Early Heart Procedures Don't Extend Survival in Stable Heart Disease, Long-Term Study Finds

On November 7, at the American Heart Association's annual Scientific Sessions, a team led by NYU Langone Health presented the long-term results of a trial that has been running for years. People with stable heart disease who had stents or bypass surgery early in their care did not live longer than people treated first with medication and lifestyle changes. The findings were published online in the Journal of the American Medical Association at the same time.

The new study, called ISCHEMIA-EXTEND, follows up on the ISCHEMIA trial, which enrolled more than 5,000 men and women with stable coronary artery disease. In this condition, fatty buildup narrows the arteries and limits blood flow, but it does not cause the sudden complete blockage of a heart attack. Every participant had an abnormal stress test. The original trial found that routine early procedures, added to medication and behavioral changes, eased symptoms and improved quality of life, but did not reduce the rate of serious heart problems.

The follow-up asked a narrower question: does the early invasive approach help people live longer? Patients came from 320 hospitals in 37 countries across Europe, North America, Asia, and the South Pacific. All received drugs to manage cholesterol and blood pressure, plus dietary and exercise counseling. One group also had procedures soon after the abnormal stress test. The other group received procedures only if symptoms worsened, if they had a heart attack, or if medical therapy otherwise failed.

After nearly a decade, the death rates were essentially the same. The chance of death was 26 percent in the invasive group and 27 percent in the conservative group. Researchers tracked survival through direct contact with patients and national health records, and recorded 1,071 deaths up to 13 years after enrollment. They confirmed whether 96 percent of participants were alive or had died, a level of completeness that Dr. Judith S. Hochman, the study's co-lead author and ISCHEMIA chair, described as rare in long-term heart research.

Hochman, the Harold Snyder Family Professor of Cardiology at NYU Grossman School of Medicine, said the analyses make clear that early procedures help relieve chest pain and improve quality of life in people who have it, but are unlikely to help patients live longer. She noted that for decades cardiologists have often recommended opening or bypassing seriously narrowed arteries even in patients who were stable and symptom-free, on the thinking that acting early might prevent life-threatening problems later. These results challenge that assumption.

Hochman also drew a boundary around the findings. They apply specifically to stable patients with chronic coronary disease. For people having a heart attack or a threatened heart attack, she said, these procedures remain lifesaving.

Co-lead author Rebecca Anthopolos, PhD, an assistant professor in NYU Grossman's Department of Population Health, said the results call for careful conversations between patients and their providers about goals and trade-offs. Early procedures relieve symptoms and improve daily life for people with chest pain, she said, but they carry risks, and those should be weighed against evidence that modern medicines and healthy habits lead to similar survival.

Anthopolos also named the study's limits. The analysis did not track nonfatal heart attacks, repeat procedures, or quality of life beyond the initial trial period, which makes it harder to see how those aspects of health changed over time.

The authors are now building tools to tailor decisions to individual patients, combining age, disease severity, heart and kidney function, and symptom burden with the long-term survival data. The work was funded by National Institutes of Health grant R01HL149888. David Maron, MD, of Stanford University, was ISCHEMIA co-chair and the study's senior author.