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TARGET-CTCAImagingNew England Journal of Medicine
Computed Tomographic Coronary Angiography for Suspected Acute Coronary Syndrome
Targeted Use of Computed Tomographic Coronary Angiography in Acute Chest Pain
View Full PaperWhy the trial?
Patients whose acute chest pain proves not to be myocardial infarction still carry meaningful longer-term coronary risk. TARGET-CTCA asked whether early outpatient CT coronary angiography after MI has been ruled out prevents subsequent infarction or cardiovascular death.
Does outpatient CT coronary angiography-guided care reduce the composite of myocardial infarction or death from a cardiac cause in patients with suspected acute coronary syndrome in whom myocardial infarction has been ruled out and who have intermediate risk?
Population
3,170 intermediate-risk patients (hs-cTn >5 ng/L) with MI ruled out, 14 UK hospitals
Comparison
Outpatient CT coronary angiography-guided care vs standard care
Design
Multicenter randomized controlled trial (1:1); blinding not described
Follow-up
Median 3.0 years
Key result
Routine CT coronary angiography-guided management did not reduce the incidence of myocardial infarction or cardiac death compared to standard care (HR 0.95; 95% CI 0.73-1.23; P=0.71).
Authors
Discussion
Key questions
Member takes
Where experts stand
Experts read TARGET-CTCA as a clear null result, reinforcing that routine CT coronary angiography after a heart attack has been ruled out does not improve outcomes and should not be adopted into practice.
Cardiologists view this trial as strong evidence against adding routine coronary CT scanning for patients whose troponin results leave them in an intermediate-risk zone once a heart attack has been excluded. The reaction is broadly one-sided, with no expert arguing the imaging strategy should still be pursued. The live question is whether these findings will prompt guideline bodies to narrow the indications for outpatient CTCA in acute chest pain pathways.
Agreement
Multiple experts agree that routine CTCA after myocardial infarction has been ruled out does not improve patient outcomes and is not warranted.
3 clinicians say this directly
What they’re arguing about
supportiveneutralcautiouscritical
Counts are expert takes we classified by axis. Tap a row to see the takes behind its count.
Still unclear
It remains uncertain whether specific subgroups within the intermediate-risk troponin population might still benefit from CTCA, and whether guidelines will now formally narrow the indications for outpatient CTCA in acute chest pain pathways.
Key expert perspectives
Anything that is routine usually does not work
Damluji sees TARGET-CTCA as confirming a broader principle: blanket application of a test to all comers rarely produces benefit. He highlights the trial design as rigorous but the result as unsurprising given prior evidence.
Implementing CTCA to guide management in these patients is not warranted
Ghanavati concludes that in suspected acute coronary syndrome without MI, routine CT coronary angiography did not reduce the incidence of MI or cardiovascular death, and explicitly states that implementing CTCA in this setting is not warranted.
NMNick MillsBHF Professor of Cardiology, University of EdinburghPractice takeAug 30
Once a heart attack is excluded, patients can be reassured and sent home without further scanning
Mills, the trial presenter, states the findings provide strong evidence that patients who have had a heart attack excluded do not benefit from early outpatient CTCA. He argues clinicians can reassure these patients that their future risk is low.
Distilled from their postOriginal post
Overview
Routine early CTCA adds no benefit after MI exclusion; confirms standard care alone suffices for event reduction in this population.
Key Points
- To evaluate whether outpatient CT coronary angiography-guided care reduces subsequent myocardial infarction or cardiac death in patients with suspected acute coronary syndrome after initial rule-out of myocardial infarction.
- Multicenter, randomized controlled trial (TARGET-CTCA; NCT03952351) in 14 UK hospitals enrolling 3170 intermediate-risk patients (high-sensitivity cardiac troponin I/T >5 ng/L) with ruled-out myocardial infarction.
- Participants were randomly assigned 1:1 to receive outpatient CT coronary angiography-guided care (N=1587) or standard care (N=1583), followed for a median duration of 3.0 years.
- The primary composite outcome of myocardial infarction or cardiac death occurred in 112 participants (7.1%) in the CT coronary angiography group versus 116 (7.3%) in the standard-care group (adjusted HR, 0.95; 95% CI, 0.73 to 1.23; P=0.71).
- By 90 days, CT coronary angiography was performed in 92.1% (1462/1587) of the intervention group and 2.2% (35/1583) of the standard-care group, with procedure-related adverse events in 0.4% (7/1587).
Evidence details
What drove the result?
| Outcome | CTCA-guided | Standard care |
|---|---|---|
| MI or death from a cardiac cause | 112/1,587 (7.1%) | 116/1,583 (7.3%) |
| Adjusted HR 0.95 (95% CI 0.73-1.23; P=0.71) · no benefit; treatment separation was good (CTCA in 92.1% vs 2.2%) | ||
Limitations & tradeoffs
Patient burden
CTCA-related adverse events 7/1,587 (0.4%) in the CTCA group.
Representation
applies only to intermediate-risk patients (peak hs-cTn >5 ng/L) after MI has been ruled out, and was conducted entirely in the UK (14 hospitals).
Design limitations
follow-up was event-driven, ending once standard-care primary-outcome events exceeded the prespecified minimum of 97.
Structured PICO
Does outpatient CT coronary angiography-guided care reduce the composite of myocardial infarction or death from a cardiac cause in patients with suspected acute coronary syndrome in whom myocardial infarction has been ruled out and who have intermediate risk?
P
Population
3,170 patients with suspected acute coronary syndrome, ruled-out myocardial infarction, and intermediate risk based on troponin testing, followed for a median of 3.0 years.
I
Intervention
Outpatient computed tomographic (CT) coronary angiography-guided care
C
Comparator
Standard care
O
Outcome
Composite of myocardial infarction or death from a cardiac causecomposite
Routine outpatient CT coronary angiography-guided management did not reduce the incidence of subsequent myocardial infarction or cardiac death compared to standard care in patients with suspected ACS and intermediate risk after MI rule-out.
Main Result
Hazard Ratio: 0.95 (95% CI 0.73–1.23)
Absolute Event Rate: 7.1% vs 7.3%
p-value: p=0.71
Coverage & sources
Journal, society, and media accounts. Useful signal, not independent expert judgment.
Cite This Study
Lee et al. (2026) conducted an RCT in Suspected acute coronary syndrome (n=3,170). CT coronary angiography-guided care vs. Standard care was evaluated on Composite of myocardial infarction or death from a cardiac cause (HR 0.95, 95% CI 0.73 to 1.23, p=0.71). Routine CT coronary angiography-guided management did not reduce the incidence of myocardial infarction or cardiac death compared to standard care (HR 0.95; 95% CI 0.73-1.23; P=0.71).