The Physiology of Cardiac Ischemia chapter provides an in depth review of coronary blood flow alterations and manifestations of myocardial ischemia. Ischemia is based on insufficient coronary blood flow (CBF) to meet myocardial oxygen demands at rest or during exercise testing resulting in ischemia or infarction. Ischemia promotes a cascade of physiological responses, including enhanced vasomotion, nitric oxide release, and metabolic shifts resulting in altered levels of free fatty acids and lactic acid often leading to ST depression and angina. The mechanism of the electrocardiographic changes of ischemia and ST depression in coronary artery disease (CAD) are reviewed. While our understanding of cardiac ischemia is incomplete, curiosity of this fascinating condition continues to motivate researchers in their search for increasingly effective therapies, opportunities and therapeutic options.