More than 30 million Americans have diabetes mellitus (DM), and heart disease is the cause of death in 68% of them. Patients with DM are at increased risk of developing stable ischemic heart disease (SIHD) by several mechanisms. While noninvasive testing for ischemia is an intuitive strategy to reduce cardiovascular events, trial data do not show a clear benefit. For the DM patient with no symptoms and no evidence of SIHD, two randomized trials found no benefit for either nuclear stress or cardiac computed tomography. While silent ischemia is associated with increased cardiovascular risk, on a population level, reducing ischemia does not appear to improve outcomes. Another important consideration in the management of SIHD in DM patients is that recent randomized trial data show no benefit from coronary revascularization for this population. In conclusion, the decision to test for ischemia may be a reasonable option in some DM patient groups; however, in many cases, revascularization for SIHD does not reduce mortality or the rate of myocardial infarction.