A patient whose troponin is measurably raised but not infarct-level occupies an uncomfortable space. They are not having a myocardial infarction, but their risk is above baseline, and the instinct to investigate further is strong. TARGET-CTCA tested whether acting on that instinct helps.
The trial enrolled 3,170 patients at 14 UK hospitals who presented to the emergency department with suspected acute coronary syndrome, in whom infarction had been ruled out, and whose maximum high-sensitivity troponin I or T exceeded 5 ng/L. Median age was 61 and 30.2% were women. They were randomised to outpatient CT coronary angiography-guided care or standard care. Separation was excellent: CT was done in 92.1% of the intervention arm and 2.2% of controls within 90 days.
After a median 3.0 years, the primary composite of myocardial infarction or cardiac death occurred in 112 patients (7.1%) with CT-guided care and 116 (7.3%) with standard care, adjusted hazard ratio 0.95 (95% CI 0.73 to 1.23, p=0.71). CT-related adverse events occurred in 7 patients (0.4%).
The result deserves care in how it is stated. It does not say CT coronary angiography is useless — it says that in this population, routinely finding and acting on coronary disease did not change hard outcomes over three years. Most of these patients were presumably already receiving secondary prevention where indicated, and the incremental yield of imaging on top of that was nil.
What it settles for an emergency department is the disposition conversation. A patient whose infarct has been excluded does not need a scan arranged before they leave, and telling them so is now supported by a trial rather than by resource pressure.
- Do not routinely arrange outpatient CT coronary angiography for a patient whose myocardial infarction has been ruled out on high-sensitivity troponin
- Note the 7% three-year event rate in both arms — this population is not low risk, so cardiovascular risk factor management still matters
- Focus discharge on modifiable risk: blood pressure, lipids, smoking, glycaemia, and a named follow-up clinician
- Reserve CT coronary angiography for a specific clinical question, such as ongoing typical symptoms, rather than as routine risk stratification
- Remember 0.4% had a scan-related adverse event, which is small but not zero for a test that changed nothing
The statistics, in plain English
An adjusted hazard ratio of 0.95 with an interval of 0.73 to 1.23 is a well-powered null: with 228 primary events across 3,170 patients over three years, the trial could have detected a 27% reduction had one existed. The absolute difference is 0.2 percentage points. The design detail that makes this trustworthy is the separation — 92.1% versus 2.2% actually scanned, so this genuinely compares scanning against not scanning rather than two similar pathways. Note the primary outcome counted only myocardial infarction and cardiac death; the trial does not tell you whether CT reduced anxiety, repeat attendance, or the number of subsequent investigations.
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