“There are now two evidence-based pathways for the management of stable angina: initiation of medical therapy, followed by more intensive therapy and then [percutaneous coronary intervention (PCI)] if the medical therapy fails to relieve symptoms or if the patient has unacceptable side effects from the medication, or performance of PCI without the use of antianginal medications as the initial therapy with the addition of medical therapy if the symptoms continue,” an editorialist comments based on the findings of the ORBITA-2 trial. “The benefits and risks of both pathways should be discussed with the patient, including the risks of PCI, the prevalence of stent thrombosis (0.5% per year), and the need for dual antiplatelet therapy with the associated risk of bleeding. Patients should express a preference, which is paramount. The selection of either pathway also depends on the angiographic findings; implanting a stent in a small branch vessel in a patient who has a high risk of stent thrombosis may be inappropriate. Moreover, guideline-directed medical therapy is very important, as seen in the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial, which showed no significant difference between a combination of intensive pharmacologic therapy and lifestyle intervention and the use of PCI on the risk of death and nonfatal myocardial infarction.”
