Closed-Loop Neurofeedback Targeting the Right Dorsolateral Prefrontal Cortex for Cardiac Autonomic Modulation in Coronary Artery Disease With Anxiety (HEART-SET-1)

April 21, 2026 updated by: Lin Tao, Shenyang Medical College

Closed-Loop Neurofeedback Targeting the Right Dorsolateral Prefrontal Cortex for Cardiac Autonomic Modulation in Coronary Artery Disease With Anxiety - A Randomized, Sham-Controlled Trial

The goal of this clinical trial is to test whether real-time fNIRS-BCI neurofeedback targeting the right dorsolateral prefrontal cortex (right DLPFC), using active volitional control during a slow-wave auditory acoustic paradigm, can suppress cardiac sympathetic activity and improve autonomic regulation in right-handed patients with stable coronary heart disease (CHD) and comorbid DSM-5 anxiety.

The main questions it aims to answer are:

Does real neurofeedback, compared with sham, reduce baseline-corrected heart rate during the auditory stimulation window? Does real neurofeedback, compared with sham, increase HRV spectral power around 0.0167 Hz (1/60 Hz) and produce stronger suppression of right DLPFC activation? Does suppression of right DLPFC activation mediate the effect of group assignment on heart rate?

If there is a comparison group: Researchers will compare the real neurofeedback group with the sham (non-contingent) feedback group, which uses identical audio and interface, to determine whether coupling feedback to right DLPFC activity yields autonomic benefits.

Participants will:

Complete eligibility screening in cardiology and psychiatry and provide informed consent; baseline demographics, medical history, vital signs, and medications are recorded (HAMA/HAMD used for eligibility only).

Undergo a 3-day adaptation phase to practice active volitional self-regulation while viewing a real-time energy bar mapped to right DLPFC statistics; adaptation data are not analyzed for outcomes.

Attend two formal sessions (Days 4-5), each with 15 blocks of 60 s (20 s rest + 40 s stimulus). The auditory stimulus is a 1 Hz amplitude-modulated pure tone at approximately 60 dB; 10-second white-noise bursts are randomly embedded within the 40-second window. During the stimulation period, participants receive real or sham feedback on right DLPFC activation and act to push the energy bar below an unlabeled threshold line using active volitional strategies.

Undergo synchronous fNIRS (HbO) and 3-lead ECG (1,000 Hz) recording throughout; online processing and rendering performance metrics are logged; adverse events are monitored and managed per protocol.

Study Overview

Status

Recruiting

Conditions

Intervention / Treatment

Detailed Description

This study is a randomised, sham-controlled, parallel-group neurofeedback trial designed to test whether real-time fNIRS-BCI targeting the right dorsolateral prefrontal cortex (right DLPFC), using active volitional control during a slow-wave auditory acoustic paradigm, can suppress cardiac sympathetic activity and improve autonomic regulation in right-handed patients with stable coronary heart disease and comorbid DSM-5 anxiety. Eligibility criteria, outcome measures, arms and interventions, and statistical analysis are specified in their dedicated fields of this record to avoid duplication.

Participants complete screening and a three-day adaptation phase, followed by two formal experimental sessions on consecutive days. No verbal guidance is provided on test days. During each formal session, participants undergo 15 block cycles of 60 seconds each, comprising 20 seconds of rest and 40 seconds of auditory stimulation. The auditory stimulus is a 1 Hz amplitude-modulated pure tone at approximately 60 dB. Within the 40-second window, a 10-second white-noise burst is randomly embedded while avoiding the first and last 2 seconds; start times are selected without replacement from a discrete set to minimise predictability and sequence effects and to probe interference resistance.

Neurofeedback targets the right DLPFC. Real-time statistical values of cortical activation are mapped to a visual energy bar that serves as the feedback signal. Participants use active volitional strategies to push the energy bar below an unlabeled threshold line during stimulation. In the real-feedback group the statistical threshold is set to T = -3.3, producing a sensitive, contingent mapping between right DLPFC activity and the energy bar. In the sham-feedback group the threshold is set to T = -1, weakening the effective coupling between neural state and on-screen feedback while keeping the interface identical. Only the session operator is aware of group assignment; outcome assessors and data analysts are blinded.

Signals are acquired synchronously. fNIRS uses a NirSmart system with 7 sources and 7 detectors forming 19 channels, dual wavelengths at 730 nm and 850 nm, source-detector separation of 3 cm, and an 11 Hz sampling rate with avalanche photodiode detectors. Optodes are positioned over bilateral prefrontal cortex using the 10-20 system with FPz as the central reference. Channels are co-registered to MNI space, with right DLPFC (Brodmann area 46) designated a priori as the region of interest; channels 11 and 13 represent right DLPFC for feedback, and channels 17 and 18 represent left DLPFC for reference. ECG is recorded using a 3-lead configuration at 1,000 Hz.

Online processing and feedback are implemented with the NeuroMind-NIRS pipeline. A MATLAB timer provides a fixed update cadence. The streaming architecture is layered into data, visualisation, control, and persistence channels. A sliding-window general linear model is applied to fNIRS signals with low-pass filtering, linear detrending, and within-window normalisation. A boxcar task regressor convolved with a canonical haemodynamic response function is used; the statistical readout at the end of each window updates the energy bar and threshold decision. Statistical inference is prioritised ahead of rendering within a fixed real-time budget to maintain a stable feedback cadence. Per-frame compute time, render time, total pipeline time, latency, and dropped-frame rate are logged. The acoustic stimulus is not triggered or gated by the statistical readout.

Offline fNIRS preprocessing is performed in MATLAB using the Homer2 toolbox. Steps include conversion to optical density, motion artefact detection by channel, spline interpolation correction, band-pass filtering at 0.01 to 0.08 Hz, and calculation of oxyhaemoglobin concentration via the modified Beer-Lambert law. Analyses focus on HbO due to its higher signal-to-noise ratio. For activation analysis, normalised HbO time series from DLPFC channels enter a general linear model with a task regressor based on the convolved canonical haemodynamic response function and its derivatives; preprocessed ECG-derived covariates are included to account for low-frequency physiological oscillations. Subject-level task β estimates are taken forward to group-level linear mixed-effects models.

ECG processing includes R-peak detection by the Pan-Tompkins algorithm, correction of spurious detections, construction of RR interval series, ectopic beat removal using robust filters, and resampling as needed for alignment with fNIRS. Heart rate and heart rate variability are computed within block-aligned windows with baseline correction using the pre-stimulation interval. For spectral analysis, time-frequency methods are applied to quantify power around 0.0167 Hz, corresponding to the 60-second block rhythm within the very low frequency band.

Safety is monitored continuously from the start of adaptation through the end of Session 2. Anticipated adverse events related to sympathetic attenuation include mild dizziness or drowsiness, transient bradycardia or hypotension-related discomfort, headache, and nausea. Standard operating procedures specify pausing or terminating sessions and initiating clinical assessment as needed; serious adverse events trigger immediate discontinuation and follow-up. Quality control includes unscheduled supervisory checks, standardised operator training, checkpointed critical steps, real-time records, de-identified data handling, tiered access control, and auditable transfer logs. De-identified individual data and analysis scripts will be shared on a recognised repository at publication in accordance with data use and ethics policies.

Study Type

Interventional

Enrollment (Estimated)

56

Phase

  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Contact

Study Locations

  • China
    • Liaoning
      • Shenyang, Liaoning, China, 110001
        • Recruiting
        • The Second Affiliated Hospital of Shenyang Medical College
        • Contact:

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

  • Adult
  • Older Adult

Accepts Healthy Volunteers

No

Description

Inclusion Criteria:

  • Age >18 years, any sex.
  • Right-handed, with resting heart rate between 60 and 100 beats per minute.

  • Confirmed diagnosis of CHD, defined as at least one of the following:

    (i) positive stress test; (ii) documented myocardial infarction (MI) with electrocardiographic changes and concurrent elevation of creatine kinase MB isoenzyme or troponin; (iii) angiographically confirmed coronary atherosclerosis with ≥50% stenosis in at least one coronary artery.

  • Diagnosis of an anxiety disorder according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).
  • Hamilton Anxiety Rating Scale (HAMA) score ≥16 and 17-item Hamilton Depression Rating Scale (HAMD-17) score ≤17.

Exclusion Criteria:

  • Acute unstable angina.
  • Severe congestive heart failure (New York Heart Association [NYHA] class IV).
  • Valvular heart disease.
  • History of atrial fibrillation.
  • Unstable blood pressure, defined as systolic blood pressure >180 mmHg or <90 mmHg.
  • Pregnancy.
  • History of unstable medical conditions, including cerebrovascular disease, dementia, hyperthyroidism, pulmonary disease, or malignancy. These are assessed through medical history, electronic health records, physical examination, and ECG findings.
  • High risk of suicide or homicide.
  • Presence of other psychiatric disorders, including psychotic disorders, bipolar disorder, or active substance use disorders.
  • Use of psychotropic medication within 1 month prior to enrolment, to avoid potential interference with haemodynamic measurements.

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Treatment
  • Allocation: Randomized
  • Interventional Model: Parallel Assignment
  • Masking: Double

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Experimental: Real Neurofeedback Group
Participants receive real-time visual feedback based on activation of the right dorsolateral prefrontal cortex (right DLPFC), computed with a stringent statistical threshold (T = -3.3). This threshold enables high-sensitivity coupling between neural activity and the energy bar displayed on screen. The interface omits numerical values, and participants are blinded to both group allocation and threshold settings, ensuring a causally interpretable closed-loop training.
Device: Real-time fNIRS-ECG neurofeedback

This intervention uses real-time neurofeedback based on right dorsolateral prefrontal cortex (right DLPFC) activity measured by functional near-infrared spectroscopy (fNIRS), with simultaneous ECG recording. During a slow-wave auditory paradigm (1 Hz amplitude-modulated tone with embedded white noise), participants attempt to downregulate right DLPFC activation via active volitional strategies, guided by a visual energy bar.

Before formal intervention, a 3-day adaptation phase familiarises participants with the interface and task, under guidance. The formal training occurs on Days 4-5 (15 blocks/day), using identical auditory input and recording protocol. Participants are randomised to real or sham feedback groups, differing only in the statistical threshold used to generate feedback (T = -3.3 vs T = -1.0). Participants and assessors are blinded to allocation.
Sham Comparator: Sham Neurofeedback Group
Participants receive feedback using a lenient threshold (T = -1), greatly reducing the effective coupling between right DLPFC activation and the visual feedback. The screen interface is identical to the real group, and no numerical values are shown. Participants are blinded to their group and threshold settings, limiting the possibility of meaningful self-regulation.
Device: Real-time fNIRS-ECG neurofeedback

This intervention uses real-time neurofeedback based on right dorsolateral prefrontal cortex (right DLPFC) activity measured by functional near-infrared spectroscopy (fNIRS), with simultaneous ECG recording. During a slow-wave auditory paradigm (1 Hz amplitude-modulated tone with embedded white noise), participants attempt to downregulate right DLPFC activation via active volitional strategies, guided by a visual energy bar.

Before formal intervention, a 3-day adaptation phase familiarises participants with the interface and task, under guidance. The formal training occurs on Days 4-5 (15 blocks/day), using identical auditory input and recording protocol. Participants are randomised to real or sham feedback groups, differing only in the statistical threshold used to generate feedback (T = -3.3 vs T = -1.0). Participants and assessors are blinded to allocation.

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Time Frame
The between-group difference (real neurofeedback vs sham) in baseline-corrected heart rate (HR) during the task stimulation window.
Time Frame: The formal experimental phase (day 4 and 5).
The formal experimental phase (day 4 and 5).

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Between-group difference in task-related activation of the right dorsolateral prefrontal cortex (right DLPFC).
Time Frame: The formal experimental phase (day 4 and 5).
Quantified as the GLM task regressor β (HbO) during the slow-wave auditory neurofeedback paradigm
The formal experimental phase (day 4 and 5).
Between-group difference in HRV spectral power at 0.0167 Hz during the task stimulation window, based on wavelet time-frequency analysis.
Time Frame: The formal experimental phase (day 4 and 5).
The formal experimental phase (day 4 and 5).

Other Outcome Measures

Outcome Measure
Time Frame
Mediation analysis: to assess the indirect effect of group assignment on baseline-corrected HR via changes in right DLPFC activation.
Time Frame: The formal experimental phase (day 4 and 5).
The formal experimental phase (day 4 and 5).
Incidence of any adverse events during training or stimulation (e.g., mild dizziness or drowsiness, transient bradycardia or blood pressure-related discomfort, headache, or nausea).
Time Frame: From the adaptation phase until completion of the formal experimental sessions (Days 1-5).
From the adaptation phase until completion of the formal experimental sessions (Days 1-5).

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

Shenyang Medical College

Collaborators

The Second Hospital of Shenyang Medical College

Investigators

  • Study Chair: Yun-En Liu, MD, Shenyang Medical College
  • Principal Investigator: Lin Tao, MM, Shenyang Medical College

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Actual)

November 19, 2025

Primary Completion (Estimated)

August 20, 2026

Study Completion (Estimated)

August 21, 2026

Study Registration Dates

First Submitted

November 14, 2025

First Submitted That Met QC Criteria

November 18, 2025

First Posted (Actual)

November 20, 2025

Study Record Updates

Last Update Posted (Actual)

April 22, 2026

Last Update Submitted That Met QC Criteria

April 21, 2026

Last Verified

November 1, 2025

More Information

Terms related to this study

Keywords

Additional Relevant MeSH Terms

Other Study ID Numbers

  • HEART-SET-1

Plan for Individual participant data (IPD)

Plan to Share Individual Participant Data (IPD)?

YES

IPD Plan Description

De-identified individual participant data, study protocol, MATLAB scripts, and supporting materials will be made publicly available at the time of formal publication. Data will be hosted on an internationally recognised third-party repository and accessible for non-commercial scientific use.

IPD Sharing Time Frame

available at the time of formal publication

IPD Sharing Supporting Information Type

  • STUDY_PROTOCOL

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

No

Studies a U.S. FDA-regulated device product

No

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

Clinical Trials on Anxiety Disorders

Clinical Trials on Real-time fNIRS-ECG neurofeedback

Search Similar Trials

Sponsors and Collaborators

Medical Conditions

Drug Interventions

CROs by country

CROs in Poland

Conditions

Rare Diseases

Drug Interventions

Dietary Supplements

Sponsor/Collaborators

Locations

Subscribe