Focal Coronary Disease Predicts Greater Benefit from PCI in Stable Angina: ORBITA-2 trial Analysis
UK: A new analysis of the ORBITA-2 trial has found that patients with stable angina and focal coronary artery disease derive the greatest benefit from percutaneous coronary intervention (PCI), particularly in terms of angina relief. Disease pattern emerged as a key factor influencing response, with focal lesions showing the most pronounced placebo-controlled improvement compared to diffuse disease.
The findings, published in the Journal of the American College of Cardiology by Kayla Chiew and colleagues from the National Heart and Lung Institute, Imperial College London, provide new evidence on how anatomical patterns of coronary artery disease can influence treatment outcomes. While earlier observational studies suggested better procedural success in focal disease, placebo-controlled data had not consistently demonstrated differences in symptom relief—until now.
For this purpose, investigators analyzed data from the ORBITA-2 trial, a randomized, placebo-controlled study evaluating the effectiveness of PCI in patients with stable angina receiving optimal medical therapy. Before randomization, participants underwent detailed physiological assessment using nonhyperemic pressure wire pullback techniques to map disease patterns within coronary arteries. These recordings were independently reviewed by seven blinded interventional cardiologists, who classified disease as focal, diffuse, or mixed. A scoring system was then applied to categorize patients into predominantly focal or diffuse disease groups.
The researchers reported the following findings:
- The analysis included 245 patients and evaluated 300 coronary vessel segments.
- After adjusting for baseline physiological parameters, PCI showed significantly greater benefit in patients with focal disease compared to diffuse disease.
- Patients with focal lesions experienced greater reductions in angina symptoms.
- Improvements were reflected in better symptom scores and fewer daily angina episodes.
- Focal disease was linked to superior placebo-controlled improvements in functional outcomes.
- Enhanced exercise capacity on treadmill testing was observed in patients with focal disease.
- Better classification on the Canadian Cardiovascular Society angina scale was noted.
- Patient-reported outcomes improved significantly, including scores on the EuroQol-5D and Seattle Angina Questionnaire.
- Consistent benefits across multiple endpoints highlight the importance of disease pattern in predicting PCI response.
- Imaging-based outcomes, such as dobutamine stress echocardiography, showed weaker interaction with disease pattern.
- Despite this, the overall trend in imaging findings still favored focal disease.
The results suggest that physiological and anatomical characteristics of coronary artery disease should be considered when selecting patients for PCI, particularly when the goal is symptom relief rather than prognostic benefit.
Overall, this study highlights the importance of personalized treatment strategies in cardiology. Identifying whether a patient has focal or diffuse coronary disease may help clinicians better predict who is most likely to benefit from PCI. These findings could refine clinical decision-making and optimize patient outcomes by aligning interventional strategies with underlying disease patterns.
Reference:
Chiew, K, Foley, M, Chotai, S. et al. Focal and Diffuse Coronary Artery Disease Patterns and Placebo-Controlled Angina Relief With Percutaneous Coronary Intervention: ORBITA-2. JACC. null2026, 0 (0). https://doi.org/10.1016/j.jacc.2026.02.5126
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