cardiology papercut lit review

Targeted CTCA in Acute Chest Pain: TARGET-CTA Trial

Nov 09, 2026

The TARGET-CTCA trial investigated whether early outpatient CTCA-guided management reduces subsequent myocardial infarction or cardiac death in patients with suspected ACS in whom acute myocardial infarction has been excluded.

THE STUDY
Lee KK et al. Targeted Use of Computed Tomographic Coronary Angiography in Acute Chest Pain. NEJM. 2026;395:1794–1804.

Introduction

Patients presenting to the Emergency Department with suspected acute coronary syndrome (ACS) frequently undergo high-sensitivity troponin testing to exclude acute myocardial infarction. Rapid rule-out protocols have enabled rapid safe discharge of patients and have reduced the need for admission.

Although myocardial infarction can be safely ruled out in many patients, this does not necessarily mean they are at low risk of future cardiovascular events.

Patients with low troponin concentrations remain at low risk for a myocardial infarction, however, those patients with intermediate troponin concentrations—above 5 ng/

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THE STUDY
Lee KK et al. Targeted Use of Computed Tomographic Coronary Angiography in Acute Chest Pain. NEJM. 2026;395:1794–1804.

Introduction

Although myocardial infarction can be safely ruled out in many patients, this does not necessarily mean they are at low risk of future cardiovascular events.

Patients with low troponin concentrations remain at low risk for a myocardial infarction, however, those patients with intermediate troponin concentrations—above 5 ng/L but below the sex-specific 99th percentile—have an increased risk of underlying coronary artery disease and subsequent cardiovascular events.

CT coronary angiography (CTCA) can identify coronary artery disease and potentially guide preventative treatment. However, whether routinely performing CTCA in these patients improves long-term clinical outcomes remains uncertain.

What They Did

TARGET-CTCA was a multicentre, open-label, randomised controlled trial conducted across 14 hospitals in the United Kingdom, with blinded assessment of clinical outcomes.

The investigators recruited 3,170 patients with suspected ACS in whom myocardial infarction had been ruled out, but whose high-sensitivity troponin concentrations suggested an intermediate risk of future cardiovascular events.

Participants had a median age of 61 years, and 30.2% were women.

Patients were randomised into two groups:

CTCA-guided care (n=1,587): Early outpatient CTCA, ideally within four weeks, with subsequent treatment guided by the imaging findings.
Standard care (n=1,583): Usual clinical management without routine CTCA.

CTCA findings were used to guide preventative medication, cardiology referral and further investigation where appropriate.

The primary outcome was a composite of myocardial infarction or death from a cardiac cause.

Secondary outcomes included: clinical, participant-reported, process and cost-effectiveness outcomes.

Median follow-up was 3 years.

What They Found

PRIMARY OUTCOME — MI OR CARDIAC DEATH

CTCA-guided care 7.1% 112 / 1,587 patients

Standard care 7.3% 116 / 1,583 patients

Adjusted hazard ratio 0.95 (95% CI 0.73–1.23); P = 0.71. No statistically significant difference.

Despite increasing the detection of coronary artery disease and the use of preventative therapies, CTCA-guided care did not significantly reduce myocardial infarction or cardiac death.

Other important findings included:

Coronary artery disease was common: Among patients undergoing CTCA, 42.5% had nonobstructive disease and 22.6% had obstructive disease.
Increased preventative treatment: At 90 days, statin use was 63.4% in the CTCA group compared with 48.5% in the standard-care group.
More invasive investigations: Invasive coronary angiography was performed in 11.2% of CTCA patients compared with 8.7% receiving standard care.
No significant reduction in myocardial infarction: MI occurred in 5.9% versus 6.3% of patients, respectively.
Incidental findings: Clinically significant noncardiac findings were identified in 10.7% of patients undergoing CTCA.
Adverse events: CTCA-related complications occurred in 0.4% of patients.

Although all-cause mortality was numerically lower in the CTCA group (4.6% versus 6.1%), this was an exploratory secondary finding and cannot establish a causal benefit.

Conclusion

"In this large, prospective, multicenter, randomized trial involving participants with suspected acute coronary syndrome in whom myocardial infarction had been ruled out and troponin levels suggested intermediate risk, use of early outpatient CT coronary angiography to guide care did not reduce the incidence of subsequent myocardial infarction or death from a cardiac cause."

Although CTCA identified substantial coronary artery disease and increased the prescription of preventative therapies, these changes did not translate into improved cardiovascular outcomes over three years.

CTCA remains useful in selected patients when there is a specific clinical indication, but the trial does not support routinely performing CTCA in all troponin-defined intermediate-risk patients following exclusion of myocardial infarction.

Following exclusion of acute myocardial infarction, further cardiac imaging should be guided by clinical assessment and individual patient risk rather than troponin concentrations alone.