Ischemic cardiomyopathy (ICM) is a major cause of cardiovascular morbidity and mortality, characterized by a complex pathophysiological substrate and heterogeneous clinical trajectories. Despite decades of investigation, its diagnosis and management remain challenging, particularly regarding the role of coronary revascularization in addition to optimal medical therapy. Recent advances in pharmacotherapy, device-based interventions, and percutaneous techniques have expanded treatment options, but important evidence gaps persist. This state-of-the-art review critically appraises the contemporary diagnosis and management of ICM. Particular emphasis is placed on the integration of multimodality non-invasive imaging into clinical decision-making, the reinterpretation of myocardial viability and revascularization in light of recent randomized evidence, and the interface between chronic coronary syndrome guidance and heart failure with reduced ejection fraction care in patients with ischemic LV dysfunction. By integrating these domains, the review supports a management approach in which guideline-directed medical and device therapy remain foundational, whereas revascularization is individualized according to myocardial substrate, coronary anatomy, symptoms, comorbidities, procedural risk, and multidisciplinary Heart Team assessment.