Sex Differences in Intracoronary Imaging and Functional Evaluation of Coronary Arteries

Coronary artery disease encompasses broad pathologies beyond atherosclerosis such as spontaneous coronary artery dissection, myocardial infarction with non-obstructive coronary artery disease, and microvascular dysfunction. These diagnoses often warrant more detailed evaluations with intracoronary imaging or functional testing. In this review, we highlight the reported sex differences in intracoronary imaging and functional evaluation of the coronary arteries. The diagnosis and treatment of women presenting with acute or chronic coronary syndromes have been fraught with disparities given the poor representation of women in trials addressing the role of conventional coronary angiography, intracoronary imaging, and coronary functional assessment. Most of the evidence for intravascular ultrasound and optical coherence tomography identified features unique to women; however, the published data do not establish validated references for women. Differences in vessel size, myocardial mass, microvascular function, hyperemic response, and plaque characteristics could explain the sex-based differences. Further evidence is required to define and validate cutoff values in women and ascertain clinical outcomes.