**7. Cardiac shock wave therapy (CSWT) in treatment of refractory angina (RA)**

Cardiac shock wave therapy (CSWT)—which is also known as extracorporeal shockwave myocardial revascularization (ESMR)—represents a recent option for the treatment of refrac‐ tory angina [17, 18]. Alunni et al. [17] performed a prospective case‐control study over 6 months. They studied the efficacy of ESMR on cardiac perfusion in 72 patients with refrac‐ tory angina (RA), 43 patients in the ESMR group and 29 in the control group (did not receive ESMR). They were compared at baseline and 6 months following ESMR therapy as regarding angina class score (CCS class score), the need for nitroglycerin consumption and the rate of hospitalization. Significant improvement in the patients' conditions occurred. Angina class score (CCS) improved in the ESMR group with an average of 1.33 versus 1.92 in the control group. Nitroglycerin consumption was lowered (20% in ESMR group versus 44.8% in control group) as well as the significant reduction in the rates of hospitalization (13.9% in the ESMR group versus 37.9% in the control group).

Vainer et al. [18] also applied cardiac shockwave therapy on the ischemic myocardial areas of 33 patients with end‐stage coronary artery disease, chronic angina and reversible ischemia on myocardial scintigraphy. Patients were followed up after 1 and 4 months from the last CSWT session and assessed using CCS class score, their need for nitrate consumption, cardiac mag‐ netic resonance imaging and myocardial scintigraphy. Follow‐up showed an improvement in CCS score to drop from class III to class II, reduction in sublingual nitrate consumption from 10 times to twice per week, and myocardial scintigraphy showed improved myocardial perfusion. In conclusion, CSWT has proven to be an efficient non‐invasive therapeutic option for patients with refractory angina.
