Determining the Physiological Threshold for Angina (ORBITA-FIRE): A Double-Blind, Randomized, Placebo-Controlled Study.
Fiyyaz, A.J., J, F.M., Shayna, C., A, R.C., Danqi, W., A, S.F., Krzysztof, M., Kayla, C., Sannidhya, M., Rupert, W., Klio, K., N, D.J., R, M.S., D, O.P., Peter, H., S, N.S., Henry, S., R, K.T., R, D.J., . . . K, A.L.R. (2026). Determining the Physiological Threshold for Angina (ORBITA-FIRE): A Double-Blind, Randomized, Placebo-Controlled Study.. Circulation. https://doi.org/10.1161/CIRCULATIONAHA.125.078738
Fiyyaz AJ, J FM, Shayna C, A RC, Danqi W, A SF, et al. Determining the Physiological Threshold for Angina (ORBITA-FIRE): A Double-Blind, Randomized, Placebo-Controlled Study.. Circulation. 2026; doi: 10.1161/CIRCULATIONAHA.125.078738
Fiyyaz AJ, J FM, Shayna C, et al. Determining the Physiological Threshold for Angina (ORBITA-FIRE): A Double-Blind, Randomized, Placebo-Controlled Study.[J]. Circulation. 2026. DOI: 10.1161/CIRCULATIONAHA.125.078738.
@article{fiyyaz2026,
author = {Ahmed-Jushuf Fiyyaz and Foley Michael J and Chotai Shayna and Rajkumar Christopher A and Wang Danqi and Simader Florentina A and Macierzanka Krzysztof and Chiew Kayla and Misra Sannidhya and Williams Rupert and Konstantinou Klio and Din Jehangir N and Mohdnazri Shah R and O'Kane Peter D and Haworth Peter and Nijjer Sukhjinder S and Seligman Henry and Keeble Thomas R and Davies John R and Clesham Gerald and Hinton Jonathan and Spratt James C and Dungu Jason N and Knight Daniel and Kotecha Tushar and Harrell Frank E and Howard James P and Francis Darrel P and Shun-Shin Matthew J and Al-Lamee Rasha K},
title = {Determining the Physiological Threshold for Angina (ORBITA-FIRE): A Double-Blind, Randomized, Placebo-Controlled Study.},
journal = {Circulation},
year = {2026},
doi = {10.1161/CIRCULATIONAHA.125.078738},
note = {PMID: 42100816},
}
TY - JOUR AU - Ahmed-Jushuf Fiyyaz AU - Foley Michael J AU - Chotai Shayna AU - Rajkumar Christopher A AU - Wang Danqi AU - Simader Florentina A AU - Macierzanka Krzysztof AU - Chiew Kayla AU - Misra Sannidhya AU - Williams Rupert AU - Konstantinou Klio AU - Din Jehangir N AU - Mohdnazri Shah R AU - O'Kane Peter D AU - Haworth Peter AU - Nijjer Sukhjinder S AU - Seligman Henry AU - Keeble Thomas R AU - Davies John R AU - Clesham Gerald AU - Hinton Jonathan AU - Spratt James C AU - Dungu Jason N AU - Knight Daniel AU - Kotecha Tushar AU - Harrell Frank E AU - Howard James P AU - Francis Darrel P AU - Shun-Shin Matthew J AU - Al-Lamee Rasha K TI - Determining the Physiological Threshold for Angina (ORBITA-FIRE): A Double-Blind, Randomized, Placebo-Controlled Study. T2 - Circulation PY - 2026 DO - 10.1161/CIRCULATIONAHA.125.078738 AN - PMID:42100816 ER -
In stable coronary artery disease, the primary goal of percutaneous coronary intervention (PCI) is symptom relief. Fractional flow reserve (FFR) and nonhyperemic pressure ratios such as resting full-cycle ratio (RFR) are used to guide revascularization. Although these indices correlate with myocardial ischemia, they have never been validated against the onset of angina. The physiological thresholds for angina (FFRangina and RFRangina) at rest and during exercise remain undefined. ORBITA-FIRE (Finding the Invasive Threshold for Symptom Relief in Exertional Angina) was a multicenter, double-blind, randomized, placebo-controlled study in patients with stable angina and single-vessel coronary artery disease. After imaging-guided PCI, an in-stent balloon was incrementally inflated until angina occurred at rest. This angina threshold was verified against placebo inflation, and corresponding FFRangina and RFRangina values were recorded at symptom onset. The protocol was repeated during low- and high-intensity exercise to assess changes in angina thresholds with increasing cardiac workload. Sixty-five patients were enrolled (mean age, 63.9±8.7 years; 74% male; 69% hypertensive; 23% diabetic; 91% with Canadian Cardiovascular Society class II-III angina). Median pre-PCI FFR was 0.59 (interquartile range [IQR], 0.46-0.70) and RFR was 0.61 (IQR, 0.40-0.82). Median FFRangina at rest was 0.29 (IQR, 0.23-0.35), increasing to 0.38 (IQR, 0.30-0.48) during low-intensity exercise and 0.45 (IQR, 0.36-0.55) during high-intensity exercise. RFRangina similarly increased from 0.22 (IQR, 0.16-0.30) at rest to 0.26 (IQR, 0.18-0.36) and 0.32 (IQR, 0.23-0.46) during low- and high-intensity exercise. All thresholds were significantly lower than clinical diagnostic cut points (P<0.001). Lower FFRangina and RFRangina thresholds were associated with greater symptom reproducibility across rest, low- and high-intensity exercise conditions (FFRangina: P=0.008, P<0.001, P<0.001, respectively; RFRangina: P=0.015, P<0.001, P=0.002, respectively). Lower angina thresholds across all conditions predicted higher baseline angina burden and greater symptom relief with PCI (Pinteraction>0.999). Physiological thresholds for angina (FFRangina and RFRangina) are highly individualized, vary with cardiac workload, and are consistently lower than the universal ischemia-based thresholds used to guide revascularization. These findings support integrating personalized, symptom-linked physiology to refine patient selection and to improve symptomatic response to PCI.