Does a heart stent prevent future heart attacks in stable patients? 25-year follow-up offers new insight

A new 25-year follow-up of the landmark COURAGE trial reveals that early heart stents do not improve long-term survival or reduce heart attacks in stable patients compared to medical therapy alone. According to Medscape, the original COURAGE trial previously failed to associate percutaneous coronary interventions with reductions in death or myocardial infarction after a median of 4.6 years of follow-up. While some specialists previously speculated that longer observation might produce a positive result, the extended 25-year analysis produced the same result. Neel M. Butala, MD, an assistant professor of cardiology at the University of Colorado School of Medicine, delivered the long-term data at the American Heart Association Scientific Sessions 2026.

Medscape reported that the follow-up evaluated a major subset of Veterans Affairs participants from the original study, tracking 959 patients out of the 2287 originally randomized. Butala noted that this VA population was almost all male and at higher risk than the overall COURAGE population, which should have provided a better opportunity to show a greater therapeutic effect. However, the 25-year results showed a hazard ratio of 1.01 with a 95% confidence interval ranging from 0.88 to 1.15 for the primary composite endpoint of death from any cause or myocardial infarction. Kaplan-Meier curves were essentially overlapping along a median follow-up of 15 years and a maximum follow-up of 25 years.

According to the data, the estimated cumulative incidence of death at 25 years was 83.9% in the PCI group and 82.2% in the optimal medical therapy group. Researchers found no significant differences when evaluating components of the primary endpoint separately, nor when comparing events at 5-year intervals through 25 years. Revascularization rates over the long-term follow-up were only slightly lower in the PCI group at 50.4% compared to 53.5% in the medical therapy group. The findings indicate that 46.5% of patients in the optimal medical therapy group were never revascularized.

Rasha Al-Lamee, MBBS, PhD, an interventionalist at Imperial College Healthcare NHS Trust in London who served as an AHA-invited discussant, stated that the findings confirm clinicians can no longer claim upfront PCI is performed for anything beyond controlling angina and improving quality of life. Al-Lamee acknowledged study limitations such as the use of bare-metal stents without advanced imaging guidance, but she emphasized that the data provide comfort when planning to manage stable coronary artery disease conservatively. The COURAGE extended follow-up received funding from the American Heart Association.