CONCRETE is an implementation study, focused on the Dutch health care system. In the Netherlands, the General Practitioner (GP) is the first physician a patient consults with non-acute chest discomfort. In the Dutch GP Guideline (NHG-Standaard) for stable chest pain complaints, a referral to the cardiologist is recommended for (a)typical angina pectoris (AP) and non-specific thoracic complaints (only when CAD is suspected). According to international guidelines, CT can also be considered. However, the impact of the implementation of calcium scoring in primary care on CAD diagnosis and treatment rate are unknown. The CT calcium score is an existing test, which is part of the cardiac CT examination as requested in outpatient clinics (scan without contrast for calcium determination, followed by scan with contrast for evaluation of coronary stenosis). The cardiologist has a variety of non-invasive tests that can be requested; however there is little consensus about which non-invasive test is preferable. These tests can be divided into functional- or anatomical testing. Non-invasive anatomical tests (e.g. CT calcium scoring) have the advantage that they can detect obstructive CAD and subclinical CAD.

At this moment, it is still unclear what the best strategy is for atypical AP and non-specific thoracic complaints in GP setting. The standard of care and the CT calcium scoring can be considered competitive tests, for which medical experts/researchers differ in opinion regarding the best diagnostic strategy as first line test for CAD in atypical chest pain and non-specific thoracic complaints with suspicion of CAD. In addition, CT calcium scoring also detects subclinical CAD. It is possible that treatment of subclinical CAD may prevent myocardial infarction or sudden cardiac death in the future due to early treatment, although at this moment this is still unclear.

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