The following are key points to remember from this state-of-the-art review of cardiovascular imaging for ischemic heart disease in women:

1. Women have a unique phenotype of ischemic heart disease characterized by fewer calcific lesions, more nonobstructive plaques, and higher prevalence of microvascular disease.
2. In low-intermediate risk women who can exercise and have a normal resting electrocardiogram (ECG), exercise treadmill testing (ETT) is recommended. While the positive predictive value of ETT is lower in symptomatic women than symptomatic men (false-positive ECG changes, less exercise-induced angina, and less often achieve target heart rate), the negative predictive value is similar.
3. The addition of imaging to exercise is recommended for intermediate-risk women who have an abnormal baseline ECG. Stress echocardiography does not use radiation and may be a preferred choice for younger women.
4. Single-photon emission computed tomography (SPECT) myocardial perfusion imaging has sex-specific challenges in women due to the heart being smaller than men and potentially resulting in a lower sensitivity to detect obstructive coronary artery disease caused by the low resolution of conventional gamma cameras. Attenuation correction is important to avoid attenuation from breast tissue or high body mass index.
5. Coronary computed tomographic angiography has high diagnostic accuracy in detecting atherosclerotic plaque and assessing plaque characteristics. One study demonstrated lower sensitivity in women compared with men in distal coronary segments and side branches, likely related to smaller epicardial size.
6. Coronary artery calcium (CAC) scoring is effective for risk stratification in asymptomatic patients. Women have fewer calcified lesions, fewer calcified vessels, and lower CAC volumes; nevertheless, a score of 0 carries a similar low risk of cardiovascular disease events for both men and women.
7. Positron emission tomography (PET) has advantages over SPECT in women due to the higher spatial resolution, improved diagnostic accuracy, and lower radiation exposure. Coronary microvascular dysfunction is prevalent in women; PET allows quantification of coronary flow reserve, which is an important marker of coronary vasomotor dysfunction and microvascular dysfunction.
8. Cardiac magnetic resonance (CMR) provides comprehensive evaluation of myocardial structure and function, inflammation, ischemia, and viability. Stress CMR has similar diagnostic accuracy in women as men.
9. CMR perfusion mapping techniques can now also provide quantitative assessment of myocardial blood flow and myocardial perfusion reserve, thus identifying coronary microvascular dysfunction in women.
10. Pretest probability scores for coronary disease guide selection of appropriate testing; however, many older pretest scores estimate the probability of obstructive coronary artery disease and may be less accurate in women.
11. Initial testing may be functional or anatomical, but women with refractory symptoms should be evaluated for coronary microvascular dysfunction utilizing a multimodality imaging approach.

Clinical Topics: Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Stable Ischemic Heart Disease, Atherosclerotic Disease (CAD/PAD), Interventions and Coronary Artery Disease, Interventions and Imaging, Angiography, Computed Tomography, Echocardiography/Ultrasound, Magnetic Resonance Imaging, Nuclear Imaging, Chronic Angina

Keywords: Angiography, Body Mass Index, Coronary Artery Disease, Diagnostic Imaging, Echocardiography, Stress, Electrocardiography, Exercise Test, Heart Rate, Inflammation, Ischemia, Myocardial Ischemia, Magnetic Resonance Imaging, Microvascular Angina, Myocardial Perfusion Imaging, Plaque, Atherosclerotic, Positron Emission Tomography Computed Tomography, Risk Assessment, Radiation Exposure, Single Photon Emission Computed Tomography Computed Tomography, Women

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