The core hypothesis to be tested is that the radiosurgery of stellate ganglion (left one or both if left-sided without full relief of symptoms) is an effective therapy of refractory angina pectoris in patients with no other therapeutic options - proof of concept study.

Design: prospective, interventional trial (University Hospital Ostrava, Cardiocentre AGEL Podlesi Hospital Trinec)

• radiosurgery of left GS after confirmation of responding to anesthetic blockade
• in case of remaining AP after three months, radiosurgery of right GS in case of response confirmation to anesthetic blockade (patients must be responders of anesthetic blockade of left stellate ganglion)
• Seattle Angina Questionary (SAQ) and amount of nitrate usage for responding confirmation
• Radiotherapy 40 Gy
• 2-year follow-up
• Scheduled follow-up visits: 1, 3, 6, 12, and 24 months (24)

Preliminary examination: selective coronary angiography, transthoracic echocardiography, stress test, 6 min walk test, SAQ (19-item)

Endopoints:

Primary Endpoints: SAQ, safety of the radiosurgery of GS Secondary Endpoints:usage decrease of angina relief drugs, 6 min walk test improvement

Follow-up visits examination, Restage: 6 min walk test, SAQ, amount of nitrate usage, ECG, blood tests incl. NT-proBNP, NSE

Inclusion Criteria:

• Patients must have coronary artery disease (CAD) with refractory angina pectoris (AP).
• Patients must have a maximum of tolerated medication therapy of angina pectoris available.
• Patients must have done the maximum possible revascularization of CAD.
• Two certificated independent interventional cardiologists and two cardiac surgeons must conclude that further revascularization (including CABG) is not possible/not effective/ with high risk.
• Age ≥ 18 years.
• Patients must have any stress test with proof of myocardial ischemia (dobutamine echocardiography, gated Tc-SPECT of myocardium).
• Life expectancy at least 24 months (not limited due to severe comorbidities)
• Patients must be responders of anesthetic blockade of the left stellate ganglion (GS) - clinically significant relief of AP symptoms after blockade at least twice.
• Patients must provide verbal and written informed consent to participate in the study.

Exclusion Criteria:

• Life expectancy less than 24 months
• Non-responders of anesthetic blockade of GS
• Impossibility to undergo a stress test.
• Myocardial infarction in last 4 weeks
• Heart failure - class IV NYHA
• Unwillingness to participate or inability to comply with the protocol for the duration of the study
• Patients who are pregnant, and patients with reproductive capability will need to use adequate contraception during the time of participation in the study
• History of radiotherapy in the head and neck region

Individual participant data may be made available upon request.