CSWT introduces low-energy pulse waves from the patient’s body surface into the myocardium, causing effects such as cavitation, shear force, microstreaming, and inward explosive force within myocardial tissue cells. This leads to subcellular ultrastructural changes in local myocardial tissue, increased permeability of biological membranes, changes in internal environment function, and thereby triggers a series of biochemical effects, inducing neovascularization of ischemic myocardium and improving myocardial ischemia. Reports have shown that at the cellular level, CSWT can protect the heart and counteract ventricular remodeling by inhibiting local inflammatory responses, reducing myocardial fibrosis, and regulating the expression of relevant exosomes19,20,21. These studies indicate that CSWT can improve cell function through its effects such as cavitation, shear force, microstreaming, and inward explosive force produced within tissue cells22,23. A series of clinical and basic studies on extracorporeal shock wave therapy for ischemic heart disease conducted in China have found that it has achieved good clinical efficacy in patients with refractory angina, severe coronary artery disease, and chronic heart failure, improving heart function, increasing ejection fraction, reducing ventricular remodeling, and improving patient quality of life24,25,26.
CSWT is a form of physical therapy that does not require medication, injections, has no side effects, and is non-invasive, safe, and effective for patients undergoing anti-ischemic treatment. It can be performed concurrently with existing clinical treatments for angina and myocardial ischemia (including drug therapy, intervention therapy, CABG), providing an effective complement to anti-ischemic treatment for angina patients.
The combination of CSWT and exercise rehabilitation in clinical practice can enhance the anti-myocardial ischemic effect, and both methods are simple and easily accessible. CSWT procedures involve no material wastage, and the treatment cost is low. The focus lies in improving local circulation and blood supply to ischemic myocardium. Exercise training is already a part of daily life; aerobic and resistance exercises not only accelerate overall blood circulation but also increase muscle capacity27. When combined, the acceleration of systemic blood flow promotes local improvement in blood supply to ischemic myocardium, thereby enhancing the effectiveness of anti-myocardial ischemia.
Residual myocardial ischemia in postoperative CHD patients has become increasingly common in clinical practice, presenting significant challenges for postoperative recovery management (PRM) physicians. These patients are often unsuitable for repeated surgical interventions, and their medication regimens are already optimized, yet symptoms of myocardial ischemia persist. This underscores the urgent need for unconventional therapeutic approaches to assist these patients. CSWT undoubtedly serves as an excellent adjunctive treatment and may, in the future, become a powerful tool for PRM physicians.
Through this study, it was observed that at baseline, the levels of CK and CK-MB were higher in the study group compared to the control group. In clinical practice, some patients may have persistently elevated levels of myocardial markers without any clinical symptoms, and upon further examination, their cardiac condition is stable, and no specific treatment is administered. Therefore, it did not affect the normal progress of the study. However, after CSWT and exercise rehabilitation intervention, the myocardial marker levels in the study group decreased. Since this study employed randomization principles for patient selection and random assignment to groups, the higher baseline levels of CK and CK-MB in the study group compared to the control group were attributed to random error rather than deliberate factors.
HDL-C is synthesized by the liver and facilitates the reverse transport of cholesterol, playing a role in anti-atherosclerosis28. Studies have shown that elevated levels of HCY are a risk factor for cardiovascular disease. HCY is an intermediate product in the metabolism of methionine to cysteine. Elevated HCY levels promote atherosclerosis by damaging coronary artery endothelial cells, enhancing platelet adhesion, activating monocyte macrophages, and promoting vascular smooth muscle proliferation29,30. This study found that after CSWT and exercise rehabilitation intervention, patients in the study group exhibited increased HDL-C and decreased HCY levels, which could have anti-inflammatory, anti-atherosclerotic, and endothelial cell protective effects.
In this study, SDS (Self-Rating Depression Scale) is used as a depression rating scale, where higher scores indicate more severe depression, and PSQI (Pittsburgh Sleep Quality Index) is used as a sleep rating scale, where higher scores indicate poorer sleep quality. The study found that in the study group, SDS scores decreased after 6 months compared to before intervention, suggesting that patients in the study group experienced some relief in their depressive symptoms after shock wave therapy and extracorporeal counterpulsation intervention. Additionally, after 6 months, PSQI scores in the study group decreased compared to the control group, indicating that patients in the study group had better sleep quality than those in the control group.
Peak VO2 refers to the maximum amount of oxygen consumed per unit of time during maximal exercise, with all body systems and organs operating at their full reserve capacity. It is considered the gold standard for assessing aerobic exercise capacity31,32. In this study, the study group showed increased peak VO2 after 3 months compared to before intervention, and it was also higher compared to the control group. After 6 months, peak VO2 continued to increase compared to before intervention. Additionally, VO2/pre and peak VO2/kg both increased after 3 months and 6 months compared to before intervention. These findings suggest that after shock wave therapy and extracorporeal counterpulsation intervention, the study group demonstrated improved aerobic exercise capacity and reserve function compared to before intervention and compared to the control group.
VO2@AT refers to the oxygen uptake at the anaerobic threshold during exercise, where the energy demand is met by anaerobic metabolism once it exceeds this threshold. It reflects the maximum oxygen consumption before anaerobic metabolism occurs during exercise. The anaerobic threshold more accurately reflects the ability of muscle mitochondria to utilize oxygen because it is not influenced by subjective factors33. In this study, the study group showed higher VO2@AT than the control group after 3 months and 6 months, indicating that after shock wave therapy and extracorporeal counterpulsation intervention, the ability of muscle mitochondria to utilize oxygen in patients in the study group was enhanced.
Mets is a measure of relative energy metabolism level. In healthy adults, the oxygen consumption at rest is 3.5 ml/kg/min, which is defined as 1 Met. It is calculated as peak VO2 divided by 3.5. Therefore, in this study, an increase in peak Mets after 6 months compared to before intervention suggests that, similarly, after shock wave therapy and extracorporeal counterpulsation intervention, the aerobic exercise capacity and reserve function of the study group were improved compared to before intervention.
RER stands for Respiratory Exchange Ratio, which is the ratio of carbon dioxide produced to oxygen consumed per minute, reflecting the source of energy production and the acid-base balance in the body. In cardiopulmonary exercise testing, an RER greater than 1.1 indicates that the subject has reached maximal effort. In this study, the study group showed higher RER than the control group after 3 months and 6 months, suggesting that patients in the study group exerted greater effort during cardiopulmonary exercise testing compared to the control group.
HRmax refers to the maximum heart rate achieved during exercise, which typically decreases with age. Individuals with lower cardiorespiratory reserve and poorer health tend to have lower HRmax. In this study, the study group showed higher HRmax than the control group after 3 months, and HRmax continued to increase compared to before intervention after 6 months. These findings suggest that after shock wave therapy and extracorporeal counterpulsation intervention, the cardiorespiratory reserve function of the study group improved compared to before intervention and compared to the control group.
Rest SBP refers to the systolic blood pressure at rest. Studies have shown that after exercise training, there is a certain degree of reduction in baseline blood pressure among hypertensive individuals34. In this study, after 6 months, Rest SBP decreased compared to before intervention in the study group. This suggests that after shock wave therapy and extracorporeal counterpulsation intervention, the baseline blood pressure of the study group decreased compared to before intervention. Therefore, for hypertensive patients, this type of rehabilitation treatment plan may be more beneficial for blood pressure control.
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