Angina Is as Subjective as Any Other Pain

Almost 80% of all patients randomized in this study reported Canadian Cardiovascular Society class II or III angina, and almost all of them (97%) had more than 1 positive non-invasive ischemia test that matched the area of their single diseased coronary vessel. Beyond fractional flow reserve (FFR) or instantaneous wave-free ratio (iFR), the study randomized patients to undergo angioplasty or a sham procedure (placebo group). We might have expected angioplasty patients to resolve their symptoms and placebo patients to continue with the same angina functional class. It should be noted that all patients were symptomatic and they all had single-vessel disease, with ischemia shown in more than one functional study.

Our expectations turned out to be quite different from reality, since almost half the patients who underwent angioplasty continued with angina and, more interestingly, 31.5% of placebo patients (i.e., those who underwent a sham procedure) reported being symptom-free. That is a significant difference, which leads us to conclude that, while angioplasty does actually improve symptoms, some things we are yet to understand.

 

Before randomization, all patients were assessed with iFR and FFR, while results were blinded. Mean FFR was 0.69 ± 0.16 and mean iFR was 0.76±0.22 (undoubtedly, all subjects were ischemic patients) in 196 study patients, among whom 103 underwent angioplasty and 93 underwent a placebo procedure.


Read also: CTO Revascularization Improves Quality of Life.


Angioplasty clearly improved stress echocardiography scores (p < 0.0001) and its effect was progressively more evident with decreasing FFR and iFR (p for interaction < 0.00001). That is the expectable, logical result for this study.

 

However, angioplasty did not improve angina frequency scores significantly more than placebo, and there was no detectable evidence of interaction with FFR (p = 0.849) or iFR (p = 0.783) results.


Read also: Manual vs. Mechanical Compression after Transradial Catheterization.


Despite all of the above, as it was mentioned at the beginning of this article, angioplasty was associated with more freedom from angina (49.5% versus 31.5%; odds ratio [OR]: 2.47; 95% confidence interval [CI]: 1.30 to 4.72; p = 0.006), although neither FFR nor iFR could predict this effect.

 

This is undoubtedly one of the most interesting studies ever published on ischemic heart disease and, despite its scarce 196 patients, it is certainly bound to start a debate.

 

Original title: Fractional Flow Reserve and Instantaneous Wave-Free Ratio as Predictors of the Placebo-Controlled Response to Percutaneous Coronary Intervention in Stable Single-Vessel Coronary Artery Disease. Physiology-Stratified Analysis of ORBITA.

Reference: Al-Lamee R et al. Circulation. 2018 May 22. Epub ahead of print.


Subscribe to our weekly newsletter

Get the latest scientific articles on interventional cardiology

We are interested in your opinion. Please, leave your comments, thoughts, questions, etc., below. They will be most welcome.

More articles by this author

Coronary Artery Disease in Aortic Stenosis: CABG + SAVR vs. TAVR + PCI: Data from Spanish Centers

Multiple randomized studies have shown comparable or superior efficacy of transcatheter aortic valve replacement (TAVR) vs. coronary artery bypass graft (CABG).  However, many of...

Evolution of Small Balloon-Expandable Valves

Small aortic rings (20 mm) have posed a significant challenge for both surgery and transcatheter aortic valve implantation (TAVI) due to their association with an...

TCT 2024 | FAVOR III EUROPA

The study FAVOR III EUROPA, a randomized trial, included 2,000 patients with chronic coronary syndrome, or stabilized acute coronary syndrome, and intermediate lesions. 1,008...

TCT 2024 – ECLIPSE: Randomized Study of Orbital Atherectomy vs Conventional PCI in Severely Calcified Lesions

Coronary calcification is associated with stent under-expansion and increased risk of both early and late adverse events. Atherectomy is an essential tool for uncrossable...

LEAVE A REPLY

Please enter your comment!
Please enter your name here

Related Articles

SOLACI Sessionsspot_img

Recent Articles

Severe Tricuspid Regurgitation: Surgical vs. Transcatheter Edge-to-Edge Repair

While highly prevalent, tricuspid regurgitation is a notably undertreated valvulopathy. Its progression has been associated with higher mortality and significant disability. According to the...

ACCESS-TAVI: Comparing Post TAVR Vascular Closure Devices

Transcatheter aortic valve replacement (TAVR) is a well-established option to treat elderly patients with severe symptomatic aortic valve stenosis. Technical advances and device development...

Endovascular Treatment of Iliofemoral Disease for the Improvement of Heart Failure with Preserved Ejection Fraction

Peripheral artery disease (PAD) is a significant risk factor in the development of difficult-to-treat conditions, such as heart failure with preserved ejection fraction (HFpEF)....