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

Background and Aims The randomized CENTURY trial tested the hypothesis that a comprehensive strategy integrating intense lifestyle modification and aggressive medical management to goals with revascularization reserved for severely reduced coronary flow capacity (CFC) by positron emission tomography (PET) would reduce risk factors, subsequent revascularization, death and myocardial infarction (MI) compared with standard of care in chronic stable coronary artery disease (CAD). Methods Participants were randomly assigned to standard or comprehensive care groups. Rest-stress PET quantified CFC for physiological CAD severity at baseline, 2, 5, and up to 11 years. The comprehensive care group reviewed PET results with frequent clinic visits and open 24/7 phone/email support. Standard care lacked supportive contact with blinded PET results that were unblinded only for severely reduced CFC with high mortality risk for potential revascularization. Results Between 2009–2017, 515 patients were assigned to comprehensive care and 513 to standard care and followed for 5 or more years. Comprehensive vs standard care decreased risk factors and summed 5-year risk score (Δ−1.1 vs + 0.33; 95% confidence interval −1.84 to −0.97; P < .0001), decreased cumulative 11-year all-cause death (4.7% vs 8.2%; P = .023), death or MI (7.0% vs 11.1%; P = .024) late revascularization (9.5% vs 14.8%; P = .021) and major adverse cardiac events (20.5% vs 29.9%; P = .0006). Only 56 of 1028 (5.4%) CENTURY patients with chronic CAD had revascularization within 90 days predominantly guided by CFC severity. Conclusions The randomized CENTURY trial demonstrates that comprehensive integrated lifestyle modification and medical management towards goals with revascularization reserved for severely reduced CFC, significantly reduced risk factor scores, death, death or MI, and revascularization.