Current international guidelines on stable ischemic heart disease (IHD) state that coronary revascularization is indicated in cases of: limiting ischemic symptoms while on optimal medical therapy (OMT); high risk coronary anatomy; high risk stress test result. At the same time, many results supporting these conclusions were obtained in relatively old studies, conducted when the approaches to medical therapy and revascularization techniques differed greatly from contemporary practice. Many of the conclusions have been based on data from observational studies and subanalyses of randomized clinical trials, therefore methodologically are not sufficiently reliable. Moreover, the results of more modern trials do not coincide with the older. This situation has generated contradictory opinions on the indications for coronary revascularization in patients with IHD in the cardiology community. This review contains analysis of the evidence base of current revascularization guidelines, data on components of OMT, and discussion of the need for large-scale randomized clinical trial comparing effectiveness of OMT and OMT+revascularization in patients with stable IHD.