Karen Clarke, MD, MS, MPH, FACP, FHM

Clinical question: Does PCI provide symptom relief in patients with stable angina?

Background: More than 500,000 PCIs are done yearly worldwide in patients with stable angina. Meta-­analyses have demonstrated no impact of PCI on rates of death and myocardial infarction in patients with stable angina. Rather, relief of angina is the main reason for performance of PCI in patients with stable coronary artery disease, and this effect is frequently noted. However, there have been no data from double-blind, randomized, controlled trials to confirm the efficacy of PCI in relieving anginal pain.
Study design: Multicenter, double-blind, randomized, controlled trial.

Setting: Five sites in the United Kingdom.

Synopsis: The Objective Randomized Blinded Investigation With Optimal Medical Therapy of Angioplasty in Stable Angina (ORBITA) trial was designed to evaluate the effect of PCI, compared with placebo, on exercise time in patients with stable angina. The 230 patients who were enrolled in ORBITA had severe (70% or more), single-vessel stenosis. After enrolling, patients’ medication regimens were optimized so that almost all were taking aspirin, a second antiplatelet drug, and a statin. Beta-blockers and calcium channel blockers also were widely used by trial participants. Two hundred patients were randomized to either PCI (105 patients) or placebo procedure (95 patients). The primary endpoint was exercise time, and no difference was observed between the two groups. ORBITA’s results apply to patients with stable angina but not to those who undergo PCI for acute coronary syndrome (which includes ST-elevation MI); in the latter population, PCI has been demonstrated to reduce morbidity and mortality.

Bottom line: In patients with stable angina, PCI does not increase exercise time.

Citation: Al-Lamee R et al. Percutaneous coronary intervention in stable angina (ORBITA): A double-­blind, randomised controlled trial. Lancet. 2018 Jan;391(10115);31-40.

Dr. Clarke is assistant professor of medicine in the division of hospital medicine, Emory University, Atlanta.

Clinical question: Does PCI provide symptom relief in patients with stable angina?

Background: More than 500,000 PCIs are done yearly worldwide in patients with stable angina. Meta-­analyses have demonstrated no impact of PCI on rates of death and myocardial infarction in patients with stable angina. Rather, relief of angina is the main reason for performance of PCI in patients with stable coronary artery disease, and this effect is frequently noted. However, there have been no data from double-blind, randomized, controlled trials to confirm the efficacy of PCI in relieving anginal pain.
Study design: Multicenter, double-blind, randomized, controlled trial.

Setting: Five sites in the United Kingdom.

Synopsis: The Objective Randomized Blinded Investigation With Optimal Medical Therapy of Angioplasty in Stable Angina (ORBITA) trial was designed to evaluate the effect of PCI, compared with placebo, on exercise time in patients with stable angina. The 230 patients who were enrolled in ORBITA had severe (70% or more), single-vessel stenosis. After enrolling, patients’ medication regimens were optimized so that almost all were taking aspirin, a second antiplatelet drug, and a statin. Beta-blockers and calcium channel blockers also were widely used by trial participants. Two hundred patients were randomized to either PCI (105 patients) or placebo procedure (95 patients). The primary endpoint was exercise time, and no difference was observed between the two groups. ORBITA’s results apply to patients with stable angina but not to those who undergo PCI for acute coronary syndrome (which includes ST-elevation MI); in the latter population, PCI has been demonstrated to reduce morbidity and mortality.

Bottom line: In patients with stable angina, PCI does not increase exercise time.

Citation: Al-Lamee R et al. Percutaneous coronary intervention in stable angina (ORBITA): A double-­blind, randomised controlled trial. Lancet. 2018 Jan;391(10115);31-40.

Dr. Clarke is assistant professor of medicine in the division of hospital medicine, Emory University, Atlanta.

Clinical question: Does PCI provide symptom relief in patients with stable angina?

Background: More than 500,000 PCIs are done yearly worldwide in patients with stable angina. Meta-­analyses have demonstrated no impact of PCI on rates of death and myocardial infarction in patients with stable angina. Rather, relief of angina is the main reason for performance of PCI in patients with stable coronary artery disease, and this effect is frequently noted. However, there have been no data from double-blind, randomized, controlled trials to confirm the efficacy of PCI in relieving anginal pain.
Study design: Multicenter, double-blind, randomized, controlled trial.

Setting: Five sites in the United Kingdom.

Synopsis: The Objective Randomized Blinded Investigation With Optimal Medical Therapy of Angioplasty in Stable Angina (ORBITA) trial was designed to evaluate the effect of PCI, compared with placebo, on exercise time in patients with stable angina. The 230 patients who were enrolled in ORBITA had severe (70% or more), single-vessel stenosis. After enrolling, patients’ medication regimens were optimized so that almost all were taking aspirin, a second antiplatelet drug, and a statin. Beta-blockers and calcium channel blockers also were widely used by trial participants. Two hundred patients were randomized to either PCI (105 patients) or placebo procedure (95 patients). The primary endpoint was exercise time, and no difference was observed between the two groups. ORBITA’s results apply to patients with stable angina but not to those who undergo PCI for acute coronary syndrome (which includes ST-elevation MI); in the latter population, PCI has been demonstrated to reduce morbidity and mortality.

Bottom line: In patients with stable angina, PCI does not increase exercise time.

Citation: Al-Lamee R et al. Percutaneous coronary intervention in stable angina (ORBITA): A double-­blind, randomised controlled trial. Lancet. 2018 Jan;391(10115);31-40.

Dr. Clarke is assistant professor of medicine in the division of hospital medicine, Emory University, Atlanta.

Clinical question: What is the association between high-sensitivity cardiac troponin T (hs-cTn) levels and outcomes in patients with chest pain?

Background: There are few data on the link between hs-cTn levels and outcomes in patients with chest pain but no myocardial infarction or any other condition that can cause acute increases in troponin levels.

Study design: Observational cohort study.

Setting: Patients older than 25 years old with chest pain presenting to the emergency department at a university hospital in Sweden.

Synopsis: 19,460 patients with chest pain who had at least one hs-cTn level obtained during their ED visit were included in this study. In comparison with patients who had hs-cTn less than 5 ng/L, the adjusted hazard ratios for all-cause mortality were 2.00, 2.92, 4.07, 6.77, and 9.68, in patients with hs-cTn levels of 5-9, 10-14, 15-29, 30-49, and 50 or greater ng/L, respectively. The yearly rates of MI were 0.3% and 4.5% in patients with hs-cTn levels less than 5 ng/L and 50 or greater ng/L, respectively. The yearly rates of hospitalization for heart failure were 0.1%, 1%, 2.8%, and 20% in patients with hs-cTn levels less than 5, 5-9, 10-14, and 50 or greater ng/L, respectively. There was a clear and graded association between any detectable levels of hs-cTn and risk factors for cardiovascular and noncardiovascular mortality, MI, and heart failure.

Bottom line: For patients with chest pain and stable troponin levels, there is an elevated risk of death, hospitalization for heart failure, and MI, if there is any detectable level of hs-cTn.

Citation: Roos A et al. Stable high-sensitivity cardiac troponin T levels and outcomes in patients with chest pain. J Am Coll Cardiol. 2017 Oct 31;70(18):2226-36. doi: 10.1016/j.jacc.2017.08.064.

Dr. Clarke is assistant professor of medicine in the division of hospital medicine, Emory University, Atlanta.

Clinical question: What is the association between high-sensitivity cardiac troponin T (hs-cTn) levels and outcomes in patients with chest pain?

Background: There are few data on the link between hs-cTn levels and outcomes in patients with chest pain but no myocardial infarction or any other condition that can cause acute increases in troponin levels.

Study design: Observational cohort study.

Setting: Patients older than 25 years old with chest pain presenting to the emergency department at a university hospital in Sweden.

Synopsis: 19,460 patients with chest pain who had at least one hs-cTn level obtained during their ED visit were included in this study. In comparison with patients who had hs-cTn less than 5 ng/L, the adjusted hazard ratios for all-cause mortality were 2.00, 2.92, 4.07, 6.77, and 9.68, in patients with hs-cTn levels of 5-9, 10-14, 15-29, 30-49, and 50 or greater ng/L, respectively. The yearly rates of MI were 0.3% and 4.5% in patients with hs-cTn levels less than 5 ng/L and 50 or greater ng/L, respectively. The yearly rates of hospitalization for heart failure were 0.1%, 1%, 2.8%, and 20% in patients with hs-cTn levels less than 5, 5-9, 10-14, and 50 or greater ng/L, respectively. There was a clear and graded association between any detectable levels of hs-cTn and risk factors for cardiovascular and noncardiovascular mortality, MI, and heart failure.

Bottom line: For patients with chest pain and stable troponin levels, there is an elevated risk of death, hospitalization for heart failure, and MI, if there is any detectable level of hs-cTn.

Citation: Roos A et al. Stable high-sensitivity cardiac troponin T levels and outcomes in patients with chest pain. J Am Coll Cardiol. 2017 Oct 31;70(18):2226-36. doi: 10.1016/j.jacc.2017.08.064.

Dr. Clarke is assistant professor of medicine in the division of hospital medicine, Emory University, Atlanta.

Clinical question: What is the association between high-sensitivity cardiac troponin T (hs-cTn) levels and outcomes in patients with chest pain?

Background: There are few data on the link between hs-cTn levels and outcomes in patients with chest pain but no myocardial infarction or any other condition that can cause acute increases in troponin levels.

Study design: Observational cohort study.

Setting: Patients older than 25 years old with chest pain presenting to the emergency department at a university hospital in Sweden.

Synopsis: 19,460 patients with chest pain who had at least one hs-cTn level obtained during their ED visit were included in this study. In comparison with patients who had hs-cTn less than 5 ng/L, the adjusted hazard ratios for all-cause mortality were 2.00, 2.92, 4.07, 6.77, and 9.68, in patients with hs-cTn levels of 5-9, 10-14, 15-29, 30-49, and 50 or greater ng/L, respectively. The yearly rates of MI were 0.3% and 4.5% in patients with hs-cTn levels less than 5 ng/L and 50 or greater ng/L, respectively. The yearly rates of hospitalization for heart failure were 0.1%, 1%, 2.8%, and 20% in patients with hs-cTn levels less than 5, 5-9, 10-14, and 50 or greater ng/L, respectively. There was a clear and graded association between any detectable levels of hs-cTn and risk factors for cardiovascular and noncardiovascular mortality, MI, and heart failure.

Bottom line: For patients with chest pain and stable troponin levels, there is an elevated risk of death, hospitalization for heart failure, and MI, if there is any detectable level of hs-cTn.

Citation: Roos A et al. Stable high-sensitivity cardiac troponin T levels and outcomes in patients with chest pain. J Am Coll Cardiol. 2017 Oct 31;70(18):2226-36. doi: 10.1016/j.jacc.2017.08.064.

Dr. Clarke is assistant professor of medicine in the division of hospital medicine, Emory University, Atlanta.