Cardiovascular Imaging for Ischemic Heart Disease in Women: Time for a Paradigm ShiftJ Am Coll Cardiol Img. 2022 Aug, 15 (8) 1488–1501

Heart disease is the leading cause of death among men and women.
Women have a unique phenotype of ischemic heart disease with less calcified lesions, more nonobstructive plaques, and a higher prevalence of microvascular disease compared with men, which may explain in part why current risk models to detect obstructive coronary artery disease (CAD) may not work as well in women.
This paper summarizes the sex differences in the functional and anatomical assessment of CAD in women presenting with stable chest pain and provides an approach for using multimodality imaging for the evaluation of suspected ischemic heart disease in women in accordance to the recently published American Heart Association/American College of Cardiology guidelines for the evaluation and diagnosis of chest pain.
A paradigm shift in the approach to imaging ischemic heart disease women is needed including updated risk models, a more profound understanding of CAD in women where nonobstructive disease is more prevalent, and algorithms focused on the evaluation of ischemia with nonobstructive CAD and myocardial infarction with nonobstructive CAD.

Highlights
• Ischemic heart disease is a leading cause of morbidity and mortality for women around the world.
• Sex-specific differences in both the pathophysiology of IHD and the performance of different noninvasive tests necessitate a sex-based diagnostic work-up.
• Whether the initial strategy is an anatomical or functional test, in patients with refractory symptoms, assessment for CMD should be performed.
• Future algorithms must include functional, anatomic, and physiological assessments of endothelial and microvascular function.

G Mohan.