Silent myocardial ischemia (SMI) is a challenging condition characterized by inadequate blood supply to the myocardium without overt symptoms. The pathogenesis involves complex interactions of vascular, neurohormonal, and metabolic factors. Understanding these mechanisms is crucial for recognizing diverse clinical presentations and designing targeted interventions. Diagnostic strategies have evolved from traditional electrocardiography to advanced imaging modalities, including stress echocardiography, single-photon emission computed tomography (SPECT), positron emission tomography (PET), and cardiac magnetic resonance imaging (MRI). Treating SMI remains controversial, with ongoing debates about the role of invasive versus medical management. This comprehensive review synthesizes current knowledge on SMI, addressing its pathophysiology, diagnostic modalities, and therapeutic interventions. Key points include the mechanisms of ischemic cardiac pain, the epidemiology and prognosis of SMI, and the screening and diagnosis methods available. The review also discusses the management of SMI, highlighting the therapeutic implications of identifying SMI and the ongoing debate about the benefits of myocardial revascularization.Silent myocardial ischemia (SMI) is a challenging condition characterized by inadequate blood supply to the myocardium without overt symptoms. The pathogenesis involves complex interactions of vascular, neurohormonal, and metabolic factors. Understanding these mechanisms is crucial for recognizing diverse clinical presentations and designing targeted interventions. Diagnostic strategies have evolved from traditional electrocardiography to advanced imaging modalities, including stress echocardiography, single-photon emission computed tomography (SPECT), positron emission tomography (PET), and cardiac magnetic resonance imaging (MRI). Treating SMI remains controversial, with ongoing debates about the role of invasive versus medical management. This comprehensive review synthesizes current knowledge on SMI, addressing its pathophysiology, diagnostic modalities, and therapeutic interventions. Key points include the mechanisms of ischemic cardiac pain, the epidemiology and prognosis of SMI, and the screening and diagnosis methods available. The review also discusses the management of SMI, highlighting the therapeutic implications of identifying SMI and the ongoing debate about the benefits of myocardial revascularization.