A Placebo-Controlled Trial of PCI for Stable Angina

In the editorial accompanying the article by Rajkumar and colleagues (Dec. 21 issue)1 on the results of the ORBITA-2 trial involving the use of percutaneous coronary intervention (PCI) in patients with stable angina, White2 begins with a flawed premise: “The primary aim of treating patients with stable angina is to decrease symptoms and improve quality of life.” That is not the primary aim of treating these patients. Relieving angina is important, but the real priority in the management of stable angina is the provision of appropriate medical therapy to reduce the risk of myocardial infarction and sudden death. Thus, we continue our orbit around PCI. Many patients undergo stent implantation at the same time that we have not made the systematic changes that are necessary to ensure that every patient receives appropriate medical therapy. That is what must be changed. The follow-up of the ORBITA-2 trial lasted only 12 weeks, and the between-group differences in the frequency of angina were modest. Five years into the COURAGE trial,3 74% of patients in the PCI group and 72% of those in the medical-therapy group were free from angina. The new orbit? Appropriate medical therapy first, followed by PCI if angina is not sufficiently relieved.