Revisiting the contemporary management of angina with percutaneous coronary intervention

The primary role of elective percutaneous coronary intervention (PCI) is symptom relief.

Despite multiple unblinded studies showing symptom improvement with PCI, the blinded ORBITA trial showed a surprisingly small effect size. Stable angina is complex with variable symptomatology.

For the first time in decades, we must revise our approach to better understand the relationship between angina, myocardial oxygen supply-demand imbalance and relief of coronary flow obstruction. I will use my ORBITA-2 trial to investigate three key areas.

First, we need new approaches to history taking using an objective approach considering multiple factors including psychosocial, sex and ethnicity-based differences. I will use contemporary tools to improve our assessment of which patients may benefit from PCI.

Second, although coronary blood flow is a fundamental determinant of angina, we usually assess it indirectly using invasive pressure gradients.

Stress cardiac magnetic perfusion mapping allows absolute quantification of coronary blood flow to directly examine the relationship between regional myocardial perfusion, symptoms, and PCI efficacy.

Third, I will use coronary venous sampling as the gold-standard biochemical index of tissue-ischaemia to enable exploration of the relationship between PCI and tissue-level supply-demand imbalance.

This fellowship will underpin future algorithms for a personalised approach to delivering symptomatically successful PCI.