Abstract Attempts at diagnosis and treatment of silent myocardial ischemia appear to be justified in patients with known or suspected coronary artery disease. A positive exercise test result or ambulatory electrocardiographic monitoring showing ST-segment deviation is an appropriate indication for adjustment of anti-ischemic therapy. With the documentation of more severe ischemia, angiography should be considered to determine the extent of coronary artery disease. Medical therapy, antianginal agents and risk reduction may improve survival. When ischemic involvement is severe, as in 3-vessel disease, interventional surgery may be required, whether or not ischemia is accompanied by angina. Selected clinical practice cases are presented to illustrate these diagnostic and therapeutic considerations, and are followed by group discussion.