Abstract Background The 2010 National Institute of Clinical Excellence (NICE) Clinical Guideline 95 (CG95) recommended coronary computed tomographic angiography (CTA) for low-intermediate risk patients with stable chest pain. The indications for CTA broadened substantially in the 2016 update, which recommended CTA for all patients with possible angina and diagnostic uncertainty. Purpose To examine trends in the use of imaging for the investigation of coronary artery disease (CAD) in England in the years before and after the 2016 CG95 guideline update. Methods Numbers of invasive coronary angiography (ICA), single positron emission tomography (SPECT), stress echocardiography (SE), CTA, and positron emission tomography (PET) scans performed from 2012–2018 were extracted from a national database of imaging procedures performed in England. Per capita average annual growth was calculated at a national and healthcare provider level, and comparisons were made before and after the 2016 CG95 update. Healthcare providers with greater than median CTA growth were compared to those with less than median growth to ascertain the impact of CTA on other forms of CAD investigation. Total healthcare provider costs for imaging were calculated using NHS tariff costs. Results From 2012–2018, 1,792,655 imaging examinations were performed for the investigation of CAD, with an overall annualized growth rate of 4%. Average annual growth (per 100,000 population per year) from 2012–2018 was 1±31% for ICA, 28±39% for CTA, −11±22% for SPECT, 0±1% for PET, 1±2% for SE and 5±16% for MRI. Following the 2016 CG95 update, there was an increase in the year-to-year average annual growth of CTA scans performed (53±79 versus 2±53 tests/100,000/yr, p<0.001) compared with a fall in the rate of ICA use (−13±48 versus +5±36 tests/100,000/yr, p=0.03). SPECT underwent a consistent fall in utilisation over the study period, with an average annual growth rate of −4%, with no difference before or after the 2016 CG95 update (P>0.1). Rates of change in the utilization of SE, PET, and MRI did not change following the introduction of the 2016 CG95 update. Regions with an above median average annual growth in CTA exhibited a greater decline in SPECT use (−19±28 versus −4±11 tests/100,000/yr, p=0.037) than regions with a below median growth in CTA use, with no difference in the average annual growth of ICA, SE, PET or MRI (p>0.1 for all; Figure 1). Per capita healthcare costs remained stable throughout the study period, with no significant change following CG95 (p>0.1). Figure 1. CTA, SPECT and ICA growth rate Conclusion There is a clear and consistent trend towards increased imaging for the diagnosis and management of CAD. The 2016 NICE CG95 update resulted in a rise in the use of CTA, and a fall in ICA. Importantly, rates of ICA utilization fell despite a rise in CTA usage. Centres with the greatest growth in CTA had the greatest fall in SPECT utilisation and consequently, overall imaging costs were unchanged.