Symptoms, coronary artery disease and percutaneous coronary intervention: connecting the dots

Symptom relief is now recognized as the primary remit of percutaneous coronary intervention (PCI) in patients with stable coronary artery disease. The relationship between the nature of angina symptoms and the likelihood of successful symptom relief from PCI had not been systematically studied until recently.

The ORBITA-2 symptom-stratified analysis found that while the severity and nature of symptoms were poorly associated with the severity of coronary disease, the nature of the symptoms powerfully predicted the efficacy of PCI in relieving angina. Specifically, patients with typical or "Rose angina" were most likely to benefit from PCI, while those with atypical symptoms were less likely to see significant improvement beyond placebo. Furthermore, the ORBITA-STAR study demonstrated that patients whose angina symptoms closely matched those induced by balloon occlusion at the site of a coronary stenosis were significantly more likely to experience symptom relief from PCI.

Symptom analysis offers a powerful tool for predicting the efficacy of PCI. Misattributing noncardiac symptoms as angina often results in ineffective intervention, highlighting the critical importance of accurate and thoughtful symptom assessment, particularly in identifying typical angina. The persistent challenge of residual angina despite technically successful PCI reflects not a failure of the intervention itself, but a shortcoming in diagnostic precision to identify those who will benefit. Future research should focus on refining clinical predictors to better guide the selection of patients most likely to benefit from revascularization.