Routine invasive procedures for stable heart disease found to offer no long-term survival advantage over drug therapy
· Medical Xpressedited by Sadie Harley, reviewed by Robert Egan
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Patients with stable heart disease and abnormal stress tests who have invasive procedures early in their care do not live longer than those initially treated with drugs and lifestyle changes alone, an international study shows.
The findings build on results from the International Study of Comparative Health Effectiveness With Medical and Invasive Approaches (ISCHEMIA) trial, which evaluated more than 5,000 men and women with stable coronary artery disease. In this condition, fatty buildup narrows arteries and limits blood flow but does not cause the sudden complete blockage seen in a heart attack.
According to the results, starting treatment with routine heart procedures—such as stent implants or bypass surgery—combined with medications and behavioral changes eased symptoms and improved quality of life, although this approach did not reduce the rate of serious heart problems.
Similar survival after nearly a decade
In the new follow-up study called ISCHEMIA-EXTEND, a team led by NYU Langone Health researchers examined whether the early routine procedures, combined with medications and lifestyle changes, improved long-term survival compared with a conservative approach of medications and lifestyle changes only, with procedures reserved for a failure of medical therapy.
The findings revealed that after nearly a decade, death rates were essentially the same: The invasive approach was associated with a 26% chance of death, versus 27% for the conservative approach.
"Our analyses make clear that while managing stable coronary artery disease with early heart procedures helps relieve chest pain and improves quality of life in those with chest pain, it is unlikely to help patients live longer," said study co-lead author and ISCHEMIA chair Judith S. Hochman, the Harold Snyder Family Professor of Cardiology in NYU Grossman School of Medicine's Department of Medicine.
The results were presented Nov. 7 at the American Heart Association's annual Scientific Sessions and simultaneously published online in the Journal of the American Medical Association.
Challenging routine intervention in stable disease
For decades, cardiologists have often recommended that patients with serious narrowing of the arteries undergo heart procedures to open the arteries with balloons and stents or to bypass the blockage, even if they were stable and had no symptoms. The thinking was that acting early might prevent life-threatening problems later, noted Hochman, who is also an associate director in the Department of Medicine's Leon H. Charney Division of Cardiology and the senior associate dean for clinical sciences at NYU Langone.
The ISCHEMIA-EXTEND findings challenge that assumption and represent one of the most complete follow-up investigations in stable heart disease to date, with 1,071 deaths recorded up to 13 years after patients entered the study.
By confirming whether 96% of participants were alive or had died, a level of thoroughness rarely seen in long-term heart research, the study provides a detailed picture of how these two treatment strategies play out over time, said Hochman.
These findings specifically apply to stable patients with chronic coronary disease. Heart procedures to open narrowed arteries with balloons and stents or to bypass the blockage are lifesaving for patients with heart attacks and threatened heart attacks, she added.
Tracking patients across 37 countries
For the trial, the research team assessed patients from 320 hospitals in 37 countries in Europe, North America, Asia and the South Pacific. All received drugs for cholesterol and blood pressure management, plus dietary and exercise counseling. One group also had heart procedures soon after having an abnormal stress test, and the other group only received such care if their symptoms worsened or if they had a heart attack.
The team then kept track of these patients over time using direct contact and national health records to assess survival. They compared the long-term risk of death between the two treatment approaches using statistical analyses.
Weighing symptom relief against procedural risks
"Our results highlight the need for thoughtful discussions between patients with stable heart disease and their health care providers about goals and trade-offs," said study co-lead author Rebecca Anthopolos, an assistant professor in NYU Grossman School of Medicine's Department of Population Health.
"For people with chest pain, early procedures relieve symptoms and improve daily life, but they also carry risks and should be weighed against evidence that taking modern medicines and following healthy habits leads to similar survival."
The study authors are now working to build tools that can help tailor decisions to each patient by combining information on age, disease severity, heart and kidney function, and symptom burden with long-term survival data.
Anthopolos cautioned that the analysis did not track nonfatal heart attacks, repeat procedures or quality of life beyond the initial trial period, making it harder to see how these other important aspects of health changed.
Publication details
Judith S. Hochman et al., Long-Term Survival After Initial Invasive or Conservative Management of Stable Coronary Disease in ISCHEMIA-EXTEND, JAMA (2026). DOI: 10.1001/jama.2026.20375
Journal information: Journal of the American Medical Association
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CardiologyCommon illnesses & Prevention Provided by NYU Langone Health Who's behind this story?
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