Design: Multicentre RCT, 14 UK emergency departments
Population: 3170 patients with MI ruled out and hs-troponin >5 ng/L
Primary outcome: MI or cardiac death
Effect: 7.1% vs 7.3%; adjusted HR 0.95 (95% CI 0.73 to 1.23)

TARGET-CTCA randomised 3170 patients at 14 UK emergency departments in whom myocardial infarction had been ruled out but whose peak high-sensitivity troponin was above 5 ng/L, a marker of intermediate future risk. They received outpatient CT coronary angiography-guided care or standard care. Median age was 61 and 30% were women. It was published in NEJM in August.

CT was performed in 92% of the intervention group within 90 days, with adverse events in 0.4%. After a median three years, myocardial infarction or cardiac death occurred in 7.1% with CT-guided care and 7.3% with standard care (adjusted HR 0.95, 95% CI 0.73 to 1.23).

This removes the case for routinely sending every intermediate-risk rule-out patient for CT. The risk these patients carry is real — about 7% over three years — but further anatomical testing did not reduce it. Risk-factor management, symptom review and selective testing for those with ongoing symptoms are the better use of resources.

Do not refer every intermediate-risk MI rule-out for routine CT coronary angiography.
Treat risk factors: statin, blood pressure, smoking, diabetes.
Arrange review for recurrent or ongoing symptoms and test selectively.
Tell patients a troponin above 5 ng/L still signals future risk worth addressing.

Why it matters

It shows that more imaging after a negative rule-out does not lower the real risk these patients carry.

The statistics, in plain English

The HR of 0.95 with an interval from 0.73 to 1.23 includes a modest benefit and a modest harm, so a small effect cannot be excluded, but a meaningful one is unlikely. The trial reached its prespecified number of events, so it was adequately powered for the question it asked.