At the present time there is no firm evidence that silent myocardial ischemia (on exercise or Holter ECG) should be treated with anti-ischemic drugs. Silent ischemic episodes obviously are a marker for ischemic activity of coronary artery disease and therefore a bad prognostic sign. However, antianginal drugs (nitrates, calcium-blockers, beta-blockers) have not been shown to improve prognosis. Patients with ischemic episodes should be further evaluated by thallium scintigraphy and coronary angiography. If a significant coronary disease is present, the established therapy with risk factor reduction, lipid lowering drugs and aspirin should be administered. In some instances PTCA or CABG may be indicated.