Background: Atypical symptoms often occur in elderly patients. It is common for elderly with ischemic heart disease (IHD) who present without chest pain or with vague symptoms which may mislead clinicians and delay the diagnosis. This might increase morbidity and mortality Aim: To measure the proportion of IHD and the proportion of atypical IHD presentations in elderly patients ≥ 60 years old attending the Geriatric outpatient clinic in Geriatric hospital in Ain Shams University and to identify forms of atypical presentations of IHD in those elderly patients. Methods: Cross-sectional study in which a total of 280 elderly patient ≥ 60 y ears old were enrolled. Data were collected using history taking, (sociodemographic and clinical data), physical examination, electrocardiogram, and echocardiography were collected. Results: The total number of participants was 280, from which 172 (61.43%) participants were not suffering IHD and 108 (38.57%) were IHD. Among 108 IHD patients, 86 (79.73%) presented with typical symptoms while (22 patients 20.37%) presented with atypical symptoms in different forms. Atypical presentations included dyspnea (12 patients 54.55%), atypical chest pain (6 patients 27.27%), palpitation (2 patients 9.09%) and epigastric pain (2 patients 9.09%). Conclusion: The study showed that elderly with IHD may present by symptoms other than the typical chest pain as found in (20.37%) of elderly with IHD. Dyspnea was the most common atypical presentation followed by atypical chest pain. So it is important to be minded with these atypical presentations to avoid misdiagnosis.