ORBITA-2 confirms PCI effective for symptom relief in patients with stable angina 

Percutaneous coronary intervention (PCI) improved the angina symptom score, increased exercise capacity, and improved quality-of-life in patients with stable angina and evidence of ischaemia who were not using anti-anginal medication. The effect occurred immediately, was sustained over 12 weeks, and was consistent across endpoints. 

“Despite guidelines recommending revascularisation as add-on therapy for symptom relief in patients with stable coronary artery disease (CAD) on maximally tolerated anti-anginal medical therapy, evidence suggests that up to half of all patients undergoing elective cardiac catheterisation do so on 0 or 1 anti-anginal agents,” outlined Dr Christopher Rajkumar (Imperial College London, UK) [1,2].

The double-blind, randomised, placebo-controlled ORBITA-2 trial (NCT03742050) included 301 participants with stable angina, either due to single-vessel or multivessel disease, with evidence of ischaemia who were not on anti-anginal medication at baseline [3,4]. The primary endpoint was the novel daily angina symptom score, including the measurement of episodes of angina, the use of anti-anginal agents, and adverse cardiovascular outcomes, i.e. unacceptable angina, acute coronary syndrome, and death. The lowest score (0) represented the best outcome, whereas the highest score (79) represented death.

“PCI improved the angina symptom score compared with placebo,” said Dr Rajkumar (OR 2.21; 95% CI 1.41–3.47; P<0.001) [3]. This effect was driven by a reduction in angina frequency (OR 3.44; 95% CI 2.00–5.91; P<0.001) but not by anti-anginal use (OR 1.21; 95% CI 0.70–2.10; P=0.5). The rates of unacceptable angina, acute coronary syndrome, or death were low and comparable between groups.

“Physicians now have a choice of 2 first-line, evidence-based pathways, either anti-anginal medication or PCI,” concluded Dr Rajkumar. Referring to the non-significant results of the previous ORBITA trial, assessing PCI in patients with MI on anti-anginal medication, Dr Rajkumar argued that current guidelines that reserve PCI to patients on optimal anti-anginal medication may systematically select patients with the least to gain [5].

Discussant of the trial Dr Connie Hess (University of Colorado, CO, USA) added that future research should investigate the cost-effectiveness of PCI as anti-anginal monotherapy, should address the understanding of residual symptoms, and needs to focus on longer term outcomes.

1. 
   
   1. Lawton JS, et al. Circulation. 2022;145:e18­–e114.
   2. Shen L, et al. Clin Cardiol. 2016;39:721–727.
   3. Rajkumar CA, et al. Percutaneous coronary intervention for stable angina (ORBITA-2): a randomised, placebo-controlled trial. LB02, AHA Scientific Sessions 2023, 11–13 November, Philadelphia, USA.
   4. Rajkumar CA, et al. N Engl J Med 2023;389:2319–2330.
   5. Al-Lamee R, et al. Lancet. 2018;391(10115):31–40. 

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Posted on 29 January 202429 January 2024