Cardiovascular disease affects more than one in three adults and approaches 70 to 80% in the elderly. Ischemic heart disease is the number one cause of mortality. Worldwide, there will be more than 230 million major noncardiac surgeries performed this year. Surgery and anesthesia lead to a hypercoagulable and adrenergic stressed state that puts patients at risk for myocardial ischemia and infarction. A large, international, prospective, cohort study demonstrates that close to 8% of adults undergoing major noncardiac surgery will sustain myocardial injury as evidenced by troponin leak and that one in ten of these patients will die within 30 days. It is imperative that anesthesia practitioners are able to define the consensus terminology that is used to describe myocardial ischemia and infarction especially as it relates to the perioperative period. The 2014 ACC/AHA guidelines on perioperative cardiac evaluation indicate that the majority of patients with cardiovascular disease will be coming to surgery. Therefore, the anesthetist must be familiar with the evidence-based strategies that are used to minimize the risk of perioperative ischemia by optimizing myocardial oxygen supply and reducing demand. It is critical that if ischemia develops, it is recognized and treated promptly and appropriately because the length of ischemia highly correlates with perioperative morbidity and mortality.