Routine CT coronary scans after chest pain did not cut later heart attacks

Patients who came to an emergency department with chest pain, had a heart attack ruled out by a blood test, and then received extra outpatient CT scans of their coronary arteries were no less likely to have a heart attack or die of a cardiac cause over the next three years than patients who received standard care [s1]. That is the result of TARGET-CTCA, a UK randomised trial published in the New England Journal of Medicine on August 29 [s1].

The trial addresses a genuine clinical gap. Many people arrive with suspected acute coronary syndrome, have myocardial infarction excluded by high-sensitivity troponin testing, and are sent home — yet some of them remain at real cardiovascular risk. The intuition that finding and treating hidden coronary disease with imaging should lower that risk is strong. TARGET-CTCA tested whether the intuition holds.

The trial

At 14 hospitals across the United Kingdom, patients were enrolled after myocardial infarction had been ruled out but their high-sensitivity troponin indicated an intermediate risk of a cardiovascular event — a maximum troponin concentration above 5 ng per litre [s1]. From September 2019 to May 2023, 3,170 participants (median age 61 years; 30.2% female) were randomly assigned in a 1:1 ratio to outpatient CT coronary angiography-guided care or to standard care [s1]. The primary outcome was a composite of myocardial infarction or death from a cardiac cause [s1].

The assignment took hold as intended: by 90 days, CT coronary angiography had been done in 1,462 of 1,587 participants (92.1%) in the imaging group, against 35 of 1,583 (2.2%) under standard care [s1]. The scan itself was low-risk, with a CT-related adverse event in 7 participants (0.4%) [s1].

What it found

After a median of 3.0 years, 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 [s1]. The adjusted hazard ratio was 0.95 (95% confidence interval, 0.73 to 1.23; P=0.71) — a confidence interval centred close to no effect and wide enough to exclude any large benefit [s1]. Routinely imaging these patients did not reduce their subsequent heart attacks or cardiac deaths [s1].

Why it did not surprise everyone

TARGET-CTCA is the second UK trial to reach this conclusion in broadly this population. The earlier RAPID-CTCA trial, whose full results were reported in an NIHR Health Technology Assessment monograph, randomised patients with suspected acute coronary syndrome to early CT coronary angiography or standard care and found the primary end point of one-year death or subsequent myocardial infarction in 51 patients (5.8%) with imaging versus 53 (6.1%) without — an adjusted hazard ratio of 0.91 (95% CI, 0.62 to 1.35; P=0.65) [s2]. In that trial too, the scan changed downstream testing — it was associated with reduced use of invasive coronary angiography — without moving hard outcomes [s2]. Two trials asking a similar question have now landed in the same place.

The limits

TARGET-CTCA answers a targeted question and should be read narrowly. It applies to patients in whom infarction had already been excluded and who sat in a specific intermediate-risk band defined by troponin, not to everyone with chest pain [s1]. It compared a strategy of routine outpatient scanning against standard care; it does not show that CT coronary angiography is useless in every setting, only that adding it routinely to this group did not lower events over three years [s1]. And a composite of myocardial infarction or cardiac death, while the outcome that matters most, does not capture every way imaging might change care, such as symptom relief or patient reassurance [s1]. The trial was funded by the British Heart Foundation, not by an imaging manufacturer [s1].

What to watch

The finding sharpens a practical question for emergency and cardiology services: where does coronary CT add value, and where is it activity without benefit? It complements the site's coverage of how rapid high-sensitivity troponin pathways decide who can be sent home safely, and it echoes a recurring lesson from recent cardiology trials — seen also when a clot-preventing drug added after acute coronary syndrome changed nothing — that more investigation or more treatment does not automatically mean fewer events.

This article describes trial results and a diagnostic strategy for informational purposes only. It is not medical advice or a recommendation about any test.

Sources

• [s1] Lee KK, et al. Targeted Use of Computed Tomographic Coronary Angiography in Acute Chest Pain. New England Journal of Medicine, published online 2026-08-29.
• [s2] Gray AJ, Roobottom C, Smith JE, et al. Early computed tomography coronary angiography in adults presenting with suspected acute coronary syndrome: the RAPID-CTCA RCT. Health Technology Assessment (NIHR) 2022;26(37).