Stents did not extend survival over medication in stable heart disease
ISCHEMIA-EXTEND followed 5,179 people with stable coronary disease for a median of nine years. All-cause mortality at 11 years was 25.8% with an invasive strategy and 26.9% with medication alone.
| Group | Value (%) |
|---|---|
| Conservative (medication) | 26.9 |
| Invasive strategy | 25.8 |
For decades it seemed self-evident that opening a narrowed coronary artery in someone with stable heart disease ought to help them live longer. The original ISCHEMIA trial, reported in 2020, challenged that intuition by finding no survival advantage over several years. The obvious rejoinder was that the benefit might take longer to appear. On 7 November, JAMA published the long-term answer [s1].
The question
ISCHEMIA-EXTEND is the extended follow-up of that landmark trial, registered as NCT04894877 [s1][s2]. The underlying question is narrow and important: for a person with stable chronic coronary disease — not someone in the middle of a heart attack — does a strategy of routinely going in with angiography and, where feasible, stenting or bypass, added on top of good medication, help them live longer than medication alone?
Crucially, the comparison is not stents versus nothing. Both groups received guideline-directed medical therapy — the statins, blood-pressure drugs and antiplatelet agents that form the backbone of modern care. The question is whether the invasive procedures add anything to that foundation over the long run.
How the trial was built
The original ISCHEMIA trial enrolled patients with chronic coronary disease who had moderate or severe ischaemia on testing, a left ventricular ejection fraction of 35% or more, and no disease of the left main coronary artery, no unacceptable angina, and no recent acute coronary syndrome [s1]. They were randomised to an initial invasive strategy — medical therapy plus angiography and revascularisation where feasible — or an initial conservative strategy of medical therapy alone, with invasive management held in reserve for when medication failed [s1].
Patients were randomised at 320 sites in 37 countries starting in August 2012 and followed through December 2025, with the analysis done by intention to treat [s1]. Among the 5,179 participants, the median age was 64, 23% were female, 42% had diabetes, and the median ejection fraction was 60% [s1].
What it found
Over a median follow-up of nine years — reaching as far as 13.4 years — 1,071 deaths occurred, 782 of them during the extended phase: 672 from cardiovascular causes, 359 from non-cardiovascular causes, and 40 unclassified [s1].
The headline result was a null. All-cause mortality at 11 years was 25.8% in the invasive group and 26.9% in the conservative group — an estimated difference of −1.0 percentage point (95% CI −4.2 to 2.1) and an adjusted hazard ratio of 0.97 (95% CI 0.86 to 1.09) [s1]. A Bayesian analysis put the posterior probability of more than a one-percentage-point survival benefit from the invasive strategy at just 18% [s1].
The components pulled gently in opposite directions. Cardiovascular mortality at 11 years was slightly lower with the invasive strategy — 15.8% versus 17.1% (adjusted hazard ratio 0.88, 95% CI 0.75 to 1.02) — while non-cardiovascular mortality was slightly higher, 9.1% versus 8.1% (adjusted hazard ratio 1.18, 95% CI 0.96 to 1.45) [s1]. Neither reached statistical significance, and they largely cancelled out: over 11 years the estimated difference in restricted mean survival time was 14 days (95% CI −41 to 70) [s1].
What is, and is not, established
With follow-up now stretching toward and beyond a decade, ISCHEMIA-EXTEND supports a durable conclusion: for people with stable coronary disease of the kind studied, a routine invasive strategy does not extend overall survival compared with starting on medication alone [s1]. The "it just needs more time" hypothesis does not hold up here — the survival curves stayed together for years [s1].
Several boundaries matter. The signal of fewer cardiovascular deaths balanced by more non-cardiovascular deaths is intriguing but did not reach significance, and the trial cannot explain it [s1]. The result applies to the population enrolled — stable disease, preserved pumping function, no left main disease, no recent acute event — and does not speak to people having a heart attack, where prompt artery-opening clearly saves lives [s1]. Nor does mortality capture everything: invasive treatment can still relieve angina and improve quality of life for some patients, which this analysis of survival does not measure [s1]. The finding is about whether the procedure prolongs life, not about whether it ever has a role.
This article describes research and is not medical advice. Decisions about managing coronary disease rest with patients and their cardiologists.
Sources
- Long-Term Survival After Initial Invasive or Conservative Management of Stable Coronary Disease in ISCHEMIA-EXTEND — JAMA , November 7, 2026
- ISCHEMIA-EXTEND (Extended Follow-up) (NCT04894877) — ClinicalTrials.gov
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