonists and nitrates. If symptoms persist, other drugs include
angiotensin-converting enzyme inhibitors, statins, ivabradine , ranolazine ,
and estrogen drugs. However, there is no specific clinical drug treatment.
Basic and clinical studies of the traditional Chinese medicine Compound
Danshen Dripping Pill have found that it can improve vascular
endothelial function and relieve angina pectoris, and is widely used in
clinical practice. However, its effect on coronary reserve function and
angina pectoris in coronary microvascular disease needs further clinical
research to confirm.
2.
Study drug
The main drug studied in this study is Compound Danshen Dripping
Pill. Compound Danshen Dripping Pills (Compound Danshen Dripping
Pills, produced by Tasly Holding Group Co., Ltd.) is a compound
traditional Chinese medicine preparation composed of Salvia miltiorrhiza,
Panax notoginseng, and Borneol. In 1994, it was approved as a drug for
the treatment of coronary heart disease and angina pectoris. It has good

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clinical efficacy and has It has the characteristics of fast onset, low
toxicity, small adverse reactions and high safety.
The active ingredients of compound Danshen dripping pills are
water-soluble phenolic acids such as salvia miltiorrhiza and Panax
notoginseng saponins. During the preparation process, borneol and
auxiliary materials are added, and a highly dispersed solid dispersion is
made through a specific process. The active ingredients of the drug have
high purity, are evenly dispersed, and can be quickly absorbed through
the mucous membrane. The dripping pills have good solid dispersion
effect. The principle is to melt the drug ingredients and matrix into a solid
solution, and the active ingredients of the drug are in the molecular state
or in extremely fine form. The crystalline state is highly uniformly
dispersed in the matrix, with fast drug dissolution and higher
bioavailability. It can be taken sublingually and can quickly relieve
angina pectoris and chest tightness.
Compound Danshen Dripping Pill has achieved a full-process
quality control method from medicinal materials, intermediates to
preparations (GAP-GEP-GMP) through the multi-factor fingerprint
quality control system of compound oral Chinese medicine preparations,
further improving the full-process quality control system of Compound
Danshen Dripping Pill , after testing and analyzing nearly 200 batches of
Compound Salvia Miltiorrhizae Dropping Pills Extract and Compound

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Salvia Miltiorrhizae Dropping Pills, the similarity is over 90%, and the
quality of the products is stable between batches. It has been confirmed
through the toxicology study of Compound Danshen Dripping Pill and
the clinical use of hundreds of millions of people: it has no toxicity, few
adverse reactions, and is safe and reliable for long-term use.
As a Chinese patent medicine for the treatment of stable angina
pectoris, Compound Danshen Dripping Pill are included in Category A of
the 2018 National Essential Drugs Catalog and the 2019 National Basic
Medical Insurance, Work Injury Insurance and Maternity Insurance Drug
Catalogue. Under the name of "Compound Danshen Dripping Pill", it has
been written into more than 20 national medical guidelines or consensus,
15 of which involve the cardiovascular field, including "Guidelines for
Rational Medication in Coronary Heart Disease (2nd Edition)", "Acute
Myocardial Medication "Guidelines for the Diagnosis and Treatment of
Infarction by Integrated Traditional Chinese and Western Medicine",
"Chinese Expert Recommendations on the Clinical Application of
Compound Danshen Dripping Pill", "Expert Consensus on the Diagnosis
and Treatment of Atherosclerosis by Integrated Traditional Chinese and
Western Medicine", etc.
In terms of international evidence-based research, large-sample,
randomized, double-blind, placebo-controlled RCT studies were used,
and 1,004 patients were included in phase III clinical studies at 127

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centers in 9 countries/regions around the world, indicating that the US
FDA-Phase III The main clinical efficacy indicators: significantly
increase the patient's exercise flat time and improve exercise tolerance.
Compared with the increase time of exercise oxygen tolerance of similar
drugs, Compound Danshen Dripping Pill has obvious advantages .
Secondary efficacy indicators: effectively reduce the number of angina
attacks per week and significantly reduce the weekly nitroglycerin
dosage.
In terms of domestic evidence-based research: 1011 studies on
Compound Danshen Dripping Pill for the treatment of stable angina, 16
Meta-analyses, with a total enrollment of more than 100,000 people; 137
studies on the treatment of peri-PCI/ thrombolysis period , the total
number of participants exceeds 10000 ; there are 36 studies on
Compound Danshen Dripping Pill improving coronary microcirculation
disorders, filling the gap in Western medicine treatment.
Systematic study of Compound Danshen Dripping Pill combined
with Western medicine in the treatment of coronary heart disease angina
pectoris: 21 articles were included, with a total number of cases of 2229.
Compound Danshen Dripping Pill combined with Western medicine can
benefit patients with coronary heart disease angina pectoris, especially in
improving clinical symptoms and electrocardiogram . It has outstanding
effects on ischemic state and regulating cholesterol levels.

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A meta-analysis based on PubMed, EMBASE, CNKI, and Wanfang
databases studied the efficacy of aspirin combined with Compound
Danshen Dripping Pill in the treatment of coronary heart disease. The
analysis included 14 randomized controlled trials with a total of 1,367
patients. The results showed that the combination Compared with aspirin
alone, the drug can achieve more significant therapeutic effects in
relieving angina pectoris symptoms and lowering blood lipids. Lu
Yuhong et al. randomly divided 128 patients with coronary heart disease
into groups. The control group took oral aspirin on the basis of
conventional treatment, and the observation group took Danshen
Dropping Pills on the basis of conventional treatment. After 2 months, the
total clinical effective rate of the patients in the observation group was
significantly higher than Control group. Compared with before treatment,
the maximum platelet aggregation rate and thromboxane B2) levels of the
two groups of patients were significantly reduced, and the decrease in the
observation group was more obvious than that in the control group . The
"Guidelines for the Diagnosis and Treatment of Integrated Traditional
Chinese and Western Medicine in Acute Myocardial Infarction", led by
Academicians Chen Keji, Academician Ge Junbo, and Professor Zhang
Minzhou, were formulated in conjunction with experts in the fields of
traditional Chinese medicine, Western medicine, integrated traditional
Chinese and Western medicine, and methodology across the country. The

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guideline clearly states that Compound Danshen Dripping Pill are
recommended for the treatment of acute myocardial infarction. The
recommendation level is the highest in the guideline. Compound Danshen
Dripping Pill can relieve chest pain, reduce the patient's risk of cardiac
death, and improve the patient's cardiac function. and the role of quality
of life.
3. Research purpose
A
randomized,
double-blind,
placebo-controlled,
multi-center
clinical study of Compound Danshen Dripping Pill and blank control was
conducted in patients with microvascular angina pectoris .
4. research design
4.1 Study title and registration
The Chinese name of this project is: Microvascular Angina Intervention
with Compound Danshen Dripping Pill. English name: Microvascular
Angina Intervention with Compound Danshen Dripping Pill. Referred to
as MAIDS Study.
4.2
Research
design
:
Randomized,
double-blind,
placebo
parallel-controlled, multi-center clinical study.
4. 3 dosing regimens (double-blind single simulation)
(1) Placebo group: Placebo (the appearance is the same as Compound
Danshen Dripping Pill , main ingredient: starch. Production unit: Tianjin
Tasly Co., Ltd.), taken orally after meals, 3 times a day, 20 pills each

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time .
(2) Treatment group: Compound Danshen Dripping Pill (Tianjin Tasly
Co., Ltd.), taken orally after meals, 3 times a day, 20 pills each time .
Note: The batch number on the drug packaging is unified as " 161299
".
5. Research objects
5.1 Source of patients:
patients with chest pain who had no obvious coronary artery stenosis
on coronary angiography or coronary CT examination were admitted to
the hospital outpatient clinics and wards .
5.2Selection criteria _
（1）With typical symptoms of exertional angina;
（2）Coronary CTA or angiography with normal coronary artery or
<50% stenosis, or <50% residual coronary stenosis after
revascularization;
（3）Ischemic downward shift of the ST segment is found in the
electrocardiogram at rest or during exercise stress (horizontal
or downsloping downward shift behind the J point >0.1mv,
lasting 0.08s );
（4）Transthoracic
ultrasound
before
and
after
intravenous
adenosine injection to check the anterior descending coronary
artery blood flow reserve test CFR <2.5;

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（5）The patient agreed to participate in this study.
5.3 Exclusion criteria
(1) Aged less than 30 years old or older than 75 years old;
(2) Have a history of carotid endarterectomy or stent implantation, and
have a history of stroke ;
(3)
Myocarditis,
pericardial
disease,
valvular
disease,
and
cardiomyopathy;
(4) Difficult-to-control diabetes (fasting blood glucose >7.0 mmol/L);
( 5 ) Uncontrollable hypertension (SBP>150 mmHg and/or DBP>90
mmHg);
( 6) Familial hypercholesterolemia;
( 7 ) Takayasu arteritis;
( 8 ) Those who are pregnant or lactating, or those who intend to have a
child within one year, or those who have not taken effective contraceptive
measures during the childbearing age;
( 9 ) Abnormal liver function (serum GPT level exceeds 3.0 times the
upper limit of normal value) or abnormal renal function (serum
creatinine level exceeds 2 mg/dl);
( 10 ) Other clinically significant respiratory, digestive, blood, infection,
immune, endocrine, neuropsychiatric, tumor diseases, etc., which
may cause serious danger to patients;
( 11 ) Take K channel openers and traditional Chinese medicine

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preparations that activate blood circulation and remove blood
stasis to improve microcirculation;
(12 ) Those allergic to intra-arterial injection of contrast media, blood,
and blood products;
(13) Patients who are participating in other clinical studies.
6. Research methods
6.1Sample size
The experimental drugs and control drugs in this clinical trial will be
selected according to the number of cases in a ratio of 1:1. 100 patients
were enrolled in the preliminary experiment .
6.2 Random grouping
The randomization method adopts the central randomization method.
The central randomization system uses DAS2.1.1 software to generate
random numbers (00 1 -100) and drug packaging numbers ( B
ZH001-100 ). The random numbers and drug packaging numbers are
separated in the system . The researcher passes the Apply to the system to
obtain the drug packaging number for the subject. The random number
and drug packaging number of the same subject are different, but their
corresponding treatment plans are consistent within the system.
6.3 Research process
After signing the informed consent form, the selected patients were

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divided into the Compound Danshen Dripping Pill treatment group and
the
placebo
group
according
to
a
random,
double-blind,
placebo-controlled method. Dosage of Compound Danshen Dripping Pill
or placebo: 3 times a day, 20 pills each time, for a total of 6 months .
Follow-up visits were conducted every 2 months, and the follow-up
period was 6 months in total .
6.4 Screening Phase
（1）CTA or CAG examination: Coronary artery CTA or angiography
examination shows that the coronary arteries are normal or stenotic
<50%, and coronary epicardial vasospasm is excluded;
（2）Electrocardiogram: Resting or exercise stress test shows ischemic
downward shift of ST segment, horizontal or downward shift
behind J point >0.1mv, lasting 0.08s.
（3）Laboratory tests: Fasting for more than 6 hours, blood routine,
urine routine, fasting blood glucose, alanine aminotransferase,
aspartate aminotransferase, troponin, serum creatine phosphokinase,
urea nitrogen, creatinine , plasma total cholesterol, triglycerides,
hypoglycemia The existing data on density lipoprotein cholesterol,
high-density lipoprotein cholesterol, high-sensitivity C-reactive
protein, and prothrombin time during the screening phase can no
longer be reviewed.
（4）Echocardiogram:

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After signing the informed consent form, the following inspections
will be performed: See Appendix 1 for inspection methods.
1)Routine ultrasound examination: two- dimensional dynamic images of
left ventricular parasternal long axis, apical four-chamber, apical
two-chamber, apical long axis and left ventricular apex level,
papillary muscle level, and mitral valve level short-axis sections. At
the same time, pulse wave Doppler was used to obtain the diastolic
mitral valve orifice blood flow spectrum, and tissue Doppler was used
to obtain the mitral valve annular motion spectrum. See Appendix 1
for details.
2)Acoustic contrast adenosine test: First, observe the distal left anterior
descending coronary artery under color Doppler guidance, measure
the blood flow velocity with pulsed Doppler ultrasound, and then
administer the contrast agent SonoVue (add 8.5ml sterile saline to one
bottle ) bolus injection, followed by slowly injecting 5 ml of normal
saline over 20 seconds, and measuring the blood flow velocity of the
distal left anterior descending coronary artery again . Finally,
adenosine 140 µg.kg -1 .min -1 was given for 6 minutes by continuous
intravenous micropump injection. During the injection process, the
coronary blood flow velocity was monitored. Pulse Doppler
ultrasound measured the maximum coronary blood flow velocity in
the distal left anterior descending artery. This could be repeated at the

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same time. Acoustic contrast enhances spectral signals.
3)The adenosine test simultaneously records a 12-lead electrocardiogram.
4)After recording the coronary blood flow in the contrast-enhanced
ultrasound examination, the two-dimensional short-axis sections of
the left ventricular parasternal long axis, apical four- chamber heart,
apical two-chamber heart, apical long axis and left ventricular apex
level, papillary muscle level, and mitral valve level were recorded.
dynamic images.
6.5 Enrollment and follow-up phase
（1）Case grouping
100 patients were selected and randomly divided into Compound
Danshen Dripping Pill group and control group, 50 cases each.
Compound Danshen Dripping Pill: 20 pills, three times a day;
Placebo: 20 pills, three times a day.
（2）Follow-up observation
Follow-up observations were conducted at 2 months, 4 months,
and 6 months after inclusion, including clinical conditions,
laboratory examinations, and ultrasound examinations. Safety
assessment.
7. Efficacy evaluation
7.1 Main observation indicators

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Difference in left anterior descending coronary flow reserve (CFR)
measured by ultrasound at 6 months compared with baseline.
7.2 Secondary observation indicators
1) Difference in left anterior descending coronary flow reserve (CFR)
measured by ultrasound at 2 months and 4 months compared with
baseline.
2) Number of angina attacks per week;
3) The time when angina pectoris occurs in exercise test;
4 ) The time when ischemic ST segment depression occurs during
exercise testing.
8.Safety assessment
Including clinical adverse reactions, laboratory indicators, etc.
9. Adverse event observation and reporting
9.1Definition of Adverse Events
Adverse events refer to any adverse medical event that occurs to a
patient in this clinical trial from the time the patient signs the informed
consent form and is selected to participate in the trial to the last follow-up
visit, regardless of whether this event is causally related to the
above-mentioned drugs. .
NOTE: An adverse reaction may be any discomfort and unconscious
signs (including abnormal laboratory test results), symptoms, or disease

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(new or worsening) related to the medication.
Events that meet the definition of adverse events include:
●Exacerbation of an existing chronic or intermittent disease,
including increased frequency and/or intensity.
●A disease that is newly detected or diagnosed after taking the
investigational drug, even though it may have been present before
the trial began.
●Signs, symptoms, or clinical sequelae suspected of being caused
by an interaction.
●Signs, symptoms or clinical sequelae caused by suspected
overdose of the investigational drug or concomitant medication
(overdose itself is not an adverse event / serious adverse event).
●" Lack of efficacy " or " failure to achieve the expected
pharmacological effect " itself is not reported as an adverse event
or serious adverse event. However, signs, symptoms, and/or
clinical sequelae due to lack of efficacy will also be reported as
adverse events or serious adverse events if they meet the
definition of an adverse event or serious adverse event.
Events that do not meet the definition of an adverse event include:
●Medical or surgical procedure (e.g., endoscopy, appendectomy);

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the event leading up to the procedure is an adverse event.
●Situations in which adverse medical events would not occur
(social security and / or admission facilitation).
●There was no worsening of pre-existing diseases or conditions
that were present or detected at the start of the trial, only expected
day-to-day fluctuations.
●/ disease being studied , or the expected progression, signs, or
symptoms of the disease being studied. Unless the situation is
more serious than expected.
Definition of serious adverse event
" serious adverse event " is an adverse event that can occur at any dose
and will:
●cause death;
●threatening life;
Note: " Life-threatening " means that the subject is in danger of
death when the event occurs, not that death could theoretically
result if the event were more serious.
●Requires hospitalization or prolonged hospitalization;
Note: Typically hospitalization refers to a subject staying in the
hospital or emergency room (usually at least overnight) to receive
observation and/or treatment that cannot be completed in the

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doctor's office or outpatient clinic. Complications that occur
during hospitalization are considered adverse events. An event is
classified as a serious adverse event if the complication prolongs
hospitalization or meets the criteria for any other serious adverse
event. When it cannot be determined whether " hospitalization "
occurred or was necessary, it will be treated as a serious adverse
event.
Elective hospitalization that does not worsen a pre-existing
condition compared with baseline is not an adverse event.
●Causes disability, or affects the ability to work and live;
Note: “ Disability ” refers to a substantial impairment of an
individual’s ability to carry out normal life. It does not include
discomforts of little clinical significance, such as common
headaches, nausea, vomiting, diarrhea, influenza, and accidental
trauma (such as sprained ankles), which may affect the quality of
daily life but will not constitute a substantial disruption.
●Cause congenital malformations;
In other cases, medical or scientific judgment should determine
whether adverse event reporting is appropriate. For example, some
important medical events may not be immediately life-threatening,
leading to death or hospitalization, but may harm subjects or require drug
or surgical intervention to avoid the serious adverse events listed above.

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These events should also be considered serious adverse events, such as
invasive or malignant cancer, allergic bronchospasm requiring close
monitoring in the emergency room or at home, hematologic cachexia, or
convulsions that do not result in hospitalization, drug dependence, or drug
abuse.
9.2 Adverse drug reactions
Definition: Refers to harmful reactions that occur under normal usage and
dosage of qualified drugs and have nothing to do with the purpose of
medication.
Causal judgment indicators for adverse reaction judgment:
Item 1 : Is there a reasonable sequence between the time of starting
medication and the time when the suspicion appears?
Item 2 : Whether the suspected adverse reaction conforms to the
known adverse reaction type of the drug;
Item 3: Whether the suspected adverse reaction can be explained by
the
patient's
pathological
condition,
concomitant
medications,
concomitant therapies, or previous therapies;
Item 4 : After stopping the drug or reducing the dose, whether the
suspected adverse reactions are reduced or disappeared;
Item 5 : Whether the same reaction reappears after using the
suspected drug again.
Causality judgment criteria: Judgment based on the order of the

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above five judgment indicators.
It is up to the investigator to evaluate possible associations between
adverse events, trial drugs, and concomitant medications according to the
table below.
Adverse reaction cause and effect judgment table
critical
result
Judgment index
Project 1
Project 2
Project 3
Item 4
Item 5
Definitely
related
+
+
-
+
+
probably
related
+
+
-
+
?
may be
relevant
+
+
±
±
?
suspicious
+
-
±
±
?
Impossibly
related
+
-
+
-
-

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Explanation: + Affirmation, - Negation, ± Difficult to affirm or deny,?
The situation is unknown.
1.
Based on the table above, determine the relationship between the
following grade 5 adverse events and the drug.
( 1 ) Definitely related, ( 2 ) Probably related, ( 3 ) Possibly related,
( 4 ) Suspicious, ( 5 ) Impossibly related.
2. The incidence rate of adverse reactions is calculated using the total
number of 1 + 2 + 3 + 4 cases as the numerator, and all selected cases that
can be evaluated for adverse reactions as the denominator.
9.3Recording of adverse events
on the basis of comprehensive consideration of comorbidities and
concomitant medications, their relevance to the experiment should be
evaluated. The relevance of the drug and documented in detail by the
physician.
If an adverse event is discovered, the observing physician can decide
whether to terminate the observation based on the condition. Cases of
drug discontinuation due to adverse events should be followed up and
investigated, and the results should be recorded in detail. If any
abnormality in safety test indicators ( blood, urine, stool routine,
electrocardiogram, liver function, kidney function ) occurs during or after
treatment , the adverse event form should be filled in in a timely manner,
reviewed at an appropriate time, and communicated with the subject A

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comprehensive analysis will be conducted on the onset, treatment, etc. to
determine whether it is related to the experimental drug.
9.4 Handling of serious adverse events
For any serious adverse events that occur during the trial ( including
events requiring hospitalization, prolonged hospitalization, disability,
affecting work ability, endangering life or death, causing congenital
malformations, etc.) during the clinical trial , the researcher shall
immediately respond to the patient's request. In addition to taking
emergency measures, the subject must also immediately report to the
ethics committee of the National Drug Clinical Trial Institution of
Shandong University Qilu Hospital and the main research unit Tianjin
Tasly Co., Ltd., the unit responsible for the research. The content of the
report of serious adverse events should include: patient's name, random
number, length of study participation, start date and stop date of serious
adverse events, maximum intensity of serious adverse events, possible
relationship between serious adverse events and study drugs, due to
serious Whether the adverse event required a change in the study drug,
the treatment given to the patient as a result of the serious adverse event,
concomitant medications if the serious adverse event occurred, and the
outcome of the serious adverse event.
10. Data management and statistical analysis
10.1Data management

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(1) Establish database: The data administrator establishes an EXCEL database
based on the research plan and CRF, and sets up logical verification according to the
data verification plan (DVP). Release for use after passing the test.
(2) Data entry: Data entry personnel conduct independent double entries and
double checks. Inconsistent results will be checked and corrected item by item against
the CRF until the results are completely consistent.
(3) Data questions and answers: After data entry is completed, the data
administrator conducts question screening according to DVP's manual verification
plan, opens database access to researchers, and answers questions remotely. The data
administrator responds to questions and can issue questions again if necessary until
the data is "clean".
(4) Database locking: After the main researcher, statistical analysts and data
managers jointly sign the "database lock record", the data administrator locks the
database.
(5) Database submission: The data administrator submits the database to the
statistician.
10.2 Statistical analysis data set
(1) Full analysis set (FAS): a set of all randomly enrolled cases that used the
study drug at least once.
(2) Per-protocol set (PPS): It is a data set generated by subjects who are fully
compliant with the trial protocol. Compliance includes the treatment received, the
availability of primary endpoint measurement, and no major impact on the trial
protocol. Violation etc. PPS analysis was used for the primary efficacy outcome
measure.
(3) Safety Data Set (SS): Actual data that received at least one treatment and had
post-treatment safety indicator records. The incidence of adverse reactions was based
on the number of SS cases as the denominator.
10.3Statistical methods
9.3.1 Subject distribution analysis

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(1) List the number of subjects selected and completed the trial, and determine
three analysis data sets (FAS, PPS, SS).
(2) Conduct a classification analysis on the reasons for not entering PPS and
calculate the number of subjects in different categories.
(3) Make a detailed list of group classifications, including the reasons for not
being included in PPS/FAS/SS.
(4) Draw a flow chart of subject distribution.
10.3.2 Demographic data and baseline analysis
Descriptive statistics Demographic information and other baseline characteristic
values:
(1) Calculate the number of cases, mean, standard deviation, 95%CI, minimum
and maximum values for continuous variables.
(2) Count and grade data calculation frequency and composition ratio.
(3) Inferential statistical results (P values) are listed as descriptive results.
10.3.3 Medication compliance and concomitant medication analysis
(1) Calculate the percentage of subjects with medication compliance in the range
of 80%-120%, and use the χ2 test or Fisher's exact probability method to compare
differences between groups.
(2) Medication exposure, use t test to compare differences between groups.
(3) Calculate the percentage of subjects with combined medications, and use the
χ2 test or Fisher's exact probability method to compare differences between groups.
10.3.4 Efficacy analysis
(1) Analysis of main efficacy indicators
FR measured by ultrasound at 6 months and the baseline between the two groups
was compared using t test.
(2) Analysis of secondary efficacy indicators
FR measured by ultrasound at 2 months and 4 months and the baseline was
compared between the two groups using t test;
②For the number of angina attacks per week, t test was used to compare the
differences between groups;

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③For the time of occurrence of angina pectoris in exercise test, t test was used to
compare the differences between groups;
④The time when ischemic ST segment downward shift occurs in exercise test,
and the t test is used to compare the differences between groups;
10.3.5 Security analysis
(1) Calculate the incidence of adverse events/reactions, serious adverse
events/reactions, and adverse events/reactions leading to dropout.
(2) List a detailed list of cases of various adverse events/reactions, serious
adverse events/reactions, and adverse events/reactions leading to dropout.
(3) List the crosstabs of laboratory tests and electrocardiograms before and after
medication.
(4) Descriptive statistics of changes from baseline in laboratory examinations,
electrocardiograms, and vital signs, and actual measured values.
(5) Make a detailed list of abnormal values in laboratory tests, electrocardiograms,
and physical examinations.
10.3.6Statistical software
(1) Analysis using S PSS software.
(2) All statistical tests adopt two-sided tests, and a P value less than or equal to
0.05 will be considered as statistically significant.
(3) Detailed statistical methods will be provided in the statistical analysis plan.
Standard operating procedures for echocardiography
1. Preparation before inspection
1. Rest for 5 minutes before examination.
2.
Connect
the
synchronized
ECG
monitoring
electrodes
to

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determine the phase of the cardiac cycle. The end of the T wave of the
electrocardiogram is used to define the end of ventricular systole, and the
peak of the R wave of the QRS wave is used to define the end of
ventricular diastole.
3. Position : The left lateral decubitus position is used as the position
for echocardiographic parasternal and apical views.
2.
Parameter
settings
of
echocardiography
equipment and technical requirements before image
acquisition
1. For two-dimensional echocardiography grayscale images, the
frame rate of observing and recording images should be greater than or
equal to 30 frames/second; for color tissue Doppler velocity images, the
frame rate of observing and saving images should be greater than or equal
to 80 frames. /second to facilitate subsequent functional parameter
analysis.
2. In order to avoid the artificial shortening effect of the long axis of
the left ventricle during apical observation, the left lateral decubitus
position should be used, avoid using too soft mattresses, avoid overly
trusting the apical pulse position palpable by palpation, adjust the probe
position and angle, and select Measurements were made on the section
with the largest inner diameter of the long axis of the left ventricle.
3. When the endocardium of two adjacent ventricular segments is

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unclearly displayed, appropriate ultrasound emission frequency, gain,
dynamic range, side sound shadow control, and grayscale color coding
can be selected to enhance the display and visualization of the
endocardial boundary. Identify.
4. In order to accurately determine the end-diastole and end-systole
of the ventricle, mitral valve motion and chamber diameter changes
should be referenced at the same time to avoid over-reliance on
electrocardiography to determine the phase.
The
sampling
line
for
inner
diameter
measurement
in
two-dimensional and M-mode echocardiography should be perpendicular
to the interface of bilateral anatomical structures. The distance parallel or
nearly parallel to the direction of the sound beam is measured from the
echo front edge to the leading edge (leading edge to leading edge). The
distance perpendicular or nearly perpendicular to the direction of the
sound beam is measured from the black and white interface. Method to
detect black-white interface to black-white interface. The area is
measured using the black and white interface depiction method.
6. The pulse wave Doppler sampling frame is set to 1mm. Adjust the
filter appropriately to avoid spectral distortion caused by too low or too
high filtering (too high filtering will cause low-speed frequency shift
signals to be filtered out, and too low filtering will cause excessive noise
signals).

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7. After using high MI ( 0.8 ) to destroy the microbubbles , use
ultra-low or low MI ( 0.1-0.3 ) mode for continuous real-time contrast
imaging to observe coronary blood flow .
8. When measuring coronary blood flow velocity, use pulse wave
Doppler technology to measure and pay attention to the sonic blood flow
angle to be as small as 40°.
3. Image acquisition and image saving
1. Save 5 consecutive cardiac cycle dynamic images of each cardiac
section in DICOM format.
2. Save one static image of each observation section parameter after
measurement in JPED format.
4. General echocardiographic examination
methods
1. Routinely collect two-dimensional dynamic images of patients'
left ventricular parasternal long axis, apical four-chamber heart, apical
two-chamber heart, apical long axis and left ventricular apex level,
papillary muscle level, and mitral valve level short-axis sections, and
adjust the depth, width, Gain and other parameters, adjust the frame rate
between 60 and 110 frames / s to obtain a clear and complete left
ventricular image.

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2. At the same time, pulse Doppler is used to obtain the diastolic
mitral valve orifice blood flow spectrum, and tissue Doppler is used to
obtain the mitral valve annular motion spectrum.
3. The images were analyzed offline using QLAB software. Enter a -
2DQ mode, select the patient's apical four-chamber and two-chamber
dynamic images respectively, the software automatically outlines the
endocardial border, and fine-tunes the tracing points to make the tracing
trajectory completely consistent with the endocardial border. After
calculation, the software automatically obtains EDV , ESV , LVEF . Then
enter the a - CMQ mode, select the apical four-chamber, three-chamber,
and two-chamber dynamic images respectively. The software
automatically traces the endocardium and epicardium and tracks the area
of interest. It can appropriately fine-tune the tracing points to make the
tracking more accurate. Determine the aortic valve closing time in the
cavocardiac view, and the software calculates the overall long-axis peak
strain ( GLS ) of the left ventricle during systole; use the same method to
track the left ventricular apex level, papillary muscle level, and mitral
valve level short-axis views, and the software Automatically obtain the
global peak circumferential strain ( GCS ) of the left ventricle during
systole and the rotation angle change curves of the apex and base during
systole. During systole, the apex rotates counterclockwise, which is a
positive curve; the base rotates clockwise, which is a negative curve.

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Read the peak apical rotation angle during systole ( Peak apical rotation ,
Prot - A ) and the peak basal rotation angle ( Peak basal rotation , Prot -
B ) on the curve. Calculate the peak systolic torsion angle ( PTW ) : PTW
= Prot - A - Prot - B.
2. measurement standard
of cardiac chambers by two-dimensional echocardiography of the
American Society of Echocardiography . The left ventricular
end-diastolic diameter (LVIDd), left ventricular end-systolic diameter
( LVIDs ), and ventricular end-diastolic diameter ( LVIDs ) are measured
at the level of the mitral valve chordae tendineae in the parasternal
long-axis view. Septal end-diastolic thickness ( SWTd ), left ventricular
posterior wall end-diastolic thickness ( PWTd )
( 2) Indicators of changes in left ventricular systolic function
1) Left ventricular ejection fraction ( LVEF , % );
2) Global long-axis peak strain of left ventricular systole ( GLS , % );
3) Global peak circumferential strain of left ventricular systole
( GCS , % );
4) Peak systolic torsion angle ( PTW , degrees).
( 3) Left ventricular diastolic function parameters
1) Ratio of peak velocity of early and late diastolic mitral valve orifice
blood flow ( E / A );

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2) The ratio of peak velocity of mitral valve orifice blood flow to peak
velocity of mitral valve annulus in early diastole ( E / e ' ).
5. Transthoracic coronary Doppler ultrasound
Transthoracic Doppler ultrasound (TTDE) can be used to measure
epicardial coronary blood flow velocity (CBFV), which is positively
correlated with coronary volume flow. The distal end of the left anterior
descending artery (LAD) was selected for CBFVR measurement because
the LAD is close to the chest wall and easier to observe than other
branches. At the same time, intravenous contrast agent is used, and its
reliability is close to 100%. Measurement of Coronary Blood Flow
Velocity Reserve (CBFVR):
1．
For routine echocardiography, select images with clear
coronary blood flow;
2．
Pulse wave Doppler is used to measure the coronary blood
flow velocity in the resting state. When the image is
complete and the maximum blood flow velocity can be
measured, a contrast -enhanced ultrasound examination is
performed and the coronary blood flow velocity is
recorded again.
3．
Then, adenosine 140 µg.kg
-1 .min
-1 was given for 6
minutes by continuous intravenous micropump injection .
At the end of the injection , a contrast-enhanced ultrasound

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examination was performed. Record coronary blood flow
velocity.
4．
CBFVR refers to the ratio of the average blood flow
velocity or peak blood flow velocity in the diastolic period
of the coronary arteries during hyperemia to the resting
blood flow velocity of the coronary arteries.
6. Myocardial Contrast Echocardiography (MCE)
1. Select a clear image of the coronary arteries and activate the low
mechanical index (MI<0.3) or ultra-low mechanical index (MI<0.2)
real-time
contrast-enhanced
ultrasound
examination
mode
of
the
ultrasound equipment. Place the focus point on the area of interest , adjust
the gain to make the image have a light noise background, adjust the
sector size and depth, and keep the image frame rate > 25Hz.
2. Bolus injection of the contrast agent SonoVue (add 8.5ml of sterile
physiological saline to one bottle ) or use a special micro-input pump to
inject the contrast agent SonoVue 0.8 – 0.9ml/min . The pump can be
manually oscillated to maintain uniform distribution of microbubbles ,
and then Slowly push 5ml of normal saline into the right brachial vein for
more than 20 seconds .
3. After the contrast agent is injected, it takes at least 30 seconds for
the left ventricle to start imaging , and the coronary blood flow signal is
dynamically recorded. Acquisition of dynamic images includes: 2 cardiac

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cycles, followed by triggered high mechanical index "flash" images
(usually 3-7 frames, MI 0.9) and 15 cardiac cycles of ultra-low or low
mechanical index reperfusion images. Continuous dynamic image
acquisition should at least include coronary blood flow signals.
4. After the angiography is completed, the venous access is
interrupted or retained according to the diagnosis and treatment
conditions of different patients.
5. The UCA intravenous injection speed should be slow, and vital
signs (blood pressure, heart rate, heart rhythm, respiration), ECG,
allergic reactions , etc. need to be monitored for about 30 minutes
after the angiography.
6. The laboratory needs to be equipped with corresponding first aid
drugs and equipment.
Use ultrasonic technology to observe the backscattered signal of
microbubbles. Since the diameter of microbubbles is smaller than that of
red blood cells, they can freely pass through the myocardial capillaries
together with red blood cells and can be regarded as tracers of red blood
cells.
Therefore,
MCE
can
evaluate
the
activity
of
coronary
microcirculation. After intravenous injection of this contrast agent
containing microbubbles similar in size and rheology to red blood cells,
the dynamic data of microbubble destruction and filling can repeatedly

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and quantitatively measure microvascular blood flow velocity and
capillary volume. With the trigger interval t as the abscissa and the visual
score of myocardial imaging as the ordinate, the imaging time-intensity
curve of the myocardium at this location is drawn. This curve conforms
to the exponential function: y = A(1 −e −β t ) . A is the maximum intensity
of myocardial imaging that rises to the plateau phase, and β is the average
slope of the curve rising to A (that is, the average microbubble velocity).
Myocardial blood volume fraction can be calculated based on the A value,
myocardial blood volume fraction × myocardial blood flow velocity =
myocardial blood flow (MBF). The decrease in MBF may reflect a
decrease in myocardial blood volume (seen after myocardial infarction,
when there is a clear culprit vessel), or a decrease in blood flow velocity
(seen in severe vascular stenosis), or both (seen when the infarcted
myocardium is supplied by collateral circulation or is blocked by
collateral circulation). supply of a blood vessel with severe stenosis and
limited blood flow).
7. Drug injection methods and precautions
Adenosine:
1. Record the blood flow spectrum distal to the LAD in the resting
state, and then inject adenosine intravenously. The adenosine injection
dose was initially 50µg·kg -1 min -1 for 1 min, and then gradually increased to 75µg·kg -1
min -1 , 100µg·kg -1 min -1 and 140µg·kg -1 min - at 1-min intervals. 1 . The

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maximum dose is 140µg·kg -1 min -1 for 5 min. CFVR is the ratio of the
maximum mean peak blood flow velocity after adenosine injection to the
resting state mean peak blood flow velocity. The coronary arteries reach
maximum dilation at a dose of adenosine of 140µg·kg -1 min -1 . The
maximum blood flow velocity can also be measured by directly injecting
140µg·kg -1 min -1 adenosine intravenously and observing for 5 minutes.
2. Clinical studies have shown that the blood flow velocity of the
coronary arteries has reached the maximum when adenosine is injected
for 2 minutes . To reduce side effects, CFVR can be measured 2-3
minutes after adenosine is injected . During the CFVR measurement,
12-lead cardiogram monitoring was performed and blood pressure was
measured every minute at rest and after adenosine injection until 5
minutes after stopping adenosine injection.
Standard operating procedures for exercise load
testing
1. Personnel and equipment requirements
In order to ensure the quality of data collection and standardization of
analysis and measurement , experienced physicians from the central
laboratory - Qilu Hospital of Shandong University first conducted
guidance and demonstrations of exercise stress testing and analysis in

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accordance with the research plan . In the screening stage , researchers
from each research unit need to submit the collected data and analysis
results to the central laboratory for review, and the central laboratory will
evaluate and provide feedback . All personnel involved in collection and
analysis have no interest in this study. Each operator needs to have
corresponding qualifications and be trained to better conduct exercise
load test inspections and analyze measurements .
2. How to operate
exercise stress testing before enrollment, 12 months and 24 months
after treatment . Patients should fast and refrain from smoking for 3 hours
before the test, and do not drink caffeinated beverages; wear comfortable
shoes and loose clothes; and try to stop taking drugs that may affect the
test results, such as digitalis drugs, before the test; 12 Strenuous physical
exercise must be avoided within hours; before the exercise test, 12-lead
electrocardiograms of the subjects in lying and standing positions should
be recorded and blood pressure should be measured as a control.
Subjects should exclude the contraindications of the following
conditions before conducting exercise stress testing: (1) acute myocardial
infarction or myocardial infarction combined with ventricular aneurysm;
(2) unstable angina pectoris; (3) heart failure; (4) moderate and Severe
valvular disease or congenital heart disease; (5) Acute or severe chronic
disease; (6) Severe hypertension; (7) Acute pericarditis or myocarditis; (8)

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Pulmonary embolism; (9) Severe aortic stenosis; (10) Those who are
severely disabled and unable to exercise.
The main instrument models used are General Medical's Series 2000
Teaadmill treadmill and the corresponding Case exercise testing system.
Let the subject walk on the movable tablet. According to the selected
exercise plan, the instrument automatically increases the speed and slope
of the tablet in order to adjust the load until the heart rate reaches the
subject's expected heart rate. Analyze the results before, during and after
exercise. ECG changes to determine the results. Recent studies have
shown that no matter what kind of exercise program, the optimal exercise
time to reach the maximum oxygen consumption value is 8-12 minutes.
Extending the exercise time does not increase the clarity of diagnosis. It
is emphasized that the choice of exercise program should be based on the
specific conditions of the subjects . It depends.
Before the exercise test, the 12-lead electrocardiogram of the subject
should be recorded in the lying and standing positions and the blood
pressure should be measured as a control. During exercise, the heart rate,
rhythm and ST-T changes were monitored through the monitor, and the
electrocardiogram and blood pressure were recorded every 3 minutes
according to the predetermined plan. After reaching the expected
submaximal load, maintain the expected maximum heart rate for 1-2
minutes before terminating the exercise. After the exercise is terminated,

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an electrocardiogram is recorded every 2 minutes and is generally
observed for at least 6 minutes. If the ischemic changes in the ST segment
have not returned to the pre-exercise pattern after 6 minutes, observation
should continue until recovery. During the test, subjects should be
observed for angina pectoris, dyspnea, fatigue, paleness, clammy skin,
claudication and lower limb joint pain.
Exercise testing is often terminated when the patient reaches the
maximum predicted heart rate. In addition, during the exercise test, if the
subject experiences the following adverse reactions, timely termination of
the test should be considered: ①ST segment elevation ≥1.0mm;
②Systolic blood pressure decrease >10mmHg, accompanied by other
signs of myocardial ischemia; ③Medium Severe angina; ④Gradually
worsening neurological symptoms (such as ataxia, dizziness or
presyncope); ⑤Signs of hypoperfusion (cyanosis or pallor); ⑥
Sustained ventricular tachycardia; ⑦Difficulty monitoring ECG or
Blood pressure; ⑧The subject requested to terminate exercise. After the
exercise test is terminated, the test conditions and data are recorded and
analyzed.
1. Analysis content: including analysis of exercise capacity, clinical
symptoms, hemodynamics and electrocardiogram changes.
2. Positive criteria for exercise test: The most important positive
electrocardiogram manifestation is ischemic downward shift of the ST

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segment, horizontal or downslope downward shift behind the J point >0.1
mv, lasting 0.08 s; upslope ST segment depression should be considered
A critical status or negative result. Ischemic chest pain during exercise
testing, especially angina that leads to termination of exercise testing, has
important clinical significance. Abnormal exercise capacity, systolic
blood pressure response and heart rate response during exercise are also
important positive manifestations.
3. Data Storage and Analysis
All data including exercise capacity, clinical symptoms,
hemodynamic and electrocardiographic changes and corresponding
analysis results should be recorded and saved in detail. Create a folder for
each patient , including the data, time and operator of each exercise stress
test. The data information will be uniformly sent to the central laboratory
by the person in charge of each center for summary and storage, and then
two experienced doctors will follow the two-way process. Based on the
principles of blindness and randomization , the situation and data of each
patient were analyzed . Data under special circumstances will be
re-examined by a team of professionals and analyzed multiple times to
determine the final analysis results .
4. Intra-observer variation and inter-observer variation observation
In order to ensure the reproducibility of the analysis, this study randomly
selected 50 subjects for repeated analysis . Inter-observer variability is the

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comparison of the differences between measurements made by two
physicians , and intra-observer variability is the comparison of the
differences between two analyzes performed by the same physician at
different times . Difference comparisons were analyzed using the
Bland-Altman method, scatter plots were drawn, and correlation
coefficients were calculated.
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