The traditional approach to managing ischemic heart disease has been to reduce symptoms, eg, angina pectoris. However, recent studies demonstrate that myocardial ischemia often can be found in the absence of common symptoms, including in elderly patients. Since elderly patients may not complain about their symptoms, or may not get enough exercise to test their cardiovascular capabilities and, thus, bring out problems, the geriatrician needs to be highly suspicious of silent myocardial ischemia. A brief overview of diagnostic testing methods suitable for the elderly and medical and surgical management options is presented.