Symptoms as a Predictor of the Placebo-Controlled Efficacy of PCI in Stable Coronary Artery Disease.

ABSTRACT

BACKGROUND: Placebo-controlled evidence from ORBITA-2 (Objective Randomised Blinded Investigation with Optimal Medical Therapy of Angioplasty in Stable Angina-2) found that percutaneous coronary intervention (PCI) in stable coronary artery disease with little or no antianginal medication relieved angina, but residual symptoms persisted in many patients. The reason for this was unclear. OBJECTIVES: This ORBITA-2 secondary analysis investigates the relationship between presenting symptoms and disease severity (anatomic, noninvasive, and invasive ischemia) and the ability of symptoms to predict the placebo-controlled efficacy of PCI. METHODS: Prerandomization symptom severity and nature were assessed using the ORBITA smartphone application and symptom and quality of life questionnaires including the World Health Organization Rose angina questionnaire (Rose). Disease severity was assessed using quantitative coronary angiography, stress echocardiography, fractional flow reserve, and instantaneous wave-free ratio. Bayesian ordinal regression was used. RESULTS: At prerandomization, the median number of daily angina episodes was 0.8 (Q1-Q3 0.4-1.6), 64% had Rose angina, quantitative coronary angiography diameter stenosis was 61% (Q1-Q3 49%-74%), stress echocardiography score was 1.0 (Q1-Q3 0.0-2.7), fractional flow reserve was 0.63 (Q1-Q3 0.49-0.75), and instantaneous wave-free ratio was 0.78 (Q1-Q3 0.55-0.87). There was little relationship between symptom severity and nature and disease severity angina symptom score with quantitative coronary angiography ordinal correlation coefficient 0.06 (95% credible interval [CrI] 0.00-0.08); stress echocardiography 0.09 (95% CrI 0.02-0.10); fractional flow reserve 0.04 (95% CrI -0.03 to 0.07); and instantaneous wave-free ratio 0.04 (95% CrI -0.01 to 0.07). However, Rose angina and guideline-based typical angina were strong predictors of placebo-controlled PCI efficacy (angina symptom score OR 1.9; 95% CrI 1.6-2.1; probability of interaction [PrInteraction] = 99.9%; and OR 1.8; 95% CrI 1.6-2.1; PrInteraction = 99.9%, respectively). CONCLUSIONS: Although symptom severity and nature were poorly associated with disease severity, the nature of symptoms powerfully predicted the placebo-controlled efficacy of PCI.