Imaging and Biomarkers for Subclinical Atherosclerosis in Women

Subclinical atherosclerosis in women remains a silent yet significant contributor to cardiovascular morbidity and mortality. Traditional risk scores often underestimate cardiovascular risk in women, particularly in younger, premenopausal, and autoimmune-prone populations. This diagnostic gap is compounded by sex-specific differences in disease presentation, hormonal influences, and underutilization of imaging modalities such as coronary artery calcium scoring and carotid intima-media thickness, breast arterial calcification, cardiac computed tomography (CT) angiography. Moreover, pregnancy-related complications such as preeclampsia and gestational diabetes are not adequately integrated into current risk models, despite their long-term vascular implications. Given the multifactorial nature of atherosclerosis, no single biomarker or imaging test offers sufficient specificity to guide prognosis or treatment. Instead, a combined approach using non-invasive imaging and novel biomarkers – such as high-sensitivity C-reactive protein, lipoprotein(a), apolipoprotein B, myeloperoxidase, and emerging candidates such as suPAR, microRNAs, and growth differentiation factor-15 – provides a more comprehensive assessment of vascular health. These tools capture both structural and inflammatory aspects of disease, enabling earlier detection and more personalized prevention strategies. Future directions emphasize the development of sex-specific diagnostic algorithms that integrate advanced imaging (e.g., positron emission tomography/magnetic resonance imaging, coronary CT angiography) with multi-biomarker panels. Machine learning models that combine clinical, biochemical, and imaging data are showing promise in refining cardiovascular risk prediction. In addition, research into metabolomics and proteomics is expanding the biomarker landscape, offering new insights into disease mechanisms and therapeutic targets. A gender-sensitive, integrated approach is essential to improve early detection, risk stratification, and outcomes in women with subclinical atherosclerosis. This paradigm shift will help close longstanding gaps in cardiovascular care and support more effective, individualized prevention strategies.