Chronic or severe ischemic heart disease can lead to damaged or infarcted myocardium that can progress to heart failure. When evaluating revascularization, one should consider noninvasive assessments, physiologic testing, angiographic characteristics, and patient comorbidities/functional status. Evaluation for advanced therapies may be needed. Considerations for early referral include repeat heart failure-related hospitalizations despite medical therapy, development of right heart failure, recurrent and refractory ventricular arrhythmias, or intolerance to goal-directed medical therapy. Mechanical circulatory support can act as a bridge to transplant. However, if patients are not candidates for such procedures, initiation of palliative services can improve outcomes and quality of life.