Women with evidence of ischemia and no obstructive coronary artery disease (INOCA) have an increased risk of major adverse cardiac events, including heart failure with preserved ejection fraction (HFpEF), we examined pathophysiological findings present in both INOCA and HFpEF and compared it to reference control to identify a potential links between INOCA and HFpEF compared to reference controls.In this study, 56 participants undergone adenosine stress cardiac magnetic resonance imaging (CMRI) in, including 35 women with suspected INOCA, 13 women with HFpEF, and 8 reference control women. Myocardial perfusion imaging was performed at rest and with vasodilator stress with intravenous adenosine. Myocardial perfusion reserve index was obtained and processed using semiquantitative measurement using CVI42 software (Circle Cardiovascular Imaging Inc). Statistical analysis was performed using linear regression models, Fisher's exact tests, ANOVA, or Kruskal-Wallis tests. Results showed that Age (P = 0.007), Body surface area (0.05) were highest in the HFpEF group. Left ventricular ejection fraction (P = 0.02) was lower among the INOCA and HFpEF groups compared to reference controls. In addition, A graded reduction was noticed in myocardial perfusion reserve index in HFpEF vs. INOCA vs. reference controls (1.5 ± 0.3, 1.8 ± 0.3, 1.9 ± 0.3, P = 0.02), but wasn’t statistically significant once adjusted to age. In conclusion, reduced myocardial perfusion reserve appears to be a common pathophysiologic feature in INOCA and HFpEF patients compared to reference control women.