Early invasive treatment of stable coronary disease shows no survival gain after a decade

People with stable coronary artery disease and abnormal stress tests live no longer if they have an early invasive procedure than if they start with medication and lifestyle changes, according to a long-term follow-up of the ISCHEMIA trial. After nearly a decade, 26% of patients in the invasive group had died, against 27% in the conservative group. The work, led by researchers at NYU Langone Health, was published in the Journal of the American Medical Association and presented at the American Heart Association's Scientific Sessions on 7 November.

What the follow-up examined

The original ISCHEMIA trial enrolled more than 5,000 men and women with stable coronary artery disease, in which fatty deposits narrow the arteries and restrict blood flow without causing the sudden blockage of a heart attack. It had shown that early procedures, such as stent implants or bypass surgery, eased symptoms and improved quality of life, but did not lower the rate of serious cardiac events.

The extension study, ISCHEMIA-EXTEND, asked a narrower question: does an early invasive strategy change survival over the long term? Participants came from 320 hospitals in 37 countries across Europe, North America, Asia and the South Pacific. All received drugs to manage cholesterol and blood pressure, plus dietary and exercise counselling. One group also underwent a procedure soon after an abnormal stress test. In the other, procedures were reserved for patients whose symptoms worsened, who had a heart attack, or for whom medical therapy otherwise failed.

Completeness of follow-up

Survival was tracked through direct contact with participants and national health records, and the researchers compared the risk of death between the two strategies statistically. A total of 1,071 deaths were recorded up to 13 years after enrolment. Vital status was confirmed for 96% of participants, which judith Hochman, chair of ISCHEMIA, described as a level of thoroughness rarely achieved in long-term cardiovascular research. Such completeness reduces the risk that missing data distort a comparison of survival.

Implications for clinical practice

For many years, cardiologists have often recommended opening or bypassing seriously narrowed arteries even in stable patients with few or no symptoms, on the assumption that early action would prevent later life-threatening events. The new results weaken the case for that reasoning as a survival argument. Hochman, a professor of cardiology at NYU Grossman School of Medicine, said early procedures help relieve chest pain but are unlikely to help patients live longer.

The authors stress the limits of this conclusion. It applies to stable chronic coronary disease only. Procedures remain lifesaving for people having a heart attack or at imminent risk of one.

Co-lead author Rebecca Anthopolos, of the Department of Population Health at NYU Grossman School of Medicine, said the findings call for careful discussion between patients and clinicians about goals and trade-offs. Early procedures can improve daily life in people with chest pain, but they carry risks, and similar survival can be achieved with modern medicines and healthy habits.

Limitations and next steps

The analysis did not follow nonfatal heart attacks, repeat procedures or quality of life beyond the original trial period. These outcomes matter to patients and could differ between strategies over the longer term, so the study cannot show how they changed.

The team is now working on decision-support tools that combine age, disease severity, heart and kidney function and symptom burden with the long-term survival data. The aim is to help tailor treatment choices to individual patients rather than apply a single default strategy. For researchers, the dataset offers a rare, near-complete long-term record against which such models can be built and tested.

Source: Routine invasive procedures for stable heart disease found to offer no long-term survival advantage over drug therapy (Medical Xpress, 10 November 2026).

Image: AI-generated illustration.