Silent myocardial ischemia (SMI) is a manifestation of coronary artery disease in which persons have episodes of myocardial ischemia that are not accompanied by chest or anginal pain. Episodes of SMI have been described as the predominant form of transient myocardial ischemia in patients with stable angina, those with unstable rest angina and even variant angina. Silent myocardial ischemia is also known to occur in some patients with myocardial infarctions and resuscitated from episodes of sudden cardiac death, thus occur frequently in patients with all of the usual symptomatic phases of coronary artery disease. A number of studies have now clearly demonstrated that patients with silent ischemia have increased risk for coronary events: sudden death or myocardial infarction. SMI is most often recognized during exercise testing or fortuitously with ambulatory electrocardiography. For today it is imperative to investigate every patient in whom multiple risk factors of IHD have been recognised, even in the absence of chest pain. The early detection of SMI may help to prevent later cardiac events. If the ischemia (symptomatic and silent) itself is the cause of the higher mortality rate, then the goal of therapy should be to abolish it either by pharmacological means or by invasive interventions as balloon angioplasty or coronary bypass surgery.