Cardiovascular disease is the leading cause of death and morbidity among women. The prevalence of coronary heart disease (CHD) and its attendant risk clearly increase with advancing age. Though traditionally underrepresented in CHD trials, the proportion of women participating in these studies has risen in recent years. The American Heart Association has recently published statements on the optimal CHD care for both the elderly and female populations. Evidence-based life style and pharmacologic interventions for CHD appear to offer similar benefits in men and women as well as for older patients. However, older women with CHD differ from men in symptoms, the diagnostic performance of cardiac stress tests, the risk of complications from coronary revascularization procedures, and use of proven beneficial therapies. This article synthesizes the current state of the evidence on optimal diagnostic and therapeutic approaches to older women with established CHD.