JAMA Study Evaluates 11-Year Mortality Outcomes in Routine Invasive Versus Conservative Management of Chronic Coronary Disease

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Summary of  JAMA. https://doi.org/10.1001/jama.2026.20375 
Dr. Judith S. Hochman et al.

Points

NYU Langone Health investigators evaluated long term all cause survival in five thousand one hundred seventy nine patients with chronic stable coronary disease across thirty seven countries over thirteen years.
Extended follow up analyses established that eleven year all cause mortality was twenty five point eight percent in the routine invasive group compared to twenty six point nine percent in conservative management.
Adjusted hazard ratios demonstrated no statistically significant differences between treatment strategies for overall mortality cardiovascular death or eleven year restricted mean survival.
Bayesian analysis confirmed an eighteen percent posterior probability that an initial invasive strategy provides greater than a one percentage point overall survival advantage over conservative care.
Authors concluded that while early invasive procedures relieve chest pain and enhance quality of life optimal medical therapy achieves comparable long term survival in stable coronary disease.

Summary

This randomized clinical trial evaluated long-term survival outcomes comparing an initial routine invasive strategy with an initial conservative management approach in patients with stable chronic coronary disease and moderate or severe ischemia. Published in the Journal of the American Medical Association and presented at the American Heart Association Scientific Sessions 2026 by researchers at NYU Langone Health led by Dr. Judith S. Hochman and Dr. Rebecca Anthopolos, the ISCHEMIA-EXTEND study followed patients from 320 centers across 37 countries. Given that revascularization via percutaneous coronary intervention or coronary artery bypass grafting improves angina but carries procedural risks, the trial sought to determine whether early invasive intervention extends all-cause survival over extended follow-up up to 13.4 years.

The cohort evaluated 5,179 participants with a median age of 64 years (IQR, 58–70), including 23% female, 42% with diabetes mellitus, and a median ejection fraction of 60% (IQR, 55%–65%). Over a median follow-up of 9 years (range, 1 day to 13.4 years), 1,071 deaths occurred (672 cardiovascular, 359 noncardiovascular, 40 unclassified). At 11-year follow-up, all-cause mortality was 25.8% in the invasive group versus 26.9% in the conservative group (estimated difference, -1.0 percentage point [95% CI, -4.2 to 2.1]; AHR, 0.97 [95% CI, 0.86–1.09]). Bayesian analysis yielded an 18% posterior probability of a >1 percentage-point survival benefit for the invasive strategy. Cardiovascular mortality at 11 years was 15.8% invasive versus 17.1% conservative (estimated difference, -1.4 percentage points [95% CI, -4.0 to 1.3]; AHR, 0.88 [95% CI, 0.75–1.02]), while noncardiovascular mortality was 9.1% versus 8.1% (estimated difference, 1.0 percentage point [95% CI, -0.9 to 2.9]; AHR, 1.18 [95% CI, 0.96–1.45]). Eleven-year restricted mean survival difference was 14 days (95% CI, -41 to 70 days).

The authors conclude that long-term all-cause mortality in high-risk chronic coronary disease does not significantly differ between routine initial invasive intervention and initial conservative medical management. While invasive management effectively reduces angina and improves daily quality of life, clinicians and patients should weigh these symptomatic benefits against procedural risks, recognizing that optimal medical therapy yields comparable long-term survival.

Link to the article: https://jamanetwork.com/journals/jama/fullarticle/2856396#google_vignette

References

Hochman, J. S., Anthopolos, R., Reynolds, H. R., Bangalore, S., Xu, Y., O’Brien, S. M., Boumakis, S., Chang, M., Rosenberg, Y., Senior, R., Banfield, A., Goodman, S. G., Lopes, R. D., Pracoń, R., Lopez-Sendon, J., Steg, P. G., Maggioni, A. P., Newman, J. D., Berger, J. S., … G. B. John, M. (2026). Long-term survival after initial invasive or conservative management of stable coronary disease in ischemia-extend. JAMA. https://doi.org/10.1001/jama.2026.20375