The History of Angina and Its Remedies: COURAGE, ORBITA, and a Path Forward

The recent publication of the second Objective Randomised Blinded Investigation with optimal medical Therapy of Angioplasty in stable angina trial has renewed debate surrounding the indications and benefits of percutaneous coronary intervention (PCI) in stable angina. The second Objective Randomised Blinded Investigation with optimal medical Therapy of Angioplasty in stable angina results show that PCI improves anginal symptoms in the absence of antianginal medications. Taken together with the first Objective Randomised Blinded Investigation with optimal medical Therapy of Angioplasty in stable angina and Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation trial results, proponents argue that in contrast to current guidance, PCI and aggressive medical therapy are both equally acceptable initial antianginal strategies and subject to patient preference. Drawing on the history of randomized studies of interventional management for stable angina, we detail our reservations with this interpretation. More broadly, we highlight the merits of elegantly designed sham-controlled trials in answering lingering clinical questions. Finally, we offer select frameworks for more conclusive trials designed to answer the looming question that cardiologists face: does the landscape of randomized evidence support a medication-first, PCI-first, or shared decision-making treatment paradigm in stable angina?