Patients with stable heart disease and abnormal stress test treated early on with an invasive approach do not live longer than those initially treated with drugs and lifestyle changes alone, randomised trial results show.
These are the long-term results of the ISCHEMIA-EXTEND trial, presented at the American Heart Association (AHA) 2026 scientific session (6–9 November, Chicago, USA) and simultaneously published in the Journal of the American Medical Associaiton (JAMA).
ISCHEMIA-EXTEND follows on from the ISCHEMIA trial, looking at the potential benefit in adding cardiac catheterisation and revascularisation—with either percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) surgery—to optimal medical therapy in stable patients with at least moderate ischaemia on a stress test.
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 (New York University School of Medicine, New York, USA).
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 counselling. 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.
“Our results highlight the need for thoughtful discussions between patients with stable heart disease and their healthcare providers about goals and trade-offs,” said study co-lead author Rebecca Anthopolos (NYU Grossman School of Medicine, New York, USA). “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.
