A revolutionary non-invasive method for the thorough evaluation of coronary artery disease (CAD) is fractional flow reserve (FFR) obtained from coronary computed tomography angiography (CCTA). Computed tomography-derived FFR (FFR_CT) assesses both the anatomical and functional significance of coronary lesions simultaneously by utilizing sophisticated computational models, including computational fluid dynamics, machine learning (ML), and Artificial Intelligence (AI) methods. The technological development, validation research, clinical uses, and real-world constraints of FFR_CT are compiled in this review. Large multicenter trials and registries consistently show that FFR_CT is a reliable gatekeeper to invasive coronary angiography (ICA) and increases diagnostic accuracy significantly when compared to coronary Computed Tomography Angiography (CTA) alone, especially in patients with intermediate-risk anatomy. Additionally, FFR_CT has demonstrated benefits in populations with in-stent restenosis (ISR) and in virtual procedural planning. Notwithstanding its advantages, the technique still requires high-quality imaging, and its practical application is constrained by expenses, processing requirements, and image distortions. Continuous developments in automation and deep learning should improve accessibility, effectiveness, and workflow integration in clinical settings. FFR_CT is expected to become more and more important in the individualized treatment of CAD by minimizing unnecessary invasive procedures and improving patient selection for revascularization.

Cardiovascular disease remains the leading cause of mortality among women worldwide, yet coronary syndromes in women continue to be under-recognized and insufficiently represented in clinical research. This review summarizes sex-specific pathophysiological mechanisms, risk factors, clinical presentation, and management considerations in women with coronary syndromes. Women are more likely than men to present with non-obstructive and non-atherosclerotic ischemic phenotypes, including ischemia or angina with non-obstructive coronary arteries, coronary microvascular dysfunction, myocardial infarction with non-obstructive coronary arteries, spontaneous coronary artery dissection, vasospastic angina, and Takotsubo syndrome. These entities often require diagnostic strategies beyond the detection of flow-limiting epicardial stenosis, including cardiac magnetic resonance imaging, intracoronary imaging, and coronary function testing. Traditional cardiovascular risk factors remain important, but several female-specific risk enhancers, including premature menopause, adverse pregnancy outcomes, polycystic ovary syndrome, autoimmune disease, and psychosocial stressors, further modify risk and remain incompletely integrated into routine clinical assessment. Women may also experience diagnostic delays due to symptom misclassification, lower baseline troponin concentrations, and clinical algorithms historically derived from male-predominant populations. Management should follow guideline-directed therapy when appropriate, while recognizing sex-related differences in pharmacology, bleeding risk, revascularization outcomes, and the need for phenotype-specific treatment in INOCA, MINOCA, SCAD, and Takotsubo syndrome. Finally, transgender and gender-diverse individuals remain largely absent from cardiovascular trials, highlighting the need for inclusive research frameworks that distinguish sex, gender identity, and hormone exposure. Improved recognition of sex- and gender-related differences is essential to advance equitable cardiovascular care.

Myocardial infarction with non-obstructive coronary arteries (MINOCA) accounts for approximately 5–15% of all myocardial infarctions and disproportionately affects women. Once treated as a diagnosis of exclusion, MINOCA is now recognised as a heterogeneous, mechanism-based syndrome encompassing atherosclerotic plaque disruption, epicardial and microvascular vasospasm, microvascular dysfunction, coronary thromboembolism, and spontaneous coronary artery dissection (SCAD). Despite the absence of obstructive disease, it carries substantial morbidity and mortality, underscoring the need for accurate aetiological characterisation and tailored therapy. Our aim is to review the contemporary evidence of the role of advanced imaging modalities—cardiac magnetic resonance imaging (CMR), optical coherence tomography (OCT), intravascular ultrasound (IVUS) and invasive functional testing—in the diagnosis, prognostic stratification, and therapeutic guidance of patients with MINOCA. CMR is the non-invasive reference standard for differentiating true ischaemic MINOCA from non-ischaemic mimics such as myocarditis and Takotsubo syndrome, reclassifying the working diagnosis in up to two-thirds of cases. OCT and IVUS provide intracoronary characterisation of culprit substrates that are invisible via angiography, particularly plaque rupture, erosion, intramural haematoma and SCAD, while acetylcholine and adenosine testing identify endothelium-dependent vasospasm and endothelium-independent microvascular dysfunction respectively. Coronary Computed Tomography Angiography (CCTA) could also play an additional role in the diagnosis of epicardial CAD. Each modality additionally carries independent prognostic value, with abnormal findings consistently linked to higher rates of major adverse cardiovascular events. The recently completed PROMISE trial provided the first randomised evidence that stratified, imaging-guided treatment might have some positive impact on angina status and quality of life compared with empirical standard care. In conclusion, advanced imaging has transformed MINOCA from a diagnosis of exclusion into a mechanism-based syndrome amenable to personalised therapy. Broader integration of these modalities into routine practice, supported by further randomised trials, is needed to optimise outcomes.

Background/Objectives: Evidence on myocardial-work indices beyond 12 months after left bundle branch area pacing (LBBAP) remains limited. We compared global myocardial work efficiency (GWE) and the left ventricular ejection fraction (LVEF) after LBBAP and right ventricular mid-septal pacing (RVP). Methods: This prospective, non-randomised cohort included 63 patients with advanced atrioventricular block and preserved pre-implantation LVEF: 34 assigned to an LBBAP strategy and 29 to RVP. Ventricular pacing burden was 100%. GWE was the primary endpoint; LVEF was the principal adjusted secondary endpoint. Analyses adjusted for age, sex, hypertension and atrial fibrillation. Follow-up averaged approximately two years, with an individual range of 0.64–4.23 years. Results: GWE was higher with LBBAP (85.23 ± 6.82% versus 80.00 ± 9.41%; p = 0.016), with an adjusted difference of +4.96 percentage points (95% CI 0.87 to 9.04; p = 0.018). The adjusted LVEF difference was +5.73 percentage points (95% CI 2.77 to 8.68; p < 0.001). Exploratory within-patient LVEF analyses showed mean changes of +1.20 percentage points with LBBAP (95% CI −1.25 to +3.65) and −6.15 with RVP (95% CI −9.16 to −3.14), with an unadjusted between-group difference of +7.35 percentage points (95% CI 3.55 to 11.16; p < 0.001). Conclusions: LBBAP was associated with higher GWE and LVEF at extended follow-up, although some propensity-score GWE confidence intervals included zero. LVEF-change findings are exploratory and do not estimate a common-time trajectory. These observational findings do not establish causality or clinical benefit.