Background Guidelines for cardiac catheterization recommend prior risk assessment and non-invasive testing. A recent contemporary study of U.S. patients found that 83.9% of patients undergoing elective catheterization had prior non-invasive testing. In addition, only 37.6% of patients had obstructive CAD, while 39.2% had no CAD. We sought to determine if similar trends existed in the VA, a national integrated health care system. Methods Using the VA Clinical Assessment, Reporting, and Tracking system for Cath Labs (CART-CL), a transactional, point-of-care software application installed at all 77 VA catheterization laboratories, we identified all patients without known CAD undergoing elective catheterization between 2005-2010. Patient demographics, risk factors, and non-invasive tests were correlated with the presence of obstructive CAD, defined as a stenosis of 50% or more of the left main coronary artery or 70% or more of a major epicardial artery. Results 28,333 elective catheterizations were performed during the study period on patients without known CAD. Prior non-invasive testing occurred in 18,117 (63.9%). 12,659 of catheterizations identified obstructive CAD (44.7%) and 9,776 (34.5%) identified no CAD (no stenosis >20%). Patient factors significantly associated with obstructive CAD included older age (OR per 5-year increment 1.25, 95% CI 1.22, 1.28), hypertension (OR 1.11, 95% CI 1.02, 1.21), diabetes (OR 1.13, 95% CI 1.06, 1.21), dyslipidemia (OR 1.72, 95% CI 1.57, 1.87), tobacco use (OR 1.23, 95% CI 1.14, 1.33), peripheral vascular disease (OR 1.48, 95% CI 1.34, 1.63), cerebrovascular disease (OR 1.2, 95% CI 1.1, 1.31), and positive non-invasive stress testing (OR 1.25, 95% CI 1.11, 1.4). Conclusions In the VA health care system, there were lower rates of prior non-invasive testing and higher yields of CAD on elective cardiac catheterization in comparison to a prior study of a non-VA patient population. The lack of a fee-for-service payment structure and better integration of health care services in the VA may partly explain these differences. Direct comparison of different health care systems is needed to further explore these hypotheses.