Angina with left ventricular dysfunction exhibits a wide range of different presentations. Approximately 45% of patients referred for coronary artery bypass surgery have some degree of left ventricular dysfunction and, given that at least a third of those suffering from angina have a history of myocardial infarction, the prevalence of left ventricular dysfunction in such patients is likely to be substantial. The major prognostic factor in patients with coronary artery disease is the degree of left ventricular function and it is important to identify those with poor or reduced left ventricular function. High-risk patients, defined by exercise testing and echocardiography, should be considered for revascularization. For the majority of patients management should be medical, consisting of nitrates plus a beta-blocker or calcium antagonist. In severe ischaemia, the combination of these agents has been shown to provide additional efficacy. In patients with heart failure the newer calcium antagonist amlodipine has been shown to have a neutral effect upon survival, indicating that it may be used safely in patients with angina and left ventricular dysfunction. Progression of left ventricular dysfunction may be slowed through the use of angiotensin converting enzyme (ACE) inhibitors, which have also been shown to improve survival, although they should be used with caution, since there is evidence that ACE inhibitors may worsen angina in some patients.