The lower prevalence of obstructive disease in conjunction with technical challenges makes the interpretation of ischemia on imaging studies somewhat more difficult. Accumulating evidence suggests that vascular reac- tivity related to abnormalities in microvascular and endothe- lial function and possibly plaque erosion or distal microem- bolization contribute to ischemia to a greater extent in women than in men.75 On exercise testing, ST-segment changes are less accurate for the detection of CAD in women than in men,175 although marked ST-segment changes (a visual interpretation $1 mm of horizontal or downsloping ST-segment depression or elevation for $60 to 80 ms after the end of the QRS complex) remain diagnostic for all patients. Challenges with exercise testing in women include their generally lower physical work capacity and the high prevalence of obesity, diabetes mellitus, frailty, and other comorbid conditions. Numerous re- ports14,315,1131,1132 and an expert consensus statement175 have examined the diagnostic accuracy of the exercise ECG and various imaging modalities in large cohorts of women. 