INVASIVE treatment for stable coronary artery disease did not significantly improve long-term survival compared with medical therapy alone. Findings from the ISCHEMIA-EXTEND trial challenge assumptions about the survival benefits of routine coronary intervention in patients with chronic coronary disease.
The international study followed 5,179 patients with stable coronary artery disease and moderate or severe myocardial ischemia across 320 sites in 37 countries.
Participants were randomized to an initial invasive strategy involving guideline-directed medical therapy, coronary angiography, and revascularization when appropriate, or a conservative strategy prioritizing medical therapy, with invasive procedures reserved for treatment failure.
Over a median follow-up of 9 years, researchers recorded 1,071 deaths. At 11 years, all-cause mortality was 25.8% in the invasive group compared with 26.9% in the conservative group, a difference that was not statistically significant (adjusted hazard ratio: 0.97; 95% CI: 0.86–1.09).
Estimated survival time differed by just 14 days over 11 years, with no statistically significant advantage for either approach.
Cardiovascular mortality was numerically lower following invasive management, affecting 15.8% of patients compared with 17.1% receiving conservative treatment.
However, this difference was not statistically significant. Noncardiovascular mortality was higher in the invasive group, at 9.1% versus 8.1%, although this difference also lacked statistical significance.
Bayesian analysis estimated an 18% probability that invasive management would provide a survival benefit exceeding one percentage point at the median 9-year follow-up.
The findings support individualized treatment decisions for patients with stable coronary artery disease, particularly when considering coronary revascularization.
Importantly, the original ISCHEMIA trial demonstrated greater angina relief and improved quality of life among symptomatic patients receiving invasive treatment, despite no demonstrated long-term survival advantage.
These results do not apply to all patients with coronary artery disease. Individuals with significant left main coronary artery disease, markedly reduced left ventricular ejection fraction, recent acute coronary syndrome, or unacceptable angina were excluded.
Extended follow-up also lacked detailed information on subsequent medication use, nonfatal cardiovascular events, and symptom progression.
Overall, ISCHEMIA-EXTEND reinforces the role of guideline-directed medical therapy while highlighting symptom burden, clinical characteristics, and patient preferences as important considerations when selecting an initial management strategy.
Reference
Hochman JS 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.
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