• Time to Diagnosis [ Time Frame: From date of first presentation with chest pain to date of CAD diagnosis or exclusion, assessed up to 24 months ]
  Time interval from time of presentation to family physician for evaluation of chest pain to the last test performed to determine etiology of chest pain or CAD exclusion.
• Wait Times to See a Cardiologist [ Time Frame: From date of cardiology referral letter sent by family physician to date of cardiologist appointment with patient, assessed up to 24 months ]
  Time interval from when family physician referral letter was sent to the cardiologist's office to appointment time to see cardiologist
• Hospital/ER visits [ Time Frame: Through study completion, which may take up to 1 year ]
  Number of hospital/ER visits while waiting to see cardiologist
• Number of Normal Invasive Diagnostic Angiograms [ Time Frame: From date of randomization to date of CAD diagnosis or exclusion, assessed up to 24 months ]
  Number of invasive diagnostic angiograms done that reveal no coronary artery disease.
• Total Cost of Investigations [ Time Frame: Through study completion, which may take up to 1 year ]
  Total cost (in Canadian dollars) of all tests completed to reach a diagnosis for chest pain
• Cumulative Radiation Dose Exposure (milliSieverts) [ Time Frame: From date of randomization to date of CAD diagnosis or exclusion, assessed up to 24 months ]
  Total effective radiation dose from all testing modalities for each patient.

• Incidence of Procedure Related Adverse Events [ Time Frame: From date of randomization to date of CAD diagnosis or exclusion, assessed up to 24 months ]
  Assessment of diagnostic procedure related adverse effects that may occur during the course of the trial.
• Incidence of Cardiovascular Events [ Time Frame: From date of randomization to date of CAD diagnosis or exclusion, assessed up to 24 months ]
  Assessment of cardiovascular events that may take place during the course of the study, while waiting for a diagnosis for the cause of chest pain

• Incidence of Procedure Related Adverse Events [ Time Frame: From date of randomization to date of CAD diagnosis or exclusion, assessed up to 24 months ]
  Assessment of diagnostic procedure related adverse effects that may occur during the course of the trial.
• Incidence of Cardiovascular Events [ Time Frame: From date of randomization to date of CAD diagnosis or exclusion, assessed up to 24 months ]
  Assessment of cardiovascular events that may take place during the course of the study, while waiting for a diagnosis for the cause of chest pain
• Patient Anxiety and Experience Questionnaire [ Time Frame: Through study completion, which may take up to 1 year ]
  Assessment of patient anxiety levels and experience for different testing modalities using a patient questionnaire.

Coronary artery disease (CAD) is the leading cause of death in women globally. Women are more likely to present with atypical chest pain that may be difficult to diagnose using traditional testing methods, resulting in over-investigation.

Coronary computed tomography angiography (CCTA) has high negative predictive value for exclusion of CAD in low to intermediate risk populations. We plan to investigate CCTA as a first line test to exclude coronary artery disease as a cause of stable chest pain and whether it is a cost effective strategy that reduces time to diagnosis, wait times to see cardiologists, emergency department visits, downstream and repeat testing and radiation exposure as compared to usual care with comparable patient safety and satisfaction level.

Another intervention being tested in this trial is the Cardiac Link pathway. This is a new clinical program at Women's College Hospital that aims to expedite cardiology referral for patients exhibiting clinically significant findings while undergoing CCTAs.

We hope that with use of CCTA as the first test, the number of women who require only one test (i.e. CCTA) to sort out whether or not CAD is responsible for their chest pain will increase, thereby decreasing over-investigation of low risk women.

• Diagnostic Test: Coronary Computed Tomography Angiography (CCTA)
  Cardiac imaging test that is able to detect changes is cardiac vessels and the heart.
• Other: Cardiac Link
  Clinical patient flow pathway that will enable radiologist to activate expedited cardiology referral for patients who exhibit clinically significant changes during CCTA.

• Experimental: CCTA first approach with Cardiac Link
  Patient will undergo Coronary Computed Tomography Angiography as the first test and have Cardiac Link pathway activated for expedited cardiology referral.
  Interventions:

  • Diagnostic Test: Coronary Computed Tomography Angiography (CCTA)
  • Other: Cardiac Link
• Experimental: CCTA first approach without Cardiac Link
  Patient will undergo Coronary Computed Tomography Angiography as the first test, but Cardiac Link pathway will not be activated.
  Intervention: Diagnostic Test: Coronary Computed Tomography Angiography (CCTA)
• Active Comparator: Usual Care with Cardiac Link
  Patient will undergo the usual diagnostic test ordered by their family physician as the first test, and have Cardiac Link pathway activated for expedited cardiology referral.
  Interventions:

  • Diagnostic Test: Coronary Computed Tomography Angiography (CCTA)
  • Other: Cardiac Link
• Active Comparator: Usual Care without Cardiac Link
  Patient will undergo the usual diagnostic test ordered by their family physician as the first test, but Cardiac Link pathway will not be activated.
  Intervention: Diagnostic Test: Coronary Computed Tomography Angiography (CCTA)

Inclusion Criteria:

• Men and women age ≥ 40 years of age
• Stable chest pain or equivalent symptoms
• Planned non-urgent, non-invasive testing for diagnosis of chest pain or equivalent symptoms

Exclusion Criteria:

• Acute coronary syndrome, including acute myocardial infarction or unstable angina, known non-ischemic cardiomyopathy or other cardiac disease (e.g. mitral valve prolapse, etc.) which would require urgent cardiac evaluation
• Known CAD
• Prior cardiac evaluation for current episode of symptoms
• Previously investigated for CAD in the last 12 months
• Severe allergic reaction to iodinated contrast (mild reactions such as urticaria that can be controlled by premedication with Benadryl & Prednisone may be included in the study)
• Renal failure or dysfunction (estimated Glomerular Filtration Rate<30ml/min/m2 within the past 3 months)
• Pregnancy (status will be confirmed verbally. For premenopausal patients who are unsure, status will be confirmed by completing a pregnancy strip test).