Novel Imaging Approaches for the Diagnosis of Stable Ischemic Heart Disease in Women

Conventional recommendations for diagnostic testing for the evaluation of stable ischemic heart disease in women have largely paralleled those in men. Although they are designed primarily for the identification of obstructive coronary artery disease (CAD), traditional approaches can lead to overtesting in women without differentiating who is truly at risk. Several unique factors related to the presentation, diagnosis, and underlying pathophysiology of stable ischemic heart disease in women necessitate a more specific approach to the assessment of their risk, complete with separate guidelines when appropriate. This overview highlights how advanced noninvasive imaging tools, including cardiac computed tomography angiography, positron emission tomography, and cardiac magnetic resonance imaging, are enabling very sensitive assessments of anatomic atherosclerotic plaque burden, macrovessel- and microvessel-related ischemia, and myocardial fibrosis, respectively. Moving forward, effective diagnostic testing will need to identify women at high risk of adverse cardiovascular events (not anatomically obstructive CAD per se) without overtesting those at low risk. Judicious application of novel imaging approaches will be critical to broadening the definitions of CAD and ischemia to better reflect the whole spectrum of pathological phenotypes in women, including nonobstructive CAD and coronary microvascular dysfunction, and aid in the development of needed evidence-based strategies for their management.