COURAGE, ORBITA, and ISCHEMIA: Percutaneous Coronary Intervention for Stable Coronary Artery Disease

Intervent Cardiol Clin 9 (2020) 469–482
https://doi.org/10.1016/j.iccl.2020.07.003

This review article summarizes key landmark trials that have shaped understanding of the role of percutaneous coronary intervention (PCI) in stable coronary artery disease (CAD). The relationship between stenosis, ischemia, and angina is more complex than first imagined. Anginal relief remains the primary indication for PCI in stable CAD.

The first placebo-controlled PCI trial showed a surprisingly small effect size, suggesting a significant placebo effect. PCI in stable CAD has not been shown to improve mortality or overall myocardial infarction rates, even in the presence of significant ischemia. Rather, risk reduction medical therapy remains the main intervention for improving outcomes.

Key points

  • Percutaneous coronary intervention (PCI) in stable coronary artery disease (CAD) has not been shown to improve mortality or overall myocardial infarction (MI) rates
  • Rather, risk reduction with medical therapy remains the most important intervention for reducing mortality and MI rate.
  • The primary indication of PCI in stable CAD remains symptom relief.
  • The role of placebo in symptom relief, however, may be underestimated. Placebo-controlled trials are needed to quantify the true physiologic effect of PCI.
  • Even in the presence of significant ischemia, an invasive treatment has not been proved to be superior to conservative treatment in improving outcomes.

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