Presenting symptoms crucial for predicting PCI efficacy for stable coronary artery disease: ORBITA-2 analysis

The analysis of the ORBITA-2 trial showed that symptom severity and nature were poorly associated with disease severity, however, the nature of symptoms powerfully predicted the placebo-controlled efficacy of PCI.

"Two groups more likely to benefit from PCI for angina relief in stable CAD: those with Rose pattern angina (OR 1.9) and those with guideline-based typical angina (OR 1.8)," the researchers reported.

"Typical angina and rose angina are excellent predictors of the placebo-controlled efficacy of PCI," Florentina Simader, MD, of Imperial College London, said at the annual EuroPCR meeting, while presenting the results.

Stable CAD, characterized by the narrowing of coronary arteries, poses a significant health risk worldwide. PCI, a commonly employed intervention, involves the insertion of a stent to alleviate arterial blockages. However, the efficacy of PCI in improving patient outcomes has remained a subject of debate.

Placebo-controlled evidence from ORBITA-2 showed that PCI in stable coronary artery disease with little or no antianginal medication relieved angina, but residual symptoms persisted in many. There was no clarity on the reason. Considering this, the research team investigated the relationship between presenting symptoms and disease severity (non-invasive, anatomic, and invasive ischemia) and the ability of symptoms to predict the placebo-controlled PCI efficacy in an ORBITA-2 secondary analysis.

For this purpose, the researchers used the ORBITA smartphone application and symptom and quality of life questionnaires including the Rose angina questionnaire to assess the pre-randomization symptom severity and nature. Disease severity was assessed using stress echocardiography, quantitative coronary angiography (QCA), instantaneous wave-free ratio (iFR), and fractional flow reserve (FFR).

The study led to the following findings:

• At pre-randomization, the median number of daily angina episodes was 0.8, 64% had Rose angina, QCA diameter stenosis 61, stress echocardiography score 1.0, FFR 0.63, and iFR 0.78.
• There was little relationship between symptom severity and nature and disease severity: angina symptom score with QCA ordinal correlation coefficient 0.06; stress echocardiography 0.09; FFR 0.04; and iFR 0.04.
• Rose angina and guideline-based typical angina were strong predictors of placebo-controlled PCI efficacy (angina symptom score: OR 1.9 and OR 1.8, respectively).

"Whether a person had chest pains resolved by angioplasty hinged on the nature, not the severity, of their presenting symptoms," the researchers concluded.

Reference:

Simader, F. A., Rajkumar, C. A., Foley, M. J., Ahmed-Jushuf, F., Chotai, S., Bual, N., Khokhar, A., Gohar, A., Lampadakis, I., Ganesananthan, S., Pathimagaraj, R. H., Nowbar, A., Davies, J. R., Keeble, T. R., O’Kane, P. D., Haworth, P., Routledge, H., Kotecha, T., Spratt, J. C., . . . Al-Lamee, R. K. (2024). Symptoms as a Predictor of the Placebo-Controlled Efficacy of PCI in Stable Coronary Artery Disease. Journal of the American College of Cardiology. https://doi.org/10.1016/j.jacc.2024.04.016