Routine heart CT scans bring no benefit after heart attack is ruled out

Chest pain sends people through emergency-department doors looking for one answer: is the heart under attack? In the UK TARGET-CTCA trial, 3,170 patients whose heart attacks had been ruled out received either a coronary CT angiography scan—CTCA, an imaging test that looks for narrowed heart arteries—or standard care. After three years, the scan had not lowered the risk of a heart attack or cardiac death.

The numbers were close. 7.1% of patients assigned to CTCA had a heart attack or died from a heart attack, heart failure or sudden cardiac death, compared with 7.3% in the standard-care group. The trial was presented at the European Society of Cardiology Congress in Munich and published in the New England Journal of Medicine.

The patients were not considered entirely risk-free. Everyone had a cardiac troponin level above 5 ng/L, placing them in an intermediate-risk category under European guidance. Troponin tests detect signs of heart damage in the blood; doctors then use the result, alongside the emergency assessment, to decide whether further testing is needed. In the trial, 1,587 people received CTCA plus standard care, while 1,583 received standard care alone, with their general practitioner deciding on follow-up treatment.

The scans did find disease: 32% of those scanned had normal coronary arteries, while nonobstructive disease was found in 42% and obstructive disease in 23%. Yet during follow-up, 112 people in the CTCA group had a heart attack or cardiac death, versus 116 in standard care, despite more people in the scan group taking preventive medication. The findings were also consistent among people with no previous heart-disease diagnosis.

So what changes in practice? Once clinicians are confident that a heart attack has been excluded, routine early CTCA may not be needed for this group. That could simplify follow-up, reduce demand on overstretched imaging and cardiology services, and lower health care costs without worsening the measured outcomes. It does not change the first step: sudden chest pain or discomfort that does not go away still calls for an ambulance and emergency assessment.