Ischemia by Dobutamine Stress Echocardiography as a Predictor of PCI Efficacy

Patients with coronary artery disease (CAD) or chronic coronary syndromes (CCS) present a challenge in selecting the most adequate treatment, which entails correctly stratifying for a potential percutaneous coronary intervention (PCI).

The ORBITA-2 outcomes have shown invasive physiological parameters, such as FFR or iFR, are useful to predict symptom relief after PCI. However, other non-invasive techniques, such as dobutamine stress echocardiography (DSE), had no solid validation so far. The current clinical guidelines recommend the use of non-invasive diagnostic methods in patients with probable pretest intermediate CAD.

The ORBITA-2 was a randomized double blind placebo controlled study carried out in 14 centers in the UK, designed to assess the symptomatic effect of PCI in patients with stable angina and minimal or no anti angina therapy. This prespecified subanalysis looked at the predictive value of DSE induced ischemia on a post PCI symptomatic response. 

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262 patients with stable angina, single or multivessel disease and evidence of ischemia were included. All patients stopped anti angina medication 48 hours before procedure and were assessed with DSE, stress test, symptom questionnaires (CCS, SAQ, EQ-5D-5L) and the ORBITA mobile application. Mean patient age was 65.5; 79.4 % were men, 80.9 % presented severe stenosis in one coronary territory and 16.8 % in two territories.

DSE score was calculated with a standardized 17 myocardial segment model, pondering segmental dysfunction degree. 94.3 % of patients reached at least 85 % of the target heart rate. 

Outcomes were conclusive: the higher the DSE score, the greater the symptom improvement after PCI vs. placebo. This was shown both by reduced angina scores (OR: 1.69; CI95%: 1.40–2.03) and a drop in daily angina episodes (OR: 1.36; CI95%: 1.24–1.49) and improved SAQ quality of life scores (QoL) (angina frequency: 8.22-points; quality of life: 895 points). This reduction was maintained even in patients with atypical symptoms. 

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Unlike other tools such as FFR or iFR, with a predictive power limited to certain contexts, DSE showed a robust capacity to anticipate clinical benefit, regardless of symptom kind. 

Conclusions

The ORBITA-2 subanalysis reinforces the clinical value of dobutamine stress echocardiography as a non-invasive tool for symptomatic patient selection looking to benefit from PCI. Data presented support its integration into a clinical decision making strategy that prioritizes functional assessment prior revascularization. 

Original Title: Ischemia on Dobutamine Stress Echocardiography Predicts Efficacy of PCI: Results From the ORBITA-2 Trial.

Reference: Ahmed-Jushuf F, Foley MJ, Rajkumar CA, Chotai S, Simader FA, Wang D, Macierzanka K, Sehmi J, Kanaganayagam G, Lloyd G, Keenan N, Bual N, Davies JR, Keeble TR, O’Kane PD, Haworth P, Routledge H, Kotecha T, Williams R, Din J, Nijjer SS, Curzen N, Sinha M, Ruparelia N, Gamma R, Spratt JC, Cole GD, Harrell FE Jr, Howard JP, Francis DP, Shun-Shin MJ, Al-Lamee RK; ORBITA-2 Investigators. Ischemia on Dobutamine Stress Echocardiography Predicts Efficacy of PCI: Results From the ORBITA-2 Trial. J Am Coll Cardiol. 2025 May 13;85(18):1740-1753. doi: 10.1016/j.jacc.2025.02.034. PMID: 40335250.