Sex-related differences in cardiovascular physiology and pathology: insights from cardiac imaging

Although cardiovascular disease (CVD) is the leading cause of mortality in women, CVD in women has long been understudied and underdiagnosed. This is largely based on a misconception that hearts in women are similar to those in men with regard to physiological characteristics and physiological responses. Nonetheless, in an era characterized by rapid advances in diagnostic cardiac imaging modalities, there is a greater need to understand sex differences in cardiac anatomy and function, and how these might influence CVD patterns. Such differences include observations that women have greater left ventricular (LV) ejection fraction and more pronounced LV hypertrophy compared with men using echocardiography and magnetic resonance imaging (MRI) respectively. Imaging can help reveal microvascular dysfunction and heart failure, both of which have different characteristics in women compared with men. This review aims to provide a brief summary of the sex differences in cardiovascular pathophysiology among men and women observed across various imaging modalities, including echocardiography, MRI, coronary computed tomography angiography, positron emission tomography, and stress testing, while also referencing sex differences in electrophysiology with respect to cardiac anatomy.