Chronic symptomatic ischemic heart failure remains a major cause of morbidity and mortality in the adult. Recently, the utility of coronary revascularization in early management of patients with stable ischemic heart failure has come into question by several randomized clinical trials. Some of these studies have also challenged the notion that determination of the predominant state of the dysfunctional left ventricular myocardium (viable or scarred) may facilitate identification of patients who would benefit the most from revascularization. These prospective, randomized, multi-center trials have also exposed many of the practical impediments to conducting an ideal clinical investigation particularly in the context of increasingly recognized need for goal-directed and personalized approaches to management of ischemic heart disease. This review summarizes the present evidence for an ischemia-guided approach to evaluation and treatment of chronic ischemic heart disease with left ventricular systolic dysfunction.