CT coronary angiography after a ruled-out infarct changed nothing over three years

The edition in brief

Two large negative trials today, and both target investigations that emergency departments have been steadily adding. TARGET-CTCA randomised 3,170 patients across 14 UK hospitals who presented with suspected acute coronary syndrome, had myocardial infarction ruled out, but had a high-sensitivity troponin above 5 ng/L marking intermediate risk. They received outpatient CT coronary angiography-guided care or standard care. CT was performed in 92.1% of the intervention group and 2.2% of controls. After a median 3.0 years, myocardial infarction or cardiac death occurred in 112 participants (7.1%) with CT and 116 (7.3%) with standard care, adjusted hazard ratio 0.95 (95% CI 0.73 to 1.23). Scan-related adverse events occurred in 0.4%. ASPIRED randomised 2,234 patients at 45 UK hospitals with syncope unexplained after emergency department assessment to 14-day ambulatory ECG monitoring or standard care. Mean patient-reported syncope episodes at one year were 1.37 versus 1.58 (incidence rate ratio 0.89, 95% CI 0.68 to 1.18). Adverse events were 49 in the monitoring arm and 8 in standard care. PRoMPT BOLUS randomised 9,041 children with septic shock across 47 emergency departments to balanced fluid or 0.9% saline. Major adverse kidney events were 3.4% versus 3.0% (risk ratio 1.10, 95% CI 0.88 to 1.40), despite hyperchloraemia in 49.0% of the saline group. A meta-analysis of 12 non-randomised studies found phenobarbital pathways for alcohol withdrawal shortened ICU stay by 0.6 days without changing intubation rates. Regulatory: a generic buprenorphine-naloxone supplement was approved on 14 August.