Cardiovascular disease (CVD) is the leading cause of death among women [1], accounting for 1 in every 5 female deaths, at a frequency of one female death every 90 seconds. Despite increasing awareness, CVD in women continues to go unrecognized and fails to receive timely, aggressive and appropriate diagnosis and treatment. Is the women’s heart, beating a different beat? Cardiovascular magnetic resonance (CMR), today, commands a unique position of supremacy versus competition including echocardiography [2,3 ], SPECT [4], PET, computed tomography [5,6], and invasive coronary angiography, on account of its accuracy, reproducibility, safety and lack of ionizing radiation. CMR is the gold standard for non-invasive evaluation of cardiac function. Conventional and multiparametric CMR enable assessment of cardiac structure, morphology, and tissue characterization; with the capability to evaluate the myocardium for edema, ischemia, fibrosis, infarction, hemorrhage, inflammation and infiltration, besides evaluation of pericardium, valves and great vessels, aimed at diagnosis and management of cardiovascular diseases. CMR with stress-rest imaging [7,2] has the ability to evaluate global and regional myocardial perfusion[8,9], microvascular dysfunction and scar. [10,11,12 ,13] Recent research on normative values have demonstrated sex specific differences in quantitative cardiac MRI, proving data extrapolation and cut offs of male values do not hold true for their female counterparts. Women have not just smaller sized hearts but are different in terms of ventricular volume, mass, ejection fraction, ventricular strain and parametric mapping, with inherent implications on pathologic states. [14,15,16,17]IHD has been the focus in CVD, where early detection is essential for improved outcome.[18] Acute coronary syndrome (ACS), in women often presents with atypical symptoms, than the classic chest pain. Pain in the upper body, neck, back, jaw, shortness of breath, cold sweats, unexplained fatigue, dizziness, light headedness, nausea and vomiting may be encountered. [19,20,21]This leads to underdiagnosis, with resultant less intensive care, higher morbidity, and mortality compared to men[22,23]. The causative agent in suspected ACS in women may not be obstructive epicardial coronary artery disease (CAD), hence we need to expand the focus beyond anatomical testing to a more sensitive functional evaluation for alternate diagnoses of myocardial infarction with non-obstructive coronary arteries (MINOCA) [24,25,26,27], ischemia with non-obstructive coronary arteries (INOCA), microvascular dysfunction, myocarditis and Takotsubo cardiomyopathy. CMR is a robust modality [28] andhigh accuracy of stress perfusion CMR is valuable for early assessment of functionally significant CAD in women [4]. In stable ischemic heart disease CMR adds value in diagnosis and prognosis of macrovascular and microvascular CAD. [10, 29, 30, 31] Beyond IHD, CMR in women, plays a critical role in peripartum cardiomyopathy, a dilated cardiomyopathy with reduced LV ejection fraction with/without RV involvement. CMR is particularly attractive in pregnancy due to the lack of ionizing radiation. Late gadolinium enhancement (LGE) with midwall, subepicardial, focal and linear distribution, [32, 33] is linked to risk stratification, heart failure, readmissions, and prognostication of current and future pregnancies. [34] Breast cancer is the commonest cancer in women and cancer related therapy can lead to cardiac dysfunction (CTRCD), morbidity and mortality with 5-year cumulative incidence of heart failure and cardiomyopathy ranging from 7.5% to 36% among patients [35]. CMR is the gold standard for volumetric and functional assessment of patients at risk for CTRCD, [36] besides superior tissue characterization and strain imaging. [37,38] Women are also more often affected by autoimmune rheumatic diseases (ARD) including systemic conditions as rheumatoid arthritis, spondyloarthropathies, systemic lupus erythematosus, systemic vasculitis, inflammatory myopathies, systemic sclerosis and mixed connective tissue disease. 78% of patients in this group are women.[39] The silent cardiac presentation in ARD often evades early detection by traditional imaging techniques as EKG, echocardiography, invasive coronary angiography and nuclear imaging, leading to missed diagnosis. CMR has the significant advantage of high spatial resolution, and accurate tissue characterization for myocardial ischemia, fibrosis, [40,41,42,43,44] macro- or micro-vascular CAD, besides assessment of clinically silent heart failure and rhythm abnormalities. [45, 46]. Based on the relevant clinical indications, protocols for CMR assessment in women may be tailored and include: 1. For cardiac structure and function, balanced steady-state free precession (bSSFP) cine studies in short and long axis planes. For serial monitoring of LV dysfunction CMR is superior to echocardiography. 2. For tissue characterization of myocardial inflammation, edema, hyperemia, capillary leak, necrosis, fibrosis, microvascular obstruction (MVO) among others, T2W imaging and/or T1-based methods including early gadolinium enhancement, and/or T1w LGE and parametric mapping techniques (T1/T2/ extracellular volume fraction (ECV)) [47, 48] 3. For functionally significant CAD, myocardial ischemia and microvascular dysfunction stress-rest first-pass perfusion [49] 4. For intramyocardial hemorrhage [48] or suspected myocardial iron, T2* mapping. Despite substantial advancements in CVD prevention, diagnosis and management, CVD in women continues to be under diagnosed and undertreated with lack of gender specific representations in clinical trials, driving higher morbidity and mortality, aggravated during the Covid pandemic. If women CVD is a different beat, a global concerted and targeted effort prioritizing women’s heart health and cardiac care is essential to achieve the goal of the Lancet Commission to reduce global burden of cardiovascular disease in women by 2030.[50]CMR most certainly plays that critical role in enabling early diagnosis, prognostication and guiding management of CVD in women.

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