PET scan-guided program superior to standard care in patients with suspected CAD
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Key takeaways:
- A strategy involving shared cardiac PET scans and frequent follow-up improved CV risk and outcomes vs. standard care.
- CENTURY is the first trial to show a PET scan-guided strategy can lower risk for CV events.
A comprehensive strategy involving shared cardiac PET scans was associated with better CV outcomes compared with standard care in patients with suspected CAD, according to the results of the CENTURY trial.
Nils Johnson, MD, MS, FACC, FESC, professor of medicine and Weatherhead Distinguished Chair of Heart Disease in the division of cardiology, department of medicine and the Weatherhead PET Imaging Center at McGovern Medical School at UTHealth (Houston) and Memorial Medical Hospital, Texas Medical Center, and colleagues randomly assigned 1,028 patients with suspected CAD to a comprehensive strategy, including an intense program involving frequent follow-up visits for monitoring and support, close contact and shared PET scans, or to a standard strategy consisting of one brief review at baseline, return to the patient’s private physician for all treatment, follow-up visits once per year and no sharing of PET images unless they indicated that PCI or CABG was needed immediately. PET scans were performed at baseline and at 2 and 5 years.
All patients were aged 40 years or older and had established CAD or a 10-year Framingham risk score of at least 10%, Johnson said during a presentation at the Annual Scientific Session and Exhibition of the American Society of Nuclear Cardiology.
The primary endpoint was a CV risk score at 5 years established by written responses and interviews by a masked certified nutritionist at baseline and at each visit; the score assessed 16 risk factors and ranged from 0 (healthiest) to 37 (unhealthiest). The secondary endpoints were MACE and its components at 5 years: death, MI, cerebrovascular accident and CABG or PCI after 90 days. Revascularization within the first 90 days was not included because it would have been triggered by the PET scan, Johnson said.
Frequent follow-up
“We saw these patients [in the comprehensive group] much more frequently, several times during the first year, and then at least every 6 months or more often if needed through the rest of follow-up,” he said. “Their PET scans were unblinded and reviewed with several different goals. One was for reassurance of patients that they don’t need procedures or, in particular cases, referral for specific procedures. And also motivation for adherence. At every visit, the patients had a chance to sit down and get counseling with nurses and physicians, as well as diet and lifestyle consultation.”
At 5 years, the CV risk score was better in the comprehensive group compared with the standard group (P < .0001), Johnson said.
MACE was lower at 5 years in the comprehensive group compared with the standard group (20.5% vs. 29.9%; HR = 0.61; 95% CI, 0.4-0.92; P = .0006), as was death (4.7% vs. 8.2%; HR = 0.38; 95% CI, 0.15-0.98; P = .023), death/MI (7% vs. 11.1%; P = .024) and revascularization after 90 days (9.6% vs. 14.8%; P = .011), he said.
Survival probability at 11 years favors the comprehensive group and more long-term data will be released in the future, Johnson said during the presentation.
Most of the patients who received revascularization within 90 days of a PET scan had severely reduced coronary flow capacity, he said.
“Without severely reduced coronary flow capacity, these patients are appropriate for medical therapy,” Johnson said. He noted, however, that only 10.4% of scans (3.6% of patients) indicating severely reduced coronary flow capacity on PET led to revascularization. “This to me is a necessary but not sufficient criterion for invasive management. The low revascularization rates reflect the value of flow layered on top of uptake maps in order to appropriately select patients for invasive management.”
First evidence of improvement in MACE
CENTURY contradicted four previous studies showing that a PET-based strategy was not associated with improvement in MACE, but that may be because CENTURY was much larger and longer than the other trials, Johnson said.
“The CENTURY study offers us the first evidence of PET-guided therapy in order to reduce not just composite major adverse cardiac events, but also all-cause mortality,” he said.
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Johnson N, et al. Featured clinical trial. Presented at: ASNC2023: Annual Scientific Session and Exhibition of the American Society of Nuclear Cardiology; Sept. 29-Oct. 7, 2023; Toronto (hybrid meeting).
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