Optimal medical care and coronary flow capacity-guided myocardial revascularization vs usual care for chronic coronary artery disease: the CENTURY trial.

Summary

In this randomized trial (n=1,028), a comprehensive PET–coronary flow capacity–guided program combining intensive lifestyle modification and aggressive goal-directed medical therapy reduced 11-year all-cause mortality, death/MI, late revascularization, and MACE compared with usual care. Revascularization within 90 days was rare and predominantly reserved for severely reduced CFC.

Key Findings

• Comprehensive care lowered 11-year all-cause mortality (4.7% vs 8.2%; P=0.023).
• Death or MI was reduced (7.0% vs 11.1%; P=0.024) and late revascularization decreased (9.5% vs 14.8%; P=0.021).
• Major adverse cardiac events were significantly lower (20.5% vs 29.9%; P=0.0006).
• Only 5.4% underwent early revascularization, predominantly guided by severely reduced CFC.

Clinical Implications

Adopt integrated programs that combine intensive lifestyle intervention and goal-directed pharmacotherapy with PET-based CFC to triage revascularization, aiming to reduce mortality and MI in stable CAD.

Limitations

• Single-center programmatic model may limit generalizability across health systems.
• Open-label comprehensive care with frequent contacts may introduce performance bias.

Future Directions

Multicenter pragmatic trials to test PET-CFC–guided comprehensive care pathways, cost-effectiveness analyses, and implementation frameworks across diverse healthcare settings.