In the perioperative period, patients with ischemie heart disease are at increased risk for cardiac morbidity, including myocardial infarction, congestive heart failure, and dysrhythmias, as well as for sudden cardiac death. Myocardial ischemia is a precursor of these events, and because it is typically symptomatically silent, we must rely on technical monitors. It is hoped that treatment upon detection of ischemie events will improve outcome in patients at risk for perioperative cardiac morbidity. This review focuses on methods used to detect perioperative myocardial ischemia and examines methods of reducing ischemia in this high-risk period. © Lippincott-Raven Publishers.