With our success in management of acute coronary syndromes (ACS), aging population and epidemics of diabetes and obesity, the management of patients with chronic coronary artery disease is becoming an increasing important part of clinical practice. Although the rates of death and myocardial infarction (MI) in this group of patients are not high as a group, a subgroup has very high risk but many have poor quality of life related to limiting angina. The purpose of this article is to review the pathophysiology of the chronic angina syndrome to provide an improved understanding of the basis for the comprehensive management required to yield patient benefits. Where possible, targets for novel therapeutic approaches are highlighted.