The Role of Advanced Imaging in Unmasking Epicardial and Microvascular Ischemia.

Myocardial ischemia in chronic coronary syndromes extends far beyond the presence of obstructive epicardial coronary stenoses. Advanced cardiovascular imaging has emerged as a cornerstone for the identification of the diverse anatomic and functional mechanisms underlying myocardial ischemia, including atherosclerotic coronary artery disease, vasospastic angina, myocardial bridging, and coronary microvascular dysfunction. Coronary computed tomography angiography, cardiac magnetic resonance, and PET provide complementary insights. This article reviews the diagnostic performance, characteristic imaging findings, and contemporary clinical applications of these modalities, highlighting their role in refining phenotypic characterization and enabling a more precise and individualized approach to patients with chronic coronary syndromes.