A trial of 5,179 heart patients followed for up to 13 years found that starting with stents or bypass did not help them live longer than medication alone

For decades, people with stable heart disease have often been sent for stents or bypass surgery on the assumption that it helps them live longer. The ISCHEMIA trial tested that idea in 5,179 patients with moderate or severe narrowing, randomly assigning them to procedures plus medication or to medication and lifestyle changes alone, with procedures only if needed. The first results came out in 2020. Now NYU Langone researchers have reported what happened over up to 13 years.

Survival was essentially the same. After 11 years, 25.8% of patients who started with procedures had died, compared with 26.9% of those who started with medication alone. That difference was not statistically significant.

The study tracked 1,071 deaths and confirmed whether 96% of participants were alive or had died, an unusually complete follow-up for a heart trial of this length.

“These findings support shared decision-making by indicating no significant survival difference between the 2 initial management approaches over approximately a decade,” JAMA said in its summary of the results.

The result echoes an earlier landmark. The COURAGE trial, published in 2007, found that adding stents to medication in stable heart disease did not reduce deaths or heart attacks, and an extended follow-up of COURAGE was published alongside the new results. The original ISCHEMIA results in 2020 reached the same conclusion over a shorter period.

The second finding is the twist inside the numbers. Deaths from heart causes were somewhat lower in the procedure group, with a hazard ratio of 0.88, but deaths from other causes were somewhat higher, at 1.18. Neither difference was statistically significant on its own, and together they canceled out. The researchers do not have a clear explanation for the non-heart deaths.

Procedures still have a role. People who had them got more relief from chest pain, called angina, and an accompanying editorial notes that about a quarter of patients who start on medication alone end up needing an angiogram within three years anyway. The editorialists summed it up as no definitive reason to default to procedures for most stable patients, while leaving room for them when symptoms are not controlled.

For people with stable heart disease, the practical point is that procedures are mainly about symptoms, not survival, and strong medication and lifestyle changes do most of the work. These findings do not apply to heart attacks or unstable chest pain, where procedures save lives. Heart health is increasingly managed through prevention and medication, as new guidance on women’s heart health also shows.

There are limits to what this shows. Many patients crossed over from one strategy to the other over the years, which blurs the comparison. The trial excluded people with very severe disease, recent heart attacks, or poorly controlled symptoms, and the extended follow-up collected little data beyond deaths.

Source

Hochman JS, Anthopolos R, Reynolds HR, 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

Also cited

Maron DJ, Hochman JS, Reynolds HR, et al. “Initial Invasive or Conservative Strategy for Stable Coronary Disease.” New England Journal of Medicine, 2020.
DOI: 10.1056/NEJMoa1915922

Boden WE, O’Rourke RA, Teo KK, et al. “Optimal Medical Therapy with or without PCI for Stable Coronary Disease.” New England Journal of Medicine, 2007.
DOI: 10.1056/NEJMoa070829