Ischaemic heart disease remains the leading cause of death in the western world and jeopardize quality of life in millions people. PTCA plus medical therapy can control symptoms in most patients with stable angina. However, many trials consistently report persistance of angina and/or ischemia in one third of patients. Awareness of the limited benefit from standard treatments is increasing and stimulates the search for innovative approaches. Improved understanding of cardiac energy metabolism offers promising alternatives and new solution to the problem. A partial shift from free fatty acid to glucose oxidations has been shown to improve cardiac efficiency and to increase tolerance to ischaemia. Large clinical trias based on metabolic agents are warranted.