Silent myocardial ischemia (SMI) is a condition where myocardial ischemia occurs without typical symptoms like chest pain. It is a significant challenge in cardiovascular medicine due to its asymptomatic nature, leading to delayed diagnosis and increased risk of severe complications. SMI results from an imbalance between ATP production and consumption, leading to biochemical changes without symptoms. It is classified into three types and is associated with various risk factors, including diabetes and coronary artery disease. SMI can occur in the absence of angina or its equivalents, such as dyspnea, nausea, and diaphoresis. The mechanisms of SMI involve complex interactions of vascular, neurohormonal, and metabolic factors, contributing to perfusion deficits without chest pain. Diagnostic methods include stress echocardiography, single-photon emission computed tomography (SPECT), positron emission tomography (PET), and cardiac magnetic resonance imaging (MRI). Treatment of SMI remains controversial, with evidence on the role of invasive versus medical management being inconclusive. The management of SMI involves a multidimensional approach focusing on early detection, risk factor management, and preventive strategies. SMI is prevalent in certain patient groups, including those with diabetes and stable angina. The prognosis of SMI is poor, with increased risk of sudden cardiac death and adverse cardiovascular outcomes. Screening and diagnosis of SMI are challenging, with limited evidence supporting the use of functional imaging in asymptomatic individuals. The role of revascularization in SMI is debated, with some studies suggesting it may not provide additional benefits. Overall, SMI remains a complex and challenging condition in cardiovascular medicine, requiring further research and development to improve diagnosis and treatment strategies.Silent myocardial ischemia (SMI) is a condition where myocardial ischemia occurs without typical symptoms like chest pain. It is a significant challenge in cardiovascular medicine due to its asymptomatic nature, leading to delayed diagnosis and increased risk of severe complications. SMI results from an imbalance between ATP production and consumption, leading to biochemical changes without symptoms. It is classified into three types and is associated with various risk factors, including diabetes and coronary artery disease. SMI can occur in the absence of angina or its equivalents, such as dyspnea, nausea, and diaphoresis. The mechanisms of SMI involve complex interactions of vascular, neurohormonal, and metabolic factors, contributing to perfusion deficits without chest pain. Diagnostic methods include stress echocardiography, single-photon emission computed tomography (SPECT), positron emission tomography (PET), and cardiac magnetic resonance imaging (MRI). Treatment of SMI remains controversial, with evidence on the role of invasive versus medical management being inconclusive. The management of SMI involves a multidimensional approach focusing on early detection, risk factor management, and preventive strategies. SMI is prevalent in certain patient groups, including those with diabetes and stable angina. The prognosis of SMI is poor, with increased risk of sudden cardiac death and adverse cardiovascular outcomes. Screening and diagnosis of SMI are challenging, with limited evidence supporting the use of functional imaging in asymptomatic individuals. The role of revascularization in SMI is debated, with some studies suggesting it may not provide additional benefits. Overall, SMI remains a complex and challenging condition in cardiovascular medicine, requiring further research and development to improve diagnosis and treatment strategies.