Max Sayers

Interventional Cardiology SpR @NHSBartsHealth | Doctoral Research Fellow @imperialcollege @imperialNHS | Trainee committee member @BrHeartValveSoc

[Max Sayers @DrMaxSayers]

@Elainebks @ItsnotrightUK @bmj_latest She had leave granted. She lied about attending training she didnt attend.

[Max Sayers @DrMaxSayers]

Riding the rollaercoaster of structural intervention training with @Martins__Joao at @BrHeartValveSoc Spring Meeting

[Stefano Garzon, MD @stefano_garzon]

🧵 ORBITA-CTO

Seeing a study like ORBITA-CTO being published — regardless of its results — is a beautiful thing.
This level of commitment to producing high-quality, as-unbiased-as-possible evidence in interventional cardiology should be praised. It took 4 years to randomize 50 patients. That's dedication.
Think about what this team had to do:
Noise-cancelling headphones, deep sedation, clocks removed from every room, scripted handovers, overnight admission for both arms, dual-operator procedures lasting 3+ hours — all to protect the blinding.
Bang blinding index ≈ 0. It worked.
Design: 50 patients, single-vessel CTO, confirmed ischemia + viability, J-CTO ≤3, no bystander disease.
1:1 to CTO PCI or placebo after dual-injection angiography.
All anti-anginals stopped at randomization. Daily symptom tracking via ORBITA-app for 6 months. Patient-initiated re-titration only.
Primary endpoint: angina symptom score (Bayesian ordinal MOST model, daily repeated measures).
CTO PCI vs placebo: OR 4.38 (95% CrI 1.57–12.69) Pr(Benefit) = 0.996
Driven by angina frequency: OR 4.38 (95% CrI 1.55–11.78) Pr(Benefit) = 0.997
In patient-centered terms: CTO PCI yielded ~31 additional angina-free days over 6 months vs placebo.
95% CrI: 11.1–50.7 Pr(Benefit) > 0.999
That's roughly 5 extra angina-free days per month.

SAQ domains were consistent:
Angina frequency: +10.7 (CrI 1.4–20.2)
Physical limitation: +13.5 (CrI 4.5–22.3)
Quality of life: +18.2 (CrI 5.4–30.5)
Summary score: +13.7 (CrI 4.2–23.2)
All Pr(Benefit) ≥ 0.988. CCS class also improved.

Dyspnea and EQ-5D did not separate.

Procedural quality was outstanding: 96% technical success, 92% IVUS-guided, experienced dual-operator teams.
One failed PCI case — averaging 6 angina episodes/day — was included in ITT. This biased against the PCI arm.
But the treatment effect survived it.

Why does this matter so much?
EuroCTO (Werner et al.) showed CTO PCI improved symptoms vs OMT at 1 year, sustained at 3 years. But it was open-label, with 17.5% crossover from OMT to PCI.
Without blinding, the placebo contribution to symptom relief was unknown.

ORBITA-CTO quantified it.
Both arms improved — so yes, the placebo response was substantial.
But the PCI effect was immediate and sustained. The placebo group progressively needed more anti-anginals.

Now, what ORBITA-CTO does NOT prove:
1. Benefit in multivessel disease or high-complexity CTOs (J-CTO 4–5)
2. Prognostic benefit (not designed for hard endpoints)
3. Generalizability beyond expert centers with 96% success rates
4. Benefit on dyspnea or generic quality of life

I know. N=50 is small. Credible intervals are wide. This was an expert-center study with carefully selected lesions. Noted.

But 8,631 follow-up days of daily symptom data, a Bayesian framework designed for this exact scenario, and verified blinding give it far more inferential weight than sample size alone suggests.
For years, CTO PCI skeptics had a legitimate point: no blinded evidence.
That point is now addressed. CTO PCI relieves angina beyond placebo — in well-selected patients, at experienced centers. Agreed.

Hats off to the ORBITA-CTO team for doing this the hard way. Our field is better for it. And by the way, this is not me celebrating the results. I don't do CTO. But it makes me happy to see good medical science being made.

#ORBITACTO #CardiologyX #InterventionalCardiology #ACC26 @JACCJournals

[Kemi Badenoch @KemiBadenoch]

https://t.co/9uyRnpKSZ2

[Max Sayers @DrMaxSayers]

@RacksSound @GarySpedding Examples of these false antisemitism claims?

[Max Sayers @DrMaxSayers]

@GordonDimmack BBC News - Two men charged with allegedly spying on London Jewish community for Iran
https://t.co/uYipG30nhG

[Max Sayers @DrMaxSayers]

@DrMohitBhagia You can’t be failed by a system that has no duty towards you

[Max Sayers @DrMaxSayers]

@LiamHug30729272 @DrBoofle @anaesthetic_spr Yet all have atleast 5 years of general medicine postgrad experience and, since last few years, all will dual accredit in GIM.

This whole argument that you can function as a consultant cardiologist without being a physician first and foremost is absurd.

[Max Sayers @DrMaxSayers]

@adamboxer1 If referring clinician needs the imaging then the patient should not have to facilitate this. Even if medical private sector, most can request digitally. Unsure re dentists as smaller practices and more variability.

[Max Sayers @DrMaxSayers]

@adamboxer1 Not really. You dont have the skillset to analyse the imaging so the platform is a moot point. Transfers between UK hospitals is done digitally. For overseas patients taking imaging back to home countries CDs work fine.

[Max Sayers @DrMaxSayers]

@adamboxer1 Obviously patients can be talked through images as part of consultation but my job is to diagnose and treat the patient in front of me, not facilitate consumerism. This is v different to your first case of professionalism/politeness imo

[Max Sayers @DrMaxSayers]

@adamboxer1 Disagree with you here. Given time constraints and data protection restrictions, as well as various file types based on reading vs analysing images, it's not appropriate for me as a clinician to be dealing with this and should be done by dedicated admin.

[Max Sayers @DrMaxSayers]

@bealelab Longer appointments

[Max Sayers @DrMaxSayers]

@RoshanaMN @ObamaWellington Where in the above example were the clinicians blamed?

[Max Sayers @DrMaxSayers]

@RoshanaMN Disagree. We have a responsibility as clinicians to challenge management within our own deprtments to ensure that patient care can be delivered safely and effectively. If theatres wasn't equipped with appropriate surgical instruments you would challenge this. This is no different

[Max Sayers @DrMaxSayers]

@RoshanaMN Agree. Therefore, 1) appointment times should be lengthened and timetabled accordingly and 2) methods to improve efficiency should be explored.

Either way, this is an organisational failure, not an error in patient expectation

[Max Sayers @DrMaxSayers]

@rollocs @thomasdolphin they do get medals tho 🤣

[Max Sayers @DrMaxSayers]

@theveindoc @denovo1973 Wasnt trying to reassure you

[Max Sayers @DrMaxSayers]

@LordLucasCD @FullFact @TheBMA @RoyalStatSoc What increase in employer cont?
Employer cont not ringfenced. Both employer and employee conts fund current recipients.
Scheme is in surplus and pays back to treasury.

[Max Sayers @DrMaxSayers]

@SarahLouisaColl @TheRealJamieKay Junior doctors are highly capable, intelligent young people who could have gone into any profession in the private sector and earn significantly more money. Stop weaponising vocation. If you want a highly skilled medical workforce you need to renumerate them appropriately.