Silent myocardial ischemia is reported to account for approximately one-fifth of all myocardial infarctions and to be very common in patients with a history of angina pectoris. It may also play an important role in sudden cardiac death. Detection of silent ischemia is best accomplished by treadmill testing, electrocardiogram, or Holter monitoring. When detected, it should be treated vigorously in high-risk patients and all postinfarction patients. Recommendations regarding to the ideal therapy still await the results of controlled clinical testing, although preliminary reports indicate that topical nitrates are effective.