Cardiovascular care sex differences are controversial. We examined sex differences in management and clinical outcomes among patients undergoing noninvasive testing for ischemic heart disease (IHD). In a rural integrated healthcare system, we identified adults age 40-79 without diagnosed IHD who underwent initial evaluation with a cardiac stress test with imaging or coronary computed tomographic angiography (CTA), 2013-2014. We assessed sex differences in statin/aspirin therapy, revascularization, and adverse cardiovascular events. The 2013 American College of Cardiology/American Heart Association statin guidelines and U.S. Preventive Services Task Force aspirin guidelines were applied. Among 2213 patients evaluated for IHD, median age was 57 years, 48.8% were women, and 9% had a positive stress test/CTA. Women were more likely to be missing lipid values than men ( < 0.001). Mean ASCVD risk score at baseline was 7.2% in women versus 12.4% in men ( < 0.001). There was no significant sex difference in statin therapy at baseline or 60-day follow-up. Women were less likely than men to be taking aspirin at baseline (adj. diff. = -8.5%; 95% CI, -4.2 to -12.9) and follow-up (adj. diff. = -7.7%; 95% CI, -3.3 to -12.1). There were no sex differences in revascularization after accounting for obstructive CAD or adverse cardiovascular outcomes during median follow-up of 33 months. In this contemporary cohort of patients with suspected IHD, women were less likely to receive lipid testing and aspirin therapy, but not statin therapy. Women did not experience worse outcomes. Sex differences in statin therapy reported by others may be due to inadequate accounting for baseline risk.