Background: Ischemic heart disease is the major cause of death in women. Men and women have many similarities in relation to cardiovascular risk factors, but they differ in the pathophysiology, clinical presentation and outcomes in the setting of coronary artery disease and myocardial ischemia. Over the last years, due to innovative imaging technologies and more specific diagnostic strategies, increasing number of clinical studies report on specific-gender characteristics on plaque composition and burden, associated to acute coronary syndromes, and also on coronary vascular dysfunction as a major cause of clinical symptoms in women with apparently normal arteries. Methods: Here we performed a review of the literature focused on atheroma burden in women that includes information provided in original articles (basic and clinical oriented), cohort studies, trial and registry data, metaanalysis and other systematic reviews. Results and Conclusions: The Studies published over the last 30 years provide a new view about the pathophysiology and presentation of ischemic heart disease in women. However, many questions remain to be addressed by future research. The mechanisms behind the delay on disease presentation in women over the fertile period and the paradoxical fact that young women have more adverse outcomes after an ischemic event need to be identified. A better understanding of these issues is expected to derive in better strategies for prevention and management of ischemic heart disease in women.