INTRODUCTION
angina, paresthesia, myocardial ischemia, pain, CAD, RAP
SPINAL CORD, PARESTHESIA, MYOCARDIAL ISCHEMIA, CORONARY ARTERY DISEASE, CAD, DISEASES, SYNDROMES
Coronary artery disease (CAD) is one of the most prevalent diseases worldwide. Due to advancements in treatment options mortality and morbidity rates in this patient population have steadily declined. However, up to 20% of patients with stable CAD have persisting angina symptoms.Spinal cord stimulation (SCS) is a last resort treatment option for this patient population in which no other treatment options are currently available. SCS is a device with a lead located in the higher thoracic epidural space and an implantable pulse generator (IPG) in the abdomen or buttock that provides stimulation at the level of the myocardial afferent sympathetic neurons (C7–Th1). The potential beneficial effects of SCS are based on four possible mechanisms: reduction of myocardial oxygen demand, reduction of pain perception, and a decrease in sympathetic tone and an improvement in the coronary microcirculatory blood flow.The majority of research into the effect of SCS on RAP has been observational in nature. To date three placebo‐controlled randomized controlled trials have been performed and one study compared SCS with usual care.Although the exact working mechanism of SCS in RAP has not been elucidated studies have repeatedly shown an improvement in the quality of life and a reduction in angina symptoms.The recently published European Society of Cardiology (ESC) guideline “Chronic Coronary Syndromes” describes varying levels of evidence with regard to treatment options in patients with RAP. The ESC guideline concludes that SCS may be considered (Class of recommendation IIB; level of evidence B).The type of SCS traditionally used in patients with RAP is conventional stimulation. With this type of stimulation the patient will feel paresthesia at the target area. For this study a paresthesia free form of stimulation, high density (HD) stimulation, will be applied. Based on previous experience it is a viable treatment modality, it allows adequate blinding of patients because no paresthesia are felt and the patient can be fully informed about the fact that the spinal cord stimulator will be turned off for a period of 6 months.The aim of this investigator‐initiated, single‐center, placebo‐controlled, double‐blind, cross‐over, randomized controlled trial is to determine if high density spinal cord stimulation, a paresthesia free form of stimulation, leads to a significant reduction in the amount of myocardial ischemia in patients with RAP. The trial has been registered at 