Design: multicentre randomised controlled trial, event-driven (TARGET-CTCA)
Population: 3,170 UK emergency-department patients with suspected ACS, myocardial infarction ruled out, maximum hs-troponin >5 ng/L; median age 61, 30.2% women
Primary outcome: composite of myocardial infarction or death from a cardiac cause
Effect: 7.1% with CT coronary angiography-guided care vs 7.3% with standard care over median 3.0 years (adjusted HR 0.95; 95% CI 0.73-1.23; P = 0.71)

TARGET-CTCA enrolled 3,170 patients across 14 UK emergency departments who had presented with suspected acute coronary syndrome, had myocardial infarction ruled out, and had a high-sensitivity troponin above 5 ng/L — a group known to remain at raised risk. They were randomised to outpatient CT coronary angiography-guided care or standard care.

The imaging was delivered: 92.1% of the CT group had the scan within 90 days, against 2.2% in the standard-care arm, so this is a clean test of the strategy rather than a diluted one. After a median of three years, myocardial infarction or cardiac death had occurred in 7.1% of the CT group and 7.3% of the standard-care group.

The finding is worth holding precisely because the underlying premise is sound. These patients do have events — about one in fourteen over three years — and the scan does find disease. What it did not do was convert that information into fewer events, which is the more demanding claim and the only one that justifies routine use.

The question this reframes is what the raised troponin should trigger. Not, on this evidence, an automatic scan. Risk-factor assessment and secondary-prevention therapy remain the parts with outcome evidence behind them.

Do not order routine outpatient CT coronary angiography solely because troponin was detectable but not diagnostic
Treat a troponin above the limit of detection as a prognostic flag for risk-factor review
Reserve the scan for a specific clinical question — ongoing symptoms, an abnormal ECG, a diagnostic uncertainty
Check lipids, blood pressure, glycaemia and smoking status at that visit, which is what the evidence supports
Set expectations with patients: a normal scan does not reduce their risk, and an abnormal one may not change their treatment

Don't overread it

This tested routine scanning in a ruled-out population — it says nothing about CT coronary angiography for stable chest pain, where the evidence is different.

The statistics, in plain English

The adjusted hazard ratio of 0.95 with a 95% confidence interval of 0.73 to 1.23 spans 1.0, which means the data are compatible with anything from a 27% relative reduction to a 23% relative increase — a genuinely null result rather than a small benefit missed. The trial was event-driven, continuing until the standard-care arm had passed a prespecified 97 primary events, which is the design feature that gives that interval its width. Its precision is adequate to exclude a large benefit; it cannot exclude a small one.