BACKGROUND: Many patients with suspected acute coronary syndrome in whom myocardial infarction has been ruled out in the emergency department remain at risk for cardiovascular events. Whether further investigation reduces this risk is unknown.
METHODS: In a multicenter, randomized, controlled trial, patients who presented to an emergency department in 14 hospitals across the United Kingdom were enrolled if myocardial infarction had been ruled out and high-sensitivity cardiac troponin testing indicated an intermediate risk of a cardiovascular event (maximum high-sensitivity cardiac troponin I or T concentration, >5 ng per liter). Participants were randomly assigned in a 1:1 ratio to receive either outpatient computed tomographic (CT) coronary angiography-guided care or standard care. The primary outcome was a composite of myocardial infarction or death from a cardiac cause.
RESULTS: From September 18, 2019, to May 11, 2023, a total of 3170 participants (median age, 61 years; female sex, 30.2%) were assigned to undergo CT coronary angiography (1587 participants) or receive standard care (1583 participants). At 90 days after randomization, CT coronary angiography had been performed in 1462 participants (92.1%) in the CT coronary angiography group and in 35 participants (2.2%) in the standard-care group. Overall, 7 participants (0.4%) had a CT coronary angiography-related adverse event. After a median of 3.0 years, at which point the number of primary-outcome events in the standard-care group exceeded the prespecified minimum of 97, a primary-outcome event had occurred in 112 participants (7.1%) in the CT coronary angiography group and in 116 (7.3%) in the standard-care group (adjusted hazard ratio, 0.95; 95% confidence interval, 0.73 to 1.23; P = 0.71).
CONCLUSIONS: In patients with suspected acute coronary syndrome in whom myocardial infarction had been ruled out, routine CT coronary angiography-guided management did not result in a lower incidence of subsequent myocardial infarction or death from a cardiac cause than standard care. (Funded by the British Heart Foundation; TARGET-CTCA ClinicalTrials.gov number, NCT03952351.).
| Discipline Area | Score |
|---|---|
| Emergency Medicine |  |
| Hospital Doctor/Hospitalists | |
| Internal Medicine | |
| Cardiology | |
Similar to the PROMISE study, which wasn't referenced for some reason.
This is an interesting RCT and must have been difficult to enrol and complete. This study suggests that a CTCA in a suspected cardiac event, in the absence of established myocardial infarction, did not provide additional benefit. This might help rationalise the use of CTCA in delineating cardiovascular risks.
This randomized trial reassures that standard care, not necessarily requiring angiographic evaluation of coronary anatomy, is acceptable in patients with an intermediate risk and troponin for a cardiovascular event.
Very interesting.
I think this is a really important negative trial that provides some push-back on the progressive creep of technology and advanced imaging.
An expensive test that we may be ordering too often.
