Angina is the global term for all symptoms associated with coronary artery disease, which occurs when vessels that copy is not receiving enough blood. It occurs when vessels that carry blood to the heart muscle become dysfunctional, and are often narrowed or blocked. Angina may feel like chest pain or pressure shortness of breath, pain in the jaw, neck, arms, back, nausea, or generalized fatigue. Each patient experience angina differently.

Ischemic heart disease or myocardial ischemia is a disease characterized by reduced blood supply to the heart muscle, usually due to coronary artery disease, results in damage of the heart muscle and is known as heart attack

Shock waves are a kind of sound waves (like ultrasound) with high intensity and short duration. The sound waves are generated by an underwater high voltage spark, which are delivered noninvasively, focused by a special ellipsoid reflector. The reflector is coupled to the patient’s skin near the affected area with a water cushion. The focal zonedistance into the patient’s body is adjusted according to the clinical requirements.

The acronym ESMR stands for Extracorporeal Shockwaves Myocardial Revascularization. ESMR can also term as Non invasive Cardiac Angiogenesis therapy (Ni-CATh). ESMR therapy is a new non invasive therapy approach using Extracorporeal Shockwave technology for Myocardial Revascularization (i. e. to improve the blood supply to heart muscles). Ischemic myocardial areas no longer accessible by conventional revascularization therapies like Bypass surgery or Balloon Angioplasty and stent, could be treated with theWSMR therapy to relieve symptoms resulted from the myocardial ischemia.

The treatment is performed using a shock wave generator that is designed to address the unique clinical-anatomical requirements of the chest cavity. A cardiac ultrasound imaging system is used to locate the treatment area and to map the exact position and extent of the ischemic zone. Shock waves are then delivered via the anatomicalacoustic window to the treatment area under E.C.G. R-wave gating. Several treatment sessions are required to obtain optimal results.

Patients with advanced CAD frequently have recurrent Angina.Surgical and interventional options for these patients typically have been exhausted or will result in only partial revascularization. The ESMR therapy offers new hope for these patients and provides therapy which complement existing treatment procedures

The therapeutic effect of shock waves is attributed to the mechanical pressure and tension that the acoustic wave exerts on the cardiac tissue. Delivery of low intensity Shock waves causes sheer stress on the vessel wall. This stimulates angiogenesis related growth factors-(eNOS, VEGF and PCNA) initiating the angiogenesis process

Angiogenesis or Neo-vascularisation means formation or growthof new blood vessels (otherwise called coronary collateral formation) naturally which in turn increases the blood supply to the ischemic area of the heart and improves the myocardial perfusion. Hence coronary collateral angiogenesis can also be called NATURAL BYPASS.

• Chronic chest pain (Refractory Angina) even after Bypass
surgery or Angioplasty.
• Having 70% – 100% blockages in angiogram.
• Reblocks after Bypass surgery or Angioplasty.
• Chronic Renal disease with heart attack problem High risk
cases medically unfit for Bypass surgery
• Patients coronary anatomy not readily amenable for Bypass
• Inability to perform angioplasty because the target lesion is
• Patients not willing for surgical procedures

The purpose of the innovative non surgical treatment is to produce new pathways around the blocked arteries in Ischemic zone of the heart by expanding networks of the tiny blood vessels called collateral that help increase and normalize the blood flow to heart muscle thereby reducing relieving angina.

ESMR treatment forms new natural blood vessels which improve the oxygenated blood supply to the affected portion of the heart non- surgically or non-pharmaceutically. For this reason it is called Non-invasive or Non- surgical Bypass treatment or NonInvasive Cardiac Angiogenesis therapy (Ni-Cath)

The whole treatment duration is 20-30 minutes and the patient should undergo a series of nine treatment sessions during a nine week period. (3 treatments at first week of each month- 1st week, 5th week, 9th week). At each treatment session shockwaves are delivered to the border of the ischemic area.

During the treatment you might feel a local tickling in the treatment area, accompanied by a certain degree of noise.

Shock wave technology is presently being used in the field of Urology for breaking Kidney stones and in Orthopedics for bone and soft tissue injuries.

Unlike Bypass surgery, Angioplasty and stenting procedures, ESMR is non-invasive, carries no risk, painless, no anesthesia or sedatives required, no retreatment limitations and is an outpatient procedure

No acute or long term side effects were reported.

• Patient can walk more distance without chest pain
• Patient would have fewer or no angina
• Episodes of angina would be less painful
• Patient need for anti anginal medications can be reduced
• Patient can return to work and can participate in their active
life style once again
• Patient would be more energetic and confident.
Shock wave therapy is the optimal therapy approach for Ischemic
Heart Disease.

ESMR was developed by Essen Institute of Cardiology, Essen University, Germany.