TARGET-CTCA Found No Benefit for Routine CT Coronary Angiography
Key Takeaways
- Among more than 3,000 intermediate-risk patients with suspected ACS after ED rule-out of MI, routine outpatient CT coronary angiography-guided care did not appear to lower subsequent MI or cardiac death versus standard care.
- Over a median of 3.0 years, the primary composite outcome occurred in 7.1% of the CT coronary angiography group and 7.3% of the standard-care group, and the difference was not significant.
- By 90 days, CT coronary angiography had been performed in 92.1% of participants assigned to imaging and 2.2% of those assigned to standard care.
- CT coronary angiography-related adverse events were uncommon, occurring in 0.4% of participants overall.
In the TARGET-CTCA trial, investigators enrolled patients presenting to EDs at 14 hospitals across the United Kingdom after MI had been ruled out but maximum high-sensitivity cardiac troponin I or T remained greater than 5 ng per liter, indicating intermediate risk.
A total of 3,170 participants were randomly assigned 1:1 to outpatient CT coronary angiography-guided care or standard care, and the primary outcome was MI or death from a cardiac cause.
By 90 days after randomization, CT coronary angiography had been performed in 1,462 participants (92.1%) assigned to imaging and 35 participants (2.2%) assigned to standard care. Overall, 7 participants (0.4%) had a CT coronary angiography-related adverse event.
After a median follow-up of 3.0 years, the primary composite occurred in 112 of 1,587 participants (7.1%) assigned to CT coronary angiography-guided care and 116 of 1,583 participants (7.3%) assigned to standard care. The adjusted hazard ratio was 0.95 (95% CI 0.73 to 1.23; P=0.71), indicating no significant difference in MI or death from a cardiac cause between groups.
Within the bounds of the reported randomized comparison, routine outpatient CT coronary angiography-guided management was not supported as a way to lower subsequent MI or cardiac death in this specific post-rule-out population.
The authors reported that, in patients with suspected ACS after MI had been ruled out, routine CT coronary angiography-guided management did not result in a lower incidence of subsequent MI or death from a cardiac cause than standard care.
Clinician Questions
Which patients does the TARGET-CTCA result apply to after emergency department rule-out of myocardial infarction?
The result applies to patients who presented to EDs with suspected ACS, had MI already ruled out, and still had high-sensitivity cardiac troponin I or T concentrations greater than 5 ng per liter, marking an intermediate-risk group. Because the randomized comparison was conducted in United Kingdom emergency departments, it does not directly establish the effect of routine outpatient CT coronary angiography outside that presentation profile and care context.
What outcome determined whether routine outpatient CT coronary angiography improved hard events in TARGET-CTCA?
Investigators used a primary composite endpoint of MI or death from a cardiac cause. The neutral conclusion is therefore bounded to that prespecified hard-outcome measure.
Did TARGET-CTCA create a real difference in imaging exposure between the CT coronary angiography and standard-care groups?
Yes. CT coronary angiography was completed in most participants assigned to the imaging strategy and only rarely in the standard-care group by 90 days, so the randomized comparison achieved clear separation in exposure to outpatient CT coronary angiography.
What safety information was reported for outpatient CT coronary angiography after myocardial infarction had been ruled out?
Investigators reported CT coronary angiography-related adverse events in a small proportion of participants overall after MI had been ruled out.
Recommended Reading
- For more on ACS management after ED rule-out: Applying Guideline Recommendations to ACS Management