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Background— Coronary artery disease is the leading cause of death in women, and underdiagnosis contributes to the high mortality. This study compared the sex-specific diagnostic performance of cardiovascular magnetic resonance (CMR) and single-photon emission computed tomography (SPECT). Methods and Results— A total of 235 women and 393 men with suspected angina underwent CMR, SPECT, and x-ray angiography as part of the Clinical Evaluation of Magnetic Resonance Imaging in Coronary Heart Disease (CE-MARC) study. CMR comprised adenosine stress/rest perfusion, cine imaging, late gadolinium enhancement, and magnetic resonance coronary angiography. Gated adenosine stress/rest SPECT was performed with 99m Tc-tetrofosmin. For CMR, the sensitivity in women and men was similar (88.7% versus 85.6%; P =0.57), as was the specificity (83.5% versus 82.8%; P =0.86). For SPECT, the sensitivity was significantly worse in women than in men (50.9% versus 70.8%; P =0.007), but the specificities were similar (84.1% versus 81.3%; P =0.48). The sensitivity in both the female and male groups was significantly higher with CMR than SPECT ( P P =0.77 and P =1.00, respectively). For perfusion-only components, CMR outperformed SPECT in women (area under the curve, 0.90 versus 0.67; P P P =1.00) but was significantly worse in women with SPECT ( P Conclusions— In both sexes, CMR has greater sensitivity than SPECT. Unlike SPECT, there are no significant sex differences in the diagnostic performance of CMR. These findings, plus an absence of ionizing radiation exposure, mean that CMR should be more widely adopted in women with suspected coronary artery disease. Clinical Trial Registration— URL: http://www.controlled-trials.com . Unique identifier: ISRCTN77246133.

Many of the issues raised by Dr Einstein have been addressed in the article1 and in previous correspondence relating to the Clinical Evaluation of Magnetic Resonance Imaging in Coronary Heart Disease (CE-MARC) study.2,3 Einstein argues that the inclusion of magnetic resonance angiography offered cardiovascular magnetic resonance (CMR) an unfair advantage. However, as discussed in the article, secondary analyses from CE-MARC showed that excluding the magnetic resonance angiography component not only had a neutral effect on overall diagnostic accuracy, but actually led to a superior positive-predictive value for CMR in comparison with single-photon emission computed tomography (SPECT; owing to a reduction in false positives).2 We also included a detailed perfusion-only component analysis that Einstein makes no reference to in his critique. For perfusion-only components, CMR still significantly outperformed SPECT in females (area under the curve, 0.90 versus …