Research Highlights:
Embargoed until 10:35 a.m. ET, Saturday, Nov. 11, 2023
PHILADELPHIA, Nov. 11, 2023 — The ORBITA-2 trial provides the first robust data confirming that stenting, also called percutaneous coronary intervention (PCI), relieves stable chest pain and improves exercise capacity among patients taking little or no chest pain medication, according to late-breaking science presented today at the American Heart Association’s Scientific Sessions 2023 . The meeting, Nov. 11-13, in Philadelphia, is a premier global exchange of the latest scientific advancements, research and evidence-based clinical practice updates in cardiovascular science.
Medication is proven to treat pain caused by reduced blood flow to the heart triggered by exertion, exposure to cold, emotional stress and other events, commonly referred to as stable angina or stable chest pain. When medication is insufficient, stenting procedures are recommended.
The only previous blinded trial examining whether stenting relieves chest pain, ORBITA published in 2017, surprisingly showed that stenting did not improve exercise tolerance or chest pain any more than a placebo procedure. It proved the feasibility of conducting placebo-controlled trials of established interventional procedures and made it possible to design subsequent research applied to a wider population of patients and clinical practice.
“However, it is possible that the effect of stenting in ORBITA was diminished by high levels of guideline-directed background, antianginal medication, which are difficult to achieve in clinical practice,” said Rasha Al-Lamee, M.B.B.S., Ph.D., reader (equivalent to associate professor) in cardiology, a British Heart Foundation intermediate research fellow and an interventional cardiology consultant at Imperial College London and Imperial College Healthcare NHS Trust.
ORBITA-2 enrolled a broader range of 301 patients with both single and multivessel disease who were randomly assigned to either coronary stenting or a placebo procedure. Neither patients nor the medical or research teams were aware of which procedure they had received. Throughout the trial, patients reported whether they were experiencing chest pain every day using a dedicated smartphone application. These daily symptom reports and the need for chest pain medication were used to calculate the angina symptom score, which is a first-of-its-kind primary study endpoint.
“We calculated an ‘angina symptom score’ daily for each participant based mainly on how much chest pain they experienced and their need for antianginal medication. We found that stents improved symptoms compared to the placebo procedure,” Al-Lamee said.
The study found:
Study Background:
“We expected that PCI would be more effective than a placebo procedure in patients taking little or no chest pain medication, and indeed, the results proved our hypothesis was correct,” Al-Lamee said. “Going forward, patients and medical teams have a choice of two pathways for chest pain relief: chest pain medication or PCI. The key finding of this trial is that it is the first therapy initiated that seems to have the maximum effect. Although PCI is neither risk-free nor cost-free, its use as an upfront procedure can now be considered evidence-based.”
“The ORBITA and ORBITA-2 trials together suggest the American and European guidelines for stable coronary artery disease may require updating. Perhaps restricting stenting to patients with inadequate response to chest pain medications may inadvertently be selecting the group of patients with the least to gain,” Al-Lamee said.
However, she said there are several reasons the findings should be interpreted cautiously:
Finally, Al-Lamee said, “I hope that the two trials will be used together to give patients and medical teams the choice of two treatment strategies with similar levels of benefit. They each have their own benefits, risks and limitations that should form part of the decision-making process. Importantly, the first therapy administered, antianginal medication or PCI as an antianginal procedure, appears to deliver most of the available symptomatic response.”
The study will be presented by today by Christopher Rajkumar, M.B.B.S., M.R.C.P., a clinical research fellow at Imperial College London, with simultaneous publication in The New England Journal of Medicine . Other co-authors, disclosures and funding sources are listed in the abstract.
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