Coronary artery disease (CAD) remains the most common cause of heart disease in the elderly, in whom it exhibits some unique features. It is more likely to be diffuse and severe and left main coronary artery stenosis and triple-vessel disease are more prevalent. Diagnosis is less dependent on the presence of chest pain since other symptoms may present as an anginal equivalent in such patients. The ECG of elderly patients often shows abnormalities that are not specific for myocardial ischaemia. In such patients, and in those who are unable to perform sufficient exercise to increase the heart rate to > or = 85% of predicted maximal heart rate for age and sex, radionuclide or pharmacological stress testing may be used. When the diagnosis of CAD remains questionable, coronary arteriography should be considered. Physical examination and basic laboratory screening should be used to identify conditions which exacerbate myocardial ischaemia and will, therefore, affect treatment. The initial approach to treatment should include risk factor modification and initiation of an anti-ischaemic pharmacological regimen. The usual anti-anginal medications are as efficacious in the elderly as in the young; however, attention must be paid to altered pharmacodynamics and pharmacokinetics. When symptoms are poorly controlled by medical therapy or when multivessel or left main coronary artery stenosis is identified, myocardial revascularization should be considered. In elderly patients with symptomatic angina or unstable angina symptoms, uncontrolled by medical therapy, percutaneous transluminal coronary angiography may be a reasonable alternative to surgical revascularization.