The course of ischemic heart disease has undergone significant changes since the beginning of coronary care units (CCU), antithrombotic protection, coronary artery by pass grafting (CABG), and percutaneous transluminal angioplasty (PTCA). Intrahospital mortality before CCU was 35% and at the present is lower than 10%. The quality of life for those who have suffered an acute ischemic event has changed favorably. On the other hand, this has allowed that a large number of patients with coronary disease reach advanced stages of the disease after having been treated with surgery, angioplasties, etc., besides medical treatments, and due to the advanced coronary obstructions it is not feasible any more to offer them any of the conventional procedures. These patients are considered "end stage" patients. To treat these conditions, cooperation of the patient is indispensable, he/she must adapt his/her life style realistically and abandon completely any potential risk factors. Therapy should be adapted with maximal tolerated doses and scheduled according to the possibility of the presentation of angina. Laser transmyocardial revascularization is an option; this procedure is still under study and the first reports have shown that although there is clinical improvement, but it has failed to demonstrate a decrease in ischemic segments.