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Cardiac Imaging and Diagnostics · Journal article
Heart · August 16, 2026
Encouraging direction, but not yet definitive.
CACS reduced unnecessary cardiology referrals by 47.1% relative to standard care and improved preventive enrolment in primary-care chest pain patients, but did not improve the primary outcome of practice-level cardiovascular risk management registration and did not significantly increase obstructive coronary artery disease detection. The test appears useful for triage in low-risk patients but lacks evidence of hard clinical benefit.
Pragmatic, non-blinded cluster-randomized controlled trial. Adults aged ≥40 years (men) or ≥45 years (women), without known coronary artery disease, with possible cardiac or non-cardiac chest pain attending Dutch general practices. Per-protocol cohort: 57.5% women, mean age 60.6±9.1 years.. Intervention: Coronary artery calcium scoring (CACS) for chest pain evaluation in general practice. Compared with: Standard of care (SOC) without CACS. n = 583. Dutch general practices (101 clusters; specific regional/national coverage not stated).
Primary outcome: no significant difference in 2-year CVRM registration increase at practice level (CACS +0.3% vs SOC +0.2%, p=0.77) CACS reduced cardiologist referral rate by 47.1% relative (42.5% vs 80.3%; modelled difference 31.3%, 95% CI 14.8%–47.8%) OCAD detection rates not significantly different (CACS 4.9% vs SOC 7.7%, p=0.14)
No hard clinical endpoints (mortality, myocardial infarction, revascularization need) reported; long-term patient outcomes unknown.
CACS appears effective for reducing unnecessary cardiology referrals in primary-care chest pain evaluation and improving preventive enrolment. However, the failure to improve practice-level preventive registrations and the lack of difference in hard OCAD detection rates suggest CACS should be interpreted as a triage tool for low-risk patients rather than a definitive diagnostic test that changes clinical management at the population level.
A pragmatic cluster-randomized trial in primary care showing CACS reduces unnecessary cardiology referrals and improves preventive enrolment, but fails on the primary outcome (practice-level CVRM registration) and detects similar OCAD rates; limited by non-blinded design, imbalanced per-protocol sample, and lack of hard clinical endpoints.
As stated by the source record.
Quoted from the source exactly as published.
CACS appears effective for reducing unnecessary cardiology referrals in primary-care chest pain evaluation and improving preventive enrolment. However, the failure to improve practice-level preventive registrations and the lack of difference in hard OCAD detection rates suggest CACS should be interpreted as a triage tool for low-risk patients rather than a definitive diagnostic test that changes clinical management at the population level.
Graded across the dimensions that decide whether you should act, each from what the source actually supports. There is no single score, and where a dimension was not assessed it says so.
BACKGROUND: General practitioners (GPs) have limited tools for chest pain patients to identify (non-)obstructive coronary artery disease (OCAD). This trial evaluates whether GP access to the coronary artery calcium score (CACS) improves diagnostic efficiency and cardiovascular risk management (CVRM). METHODS: COroNary Calcium scoring as fiRst-linE Test to dEtect and exclude coronary artery disease in GP patients with stable chest pain (CONCRETE) is a pragmatic, non-blinded implementation study that cluster-randomised 101 Dutch GP offices into CACS or standard of care (SOC). Patients aged ≥40 (men) or ≥45 (women) years, without known CAD, with possible cardiac or non-cardiac chest pain were included. The primary outcome was the proportional 2-year increase in CVRM registrations at GP office level. Patient-level secondary outcomes included cardiologist referral rate, OCAD diagnosis and CVRM enrolment. RESULTS: At GP office level, no significant difference in CVRM registration increase was seen for CACS versus SOC (46 CACS practices: +0.3%, 45 SOC practices: +0.2%, p=0.77). Per protocol analysis for patient-level outcomes included 583 patients (57.5% women, mean age 60.6±9.1 years) (CACS arm: 466; SOC arm: 117), recruited between January 2019 and October 2023. The CACS arm showed 47.1% relative reduction in cardiologist referrals compared with SOC (42.5% vs 80.3%; modelled difference 31.3% (95% CI 14.8% to 47.8%)). OCAD detection rates were not significantly different (CACS: 4.9, SOC: 7.7%, p=0.14). Patients with higher CACS had a higher probability of cardiologist referral (from 8.4% for CACS 0 to 94.2% for CACS ≥400, difference +85.7% (95% CI 79.4% to 91.9%)) and of OCAD diagnosis (0% for CACS 0 to 21.2% for CACS ≥400, OR 9.08 (95% CI 4.20 to 19.67)). Compared with SOC, more CACS patients were enrolled in CVRM (36.3% vs 17.0%, p<0.01). CONCLUSIONS: In this pragmatic, primary-care implementation and proof-of-concept trial, CACS was an effective diagnostic test for stable chest pain patients with (very) low likelihood of OCAD. CACS reduced unnecessary cardiology referrals and enhanced individual preventive care, without demonstrable practice-level impact on CVRM registrations. REGISTRATION: The CONCRETE study is registered under CCMO Register NL66821.042.18 and closed for enrolment.
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