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.