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Research on sex and gender aspects cardiovascular disease has contributed to a reduction in cardiovascular mortality in women. However, cardiovascular disease remains the leading cause of death of women in the United States. Disparities in cardiovascular risk and outcomes among women overall persist and are amplified for women of certain ethnic and racial subgroups. We review the evidence of racial and ethnic differences in cardiovascular risk and care among women and describe a path forward to achieve equitable cardiovascular care for women of racial and ethnic minority groups.There is a disproportionate effect on cardiovascular outcomes in women and certain racial and ethnic groups in part due to disparities in triage, diagnosis, treatment, which lead to amplification of inequalities in women of minority racial and ethnic background. Data suggest gender and racial bias, underappreciation of nontraditional risk factors, underrepresentation of women in clinical trials and undertreatment of disease contributes to persistent differences in cardiovascular disease outcomes in women of color. Understanding the myriad of factors that contribute to increased cardiovascular risk, and disparities in treatment and outcomes among women from racial/ethnic minority backgrounds is imperative to improving cardiovascular care for this patient population.

In this review, we highlight the need for innovation and creativity to reinvent the field of nuclear cardiology. Revolutionary ideas brought forth today are needed to create greater value in patient care and highlight the need for more contemporary evidence supporting the use of nuclear cardiology practices. We put forth discussions on the need for disruptive innovation in imaging-guided care that places the imager as a central force in care coordination. Value-based nuclear cardiology is defined as care that is both efficient and effective. Novel testing strategies that defer testing in lower risk patients are examples of the kind of innovation needed in today's healthcare environment. A major focus of current research is the evolution of the importance of ischemia and the prognostic significance of non-obstructive atherosclerotic plaque and coronary microvascular dysfunction. Embracing novel paradigms, such as this, can aid in the development of optimal strategies for coronary disease management. We hope that our article will spurn the field toward greater innovation and focus on transformative imaging leading the way for new generations of novel cardiovascular care.

This document from the American Society of Nuclear Cardiology represents an updated consensus statement on the evidence base of stress myocardial perfusion imaging (MPI), emphasizing new developments in single-photon emission tomography (SPECT) and positron emission tomography (PET) in the clinical evaluation of women presenting with symptoms of stable ischemic heart disease (SIHD). The clinical evaluation of symptomatic women is challenging due to their varying clinical presentation, clinical risk factor burden, high degree of comorbidity, and increased risk of major ischemic heart disease events. Evidence is substantial that both SPECT and PET MPI effectively risk stratify women with SIHD. The addition of coronary flow reserve (CFR) with PET improves risk detection, including for women with nonobstructive coronary artery disease and coronary microvascular dysfunction. With the advent of PET with computed tomography (CT), multiparametric imaging approaches may enable integration of MPI and CFR with CT visualization of anatomical atherosclerotic plaque to uniquely identify at-risk women. Radiation dose-reduction strategies, including the use of ultra-low-dose protocols involving stress-only imaging, solid-state detector SPECT, and PET, should be uniformly applied whenever possible to all women undergoing MPI. Appropriate candidate selection for stress MPI and for post-MPI indications for guideline-directed medical therapy and/or invasive coronary angiography are discussed in this statement. The critical need for randomized and comparative trial data in female patients is also emphasized.

Evolving knowledge regarding sex differences in coronary heart disease has demonstrated that the prevalence, symptomatology, and pathophysiology of coronary atherosclerosis vary between genders. Women experience higher mortality rates and more adverse outcomes after acute myocardial infarction than men, despite a lower prevalence of obstructive coronary artery disease. Based on recent insights into the complex pathophysiology of coronary heart disease which includes a spectrum of obstructive coronary artery disease and dysfunction of the coronary microvasculature and endothelium, the term ischemic heart disease is a more accurate term for discussion of coronary atherosclerosis specific to women. In women, with clinical features and risk factors for ischemic heart disease, the detection and evaluation of ischemic heart disease is challenging due to the diverse pathogenic mechanisms of ischemic heart diseases in women. In this article, we discuss noninvasive imaging tests, provocative tests, including exercise testing in women with suspected ischemic heart disease.

Significant progress in research has been made in the areas of sex-specific aspects of cardiovascular disease. Despite these advances, coronary artery disease (CAD) is the leading cause of death of women in the Western world. Over the past decade, the focused research on women at risk for ischemic heart disease has helped to clarify our understanding of some of the sex-specific factors, which are important in detecting CAD. In women, the detection and evaluation of physiologically significant CAD is challenging, especially given that traditional tests designed to detect focal areas of coronary artery stenosis are less sensitive and specific in female patients who have a lower prevalence of obstructive coronary disease, greater burden of symptoms, and a high atherosclerotic burden. In this article, we review the available evidence on the role of contemporary cardiovascular imaging techniques in evaluating ischemic heart disease in women.

The IMAGING in Heart Failure study was a prospective, multi-national trial designed to explore the role of single-photon emission computed tomographic (SPECT) myocardial perfusion imaging (MPI) as an initial investigative strategy in patients hospitalized with new-onset heart failure. We recruited 201 patients (age 65.3 ± 14.5 years, 43% women) hospitalized with their first episode of heart failure. Rest/stress gated SPECT Tc-99m sestamibi MPI was performed during or within 2 weeks of the index hospitalization, in addition to standard care. SPECT MPI revealed a broad range of ejection fractions with preserved systolic function in 36% of patients. Forty-one percent of patients had normal perfusion. In the remaining patients, perfusion abnormalities were predominantly due to prior myocardial infarction, with extensive ischemia seen only in 6%. Among patients who underwent coronary angiography, SPECT performance characteristics revealed excellent negative predictive value (96%) for extensive coronary artery disease (CAD). In multivariable analyses, the extent of perfusion abnormality and advancing age predicted the presence of extensive CAD. These preliminary data derived from a non-randomized observational cohort suggest potential diagnostic utility of MPI for ischemic LV dysfunction in new-onset HF, and sets the stage for a prospective randomized study to confirm these findings.

Heart disease is the #1 killer of women and a major contributor to morbidity and disability. This statement cannot be repeated enough and is often neglected. In 2008, there were 9,127,416 cardiovascular deaths in women worldwide, accounting for 33.2 % of all deaths in women. Coronary artery disease (CAD) differs in symptom presentation, diagnosis, treatment, and outcomes in women compared to men. We have made great strides in diagnosing and managing cardiovascular disease (CVD) in women. However, this progress continues to be overshadowed by the improvements made on the understanding and management of CVD in men.

Cardiovascular disease remains the number one cause of mortality for women in the United States, with coronary artery disease (CAD) accounting for 54% of all cardiovascular deaths. CAD claims the lives of more than 250,000 women each year and is therefore the single largest killer of American women. For several decades, the under-representation of women in clinical trials led to both a lack of available sex-specific evidence and a generalized misconception that CAD was a "man's disease." In actuality, not only are women vulnerable to CAD, they typically develop it 10 to 15 years later than men. Furthermore, sex differences exist in the mortality rates of women and men with CAD, such that once CAD is present in women, they have worse outcomes than their male counterparts. Consequently, early and accurate diagnosis of CAD is crucial for reducing mortality rates in women. Stress myocardial perfusion imaging (MPI) using contemporary techniques has been shown to have significant value in the diagnosis and prognosis of CAD in women. In the risk assessment of women with an intermediate clinical pretest likelihood of CAD, using MPI with exercise or pharmacologic stress has been shown to add incremental value to clinical variables or exercise electrocardiogram stress testing alone. This review discusses the clinical role of stress MPI in the management of women with suspected CAD.

The American Society of Nuclear Cardiology (ASNC), founded in 1993, is a professional medical society whose mission is to foster optimal delivery of nuclear cardiology services through professional education and leadership in the establishment of standards and guidelines for the practice of nuclear cardiology. ASNC will from time to time publish position, policy, or consensus statements that reflect a body of knowledge and clinical evidence for an application of radionuclide imaging techniques in the clinical care of patients with known or suspected heart disease. Position, policy, or consensus statements are approved by the ASNC Board of Directors before publication. This consensus statement will examine the role of myocardial perfusion imaging studies in the diagnosis, risk assessment, and treatment of women with known or suspected coronary artery disease.

Left ventricular volumes and ejection fractions constitute important information in the diagnosis of cardiac disease. This investigation examined the relations of functional parameters computed with a recently published scintigraphic gated tomographic method with those from angiography, analyzing discrepancies arising from differences involved in modeling the left ventricle. While left ventricular ejection fractions obtained from myocardial perfusion gated single-photon emission computed tomography (SPECT) have demonstrated accurate comparisons with other imaging modalities, validations of volumes have not been examined as extensively, and some recent studies have reported a wide range of angiographic correlation. It is important to know how volumes obtained by a new class of methods compare with those from older, well-established techniques in order to interpret individual patients’ results, particularly when scintigraphic images are severely hypoperfused. Tc-99m sestamibi myocardial perfusion gated SPECT data were processed retrospectively for 58 patients studied by single-plane angiography. Endocardial borders were generated automatically on paired vertical and horizontal long-axis Tc-99m sestamibi gated tomograms for computing ventricular volume using a Simpson’s rule summation of elliptical slices. Linear regression and paired t tests were used to compare SPECT with angiographic parameters for all patients and for groups identified on the basis of tomogram visual examination as hypoperfused, ischemic or nonischemic, with the latter category further subgrouped as to fixed defects or normal perfusion. Linear regression analysis demonstrated Pearson correlation coefficients of 0.87 for end-diastolic volumes, 0.91 for end-systolic volumes, and 0.86 for ejection fraction: paired t test analysis showed end-systolic volumes to be nearly identical (p>0.99) to angiographic values. However, paired t tests also revealed gated SPECT end-diastolic volumes and ejection fractions were significantly lower (p