Implication of Cardiac Shock Wave Therapy on Coronary Artery Disease Patients

Study Overview
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Brief Summary
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CAD is a challenging affliction which has a high annual morbidity rate in China and the world. Severe CAD may lead to compromised cardiac function, decreased exertional capacity and poor quality of life (QOL). The most common treatment for CAD is medication, percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG). However, some patients had long-term of history with complex severe artery lesions, they are not candidate for redo interventional therapy. Cardiac shock wave therapy (CSWT) is an exploring therapy used globally for CAD patients, which is known for its safety, non-invasiveness and effectiveness.The previous RCT from the investigators' team has already finished, and results are in submission processing. This is a prospective, single arm, observational study design. CAD patients will be enrolled consecutively. The entire treatment period will last 3 months with 9 sessions. Outcomes are assessed as efficacy outcomes and safety outcomes. Efficacy outcomes include symptom (CCS score, NYHA classification, nitroglycerin dosage, SAQ questionnaire), exertional capacity (6MWT), quality of life (SF-36 questionnaire) and imaging evaluation (myocardial perfusion imaging and echocardiography). Safety outcome include the change of serum TNT, CKMB, BNP and adverse event (AE) occurrence. The participants will be followed up at 13th week, 6th months and 12th months.

Detailed Description
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CAD is a challenging affliction which has a high annual morbidity rate in China and the world. Severe CAD may lead to compromised cardiac function, decreased exertional capacity and poor quality of life (QOL). The most common treatment for CAD is medication, percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG). However, some patients had long-term of history with complex severe artery lesions, they are not candidate for redo interventional therapy. Cardiac shock wave therapy (CSWT) is an exploring therapy used globally for CAD patients, which is known for its safety, non-invasiveness and effectiveness. In the previous clinical studies, CSWT can alleviated angina symptom, improved myocardial ischemia and increased exertional capacity. Many single arm studies proved its efficacy and safety. Our RCT has already finished, and results are in submission processing. This is a prospective, single arm, observational study design. CAD patients will be enrolled consecutively. The entire treatment period will last 3 months with 9 sessions. CSWT will be administered in the first week, follow by a 3-week non-treatment interval. Outcomes are assessed as efficacy outcomes and safety outcomes. Efficacy outcomes include symptom (CCS score, NYHA classification, nitroglycerin dosage, SAQ questionnaire), exertional capacity (6MWT), quality of life (SF-36 questionnaire) and imaging evaluation (myocardial perfusion imaging and echocardiography). Safety outcome include the change of serum TNT, CKMB, BNP and adverse event (AE) occurrence. Symptom, 6MWT and questionnaires will be evaluated at baseline and 13th week, 6th months, 12th months of CSWT. Imaging outcomes will be evaluated at baseline and 13th week, 12th months of CSWT. The level of TNT, CKMB and BNP will be tested before and 1st week after initiation of CSWT.

Official Title
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Implication of Cardiac Shock Wave Therapy on Coronary Artery Disease Patients - An Observational Long-term Study

Conditions
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Coronary Artery Disease

Intervention / Treatment
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* Device: cardiac shock wave therapy


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Multiple or diffused coronary artery stenosis via coronary angiography, and not the candidates for PCI or CABG; Myocardial ischemia documented by stressed MPI and echocardiography; Refractory angina that has not been alleviated after at least three months of optimal medication treatment (OMT); Left ventricular ejection fraction (LVEF) ≥ 30%. Exclusion Criteria: Acute myocardial infarction within one month; PCI or CABG within one month; Heart transplant patient; Patients with prosthetic valves; Cases of atrial or ventricular thrombosis; Uncontrolled heart failure with LVEF <30%; Severe arrhythmia; (viii) patients with pacemakers; Cases of infective endocarditis; Chronic obstructive pulmonary disease patients; Pregnant or nursing women; Patients with silicone breast implants; Chest tumor patients; Patients already participating in other clinical trials.
Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Treatment group<br>The treatment group will receive cardiac shock wave therapy. The CSWT entire treatment will period last 3 months with 9 sessions. CSWT will administered in the first week, followed by a 3-week non-treatment interval. | Device: cardiac shock wave therapy<br>* Two target segments of left ventricle will be chosen for all participants. In each target segment, 9 sties will be administered with 200 shots at each site. Low-intensity SW (200 impulses/spot; energy flux 0.09 mJ/mm2), will be administered under electrocardiographic R-wave gating. The entire treatment period will last 3 months with 9 sessions. CSWT will be administered in the first week, followed by a 3-week non-treatment interval.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Summed Rest Score | Summed Rest Score of 17 segments of left ventricle under myocardial perfusion imaging. Each segment will be scored from 0 to 4. The minimum score is 0 while the maximum score is 68. Higher score means worse ischemia. | Change from Baseline Summed Rest Score at 12 months. | 
| Summed Stress Score | Summed Stress Score of 17 segments of left ventricle under myocardial perfusion imaging. Each segment will be scored from 0 to 4. The minimum score is 0 while the maximum score is 51. Higher score means worse ischemia. | Change from Baseline Summed Stress Score at 12 months. | 
| Summed Reverse Score | Summed Reverse Score of 17 segments of left ventricle under myocardial perfusion imaging. Each segment will be scored from 0 to 4. The minimum score is 0 while the maximum score is 51. Higher score means worse ischemia. | Change from Baseline Summed Reverse Score at 12 months. | 
| Regional Rest Score | Rest Score of target treatment segments of left ventricle under myocardial perfusion imaging. Each segment will be scored from 0 to 4. The minimum score is 0 while the maximum score is 8. Higher score means worse ischemia. | Change from Baseline Regional Rest Score at 12 months. | 
| Regional Stress Score | Stress Score of target treatment segments of left ventricle under myocardial perfusion imaging will be calculate. Each segment will be scored from 0 to 4. The minimum score is 0 while the maximum score is 8. Higher score means worse ischemia. | Change from Baseline Regional Stress Score at 12 months. | 
| Regional Reverse Score | Reverse Score of target treatment segments of left ventricle under myocardial perfusion imaging will be calculate. Each segment will be scored from 0 to 4. The minimum score is 0 while the maximum score is 8. Higher score means worse ischemia. | Change from Baseline Regional Reverse Score at 12 months. | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| CCS score | Canadian Cardiovascular Society score. The score is from 1 to 4 score. Higher score means worse ischemia. | Change from Baseline CCS score at 12 months. | 
| NYHA classification | Now York Heart Association classification. The score is from 1 to 4. Higher score means worse heart function. | Change from Baseline NYHA classification at 12 months. | 
| Seattle Angina Questionnaire | Seattle Angina Questionnaire has five domain: physical limitation, angina stability, angina frequency, treatment satisfaction and quality of life. Each domain are 0-100 scale. | Change from Baseline NYHA classification at 12 months. | 
| QOL: SF-36 Questionnaire | SF-36 Questionnaire include vitality, physical functioning, body pain, general health perceptions, physical role functioning, emotional role functioning, social role functioning, mental health. Each items are 0-100 scale. | Change from Baseline SF-36 score at 12 months. | 
| Six minutes walk test | Six minutes walk test proceed according to ATS guideline. The total distance will be recored. | Change from Baseline 6MWT at 12 months. | 
| Left ventricular ejection fraction | Left ventricular ejection fraction on echocardiography | Change from Baseline status at 12 months | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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coronary artery disease, myocardial ischemia, cardiac shock wave therapy, myocardial perfusion imaging