Quantitative PET coronary flow capacity and comprehensive management of chronic CAD: Lessons from the randomized CENTURY trial.

Summary

In the randomized CENTURY trial (n=1,028), PET-derived coronary flow capacity–guided, comprehensive CAD care reduced all-cause death, death/MI, late revascularization, and MACE versus standard care. Early revascularization was reserved for severe CFC (5.4% within 90 days), while intensive risk-factor control tracked with sustained long-term benefits.

Key Findings

• All-cause mortality was lower with comprehensive care (4.7%) versus standard care (8.2%; P=0.023).
• Death or MI occurred less often with comprehensive care (7.0% vs 11.1%; P=0.024) and MACE was reduced (20.5% vs 29.9%; P=0.0006).
• Late revascularization decreased (9.6% vs 14.8%; P=0.011), with only 5.4% undergoing early revascularization within 90 days guided by severe PET-CFC.
• Greater adherence to risk-factor control over 5 years was associated with additional reductions in death, MI, and revascularization over the subsequent 5–11 years.

Clinical Implications

Implement comprehensive CAD programs that integrate intensive lifestyle/medical therapy and reserve revascularization for PET-identified severe CFC. Embed structured follow-up and patient support to sustain risk-factor control and outcomes.

Limitations

• Open-label behavioral/management intervention may introduce performance bias between groups.
• Generalizability may depend on PET access, infrastructure, and adherence to intensive follow-up; extended follow-up analyses were not pre-specified.

Future Directions

Multicenter implementation trials across diverse health systems, cost-effectiveness analyses, and comparisons with invasive physiology (FFR/iFR)-guided strategies.