Changing the Orbit around Percutaneous Coronary Intervention for Stable Angina

   This editorial interprets the findings of the ORBITA-2 trial—a double-blind, placebo-controlled study showing that PCI significantly reduces angina frequency and improves quality of life in patients with stable angina and objective ischemia, even without antianginal medications. Unlike earlier trials (e.g. ORBITA-1), ORBITA-2 demonstrated sustained symptomatic relief, improved treadmill time (by 60 seconds), better CCS class, and reduced noninvasive imaging ischemia. The trial innovatively used smartphone-based daily symptom tracking as its primary endpoint. However, 59% of PCI-treated patients continued to experience angina, suggesting microvascular or non-coronary contributors. The editorial proposes two clinical pathways: (1) initial medical therapy followed by PCI if symptoms persist or medications are poorly tolerated; or (2) upfront PCI with medical therapy added if symptoms continue. The author advocates shared decision-making, underscores risks of PCI (e.g. stent thrombosis, bleeding), and highlights the importance of guideline-directed therapy as per COURAGE trial outcomes. ORBITA-2 reshapes symptom-based PCI discussions, emphasizes individualized care, and suggests broader roles for PCI beyond mortality reduction.

   This editorial interprets the findings of the ORBITA-2 trial—a double-blind, placebo-controlled study showing that PCI significantly reduces angina frequency and improves quality of life in patients with stable angina and objective ischemia, even without antianginal medications. Unlike earlier trials (e.g. ORBITA-1), ORBITA-2 demonstrated sustained symptomatic relief, improved treadmill time (by 60 seconds), better CCS class, and reduced noninvasive imaging ischemia. The trial innovatively used smartphone-based daily symptom tracking as its primary endpoint. However, 59% of PCI-treated patients continued to experience angina, suggesting microvascular or non-coronary contributors. The editorial proposes two clinical pathways: (1) initial medical therapy followed by PCI if symptoms persist or medications are poorly tolerated; or (2) upfront PCI with medical therapy added if symptoms continue. The author advocates shared decision-making, underscores risks of PCI (e.g. stent thrombosis, bleeding), and highlights the importance of guideline-directed therapy as per COURAGE trial outcomes. ORBITA-2 reshapes symptom-based PCI discussions, emphasizes individualized care, and suggests broader roles for PCI beyond mortality reduction.