Discussion
acute myocardial infarction, myocardial infarction, acute chest pain, TARGET-CTCA, chest pain, acute coronary syndrome, coronary artery disease
ACUTE MYOCARDIAL INFARCTION, MYOCARDIAL INFARCTION, CARDIAC DEATH, SECONDARY, ACUTE CORONARY SYNDROME, CARDIAC EVENTS, SUBSEQUENT MYOCARDIAL INFARCTION, CORONARY ARTERY DISEASE
In patients presenting to the emergency department with intermediate high-sensitivity cardiac troponin concentrations in whom myocardial infarction is ruled out, the TARGET-CTCA trial will evaluate whether early outpatient CTCA reduces subsequent myocardial infarction or cardiac death. The trial will evaluate the clinical and cost-effectiveness of using high-sensitivity cardiac troponin to target CTCA in patients at increased risk despite having myocardial infarction ruled out.The recent update of the NICE Clinical Guideline 95 evaluated the cost utility and performance of different diagnostic modalities and now recommends CTCA as the first line investigation for all patients presenting with stable chest pain suggestive of underlying coronary artery disease [The role of CTCA in the assessment of patients with acute chest pain is less clear. Due to the large number of patients presenting to emergency departments worldwide every year, the use of further investigations to assess patients in whom the diagnosis of myocardial infarction is ruled out need to be both clinically efficacious and cost-effective. Economic modelling suggests that CTCA may be the most cost-effective modality for the diagnosis of important coronary artery disease in patients with suspected acute coronary syndrome in whom myocardial infarction is ruled out [High-sensitivity cardiac troponin testing is already performed routinely in all patients with suspected acute coronary syndrome. As such, testing has major potential to improve the risk stratification of those patients in whom acute myocardial infarction is ruled out. Patients with intermediate cardiac troponin concentrations are at increased risk of cardiac events and are therefore more likely to benefit from further evaluation using CTCA and from secondary prevention in those found to have coronary artery disease. Currently, there is marked variation in the approach to the further evaluation and follow-up of patients after myocardial infarction has been ruled out, due to a lack of evidence from clinical trials to guide practice. Local pathways are based on expert opinion extrapolated from evidence derived in other patient populations. Consequently, current guidelines do not recommend any particular investigative approach for this large group of patients. As such, there is clinical equipoise to justify randomising patients to standard care or standard care with targeted CTCA in those with intermediate cardiac troponin concentrations.The TARGET-CTCA trial will determine whether high-sensitivity cardiac troponin-guided CTCA can improve outcomes and reduce subsequent major adverse cardiac events in patients presenting to the emergency department who do not have myocardial infarction.