Early Stents or Bypass Gave No Survival Edge in Stable Heart Disease

CATEGORY: HEART & CIRCULATION

The survival payoff never showed up. Eleven years after 5,179 adults with stable coronary artery disease were randomly split between two starting strategies—prompt angioplasty or bypass surgery where needed, versus medicines alone with procedures held in reserve—25.8% of the procedure-first group had died, compared with 26.9% of the medicines-first group. That one-point gap is small enough to be chance.¹ For anyone living with this diagnosis, the decade-long answer is that neither starting point led to a longer life.

The Hope Was That Fewer Heart Attacks Would Add Up

Stable coronary disease means arteries narrowed by plaque, usually found during a workup for chest pressure or an abnormal stress test, not during a heart attack. The original ISCHEMIA trial enrolled people in this situation at 320 hospitals in 37 countries, starting in 2012, with funding from the US National Heart, Lung, and Blood Institute. Each person’s starting path was dealt at random, before doctors or patients could weigh in. In 2020, the first results showed that death and heart attack rates were the same over about three years. But those who had treatment early had fewer sudden heart attacks. Some experts proposed that, given enough time, those avoided heart attacks would turn into longer lives. The new paper in JAMA is the test of that idea. It didn’t happen.¹

1,071 Deaths, Sorted Into Two Columns

By the end of 2025, after a median of nine years of tracking, 1,071 participants had died.¹ Deaths from cardiovascular causes were somewhat less common in the procedure-first group: 15.8% versus 17.1% at eleven years. That difference fell short of statistical significance. Deaths from everything else leaned the opposite way, 9.1% versus 8.1%, and the two leans roughly canceled out. On average, the procedure added about 14 days of life over eleven years, with a margin of error ranging from 41 days lost to 70 days gained.1 Fourteen days is roughly the length of a summer vacation compared with a decade of living.

A Companion Check Reaches Back a Quarter Century

The same issue of JAMA carries a second look at an older trial of the same question. Researchers traced 959 veterans from the COURAGE study through as long as 25 years of health records. Death or heart attack eventually reached 93.3% of those who’d gotten early stenting and 91.0% of those who’d started on medicines alone. The curves never separated.² Over a quarter century, early stenting didn’t change when people died. Two randomized trials, run a generation apart, now agree on that.

Stable Disease Only, and Medicines Alone Means Quite a Lot

These results describe people whose disease was stable at enrollment. They don’t say anything about someone having a heart attack right then, when emergency procedures can save their life, and the trial left out people with severe narrowing of the left main artery or very weak heart muscle. The medicines-first group wasn’t left untreated either; that approach still meant statins, blood-pressure control and all the other modern drug therapies, with a procedure available if symptoms worsened. The editorial published alongside the paper calls a medicines-first start safe for most people in this situation, while noting it carries a somewhat higher chance of a spontaneous heart attack along the way, and cautions that the late-phase tracking covered only trial survivors and drew causes of death from records rather than committee review.³

Key Takeaways

• Whether treatment began with a procedure or with medicines alone, about one in four people with stable coronary disease had died by eleven years: 25.8% versus 26.9%.
• Fewer cardiovascular deaths in the procedure group were offset by more deaths from other causes, and neither shift was large enough to rule out chance.
• The evidence comes from a randomized comparison of 5,179 people, and a 25-year follow-up of the earlier COURAGE trial points the same way.
• None of this covers a heart attack in progress, severe left main artery disease, or a badly weakened heart; those situations were excluded.

References

1. 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. link
2. Butala NM, Murali N, Rahman N, et al. Percutaneous Coronary Intervention and Long-Term Outcomes in Stable Coronary Artery Disease: Extended Follow-Up of the COURAGE Randomized Trial. JAMA. 2026;doi:10.1001/jama.2026.23488. link
3. Cutlip DE, Yeh RW. The ISCHEMIA Trial a Decade Later—What Have We Learned? JAMA. 2026;doi:10.1001/jama.2026.23003. link