The management of patients with ischemic cardiomyopathy involves evaluation of the relative benefits of revascularization versus medical management, or the referral for advanced heart failure therapies. While the decision to proceed with revascularization may be straight-forward in patients with severe angina or important stenosis of the left main coronary artery, many patients have less clear indications for revascularization and require additional evaluation, which may include viability testing, assessment of hemodynamics or evaluation of mechanical dyssynchrony which may provide information that may help define the relative risks of revascularization and medical management. Even in the situation where the operative risk is elevated, it may still be less than the risk of non-operative therapy. When faced with a patient with very high operative risk or limited benefit with revascularization, one should consider alternative approaches such as durable ventricular assist devices or cardiac transplantation.