One of every four persons in the Western industrialised nations has cardiovascular disease. The perioperative setting in those patients is associated with the risk of myocardial ischaemia (PMI) and myocardial infarction, and also with the risk of perioperative stroke and dysfunction of the central nervous system (CNS). Perioperative cardiovascular morbidity represents a major healthcare challenge. The relevance of PMI is well documented. It has been demonstrated in early trials that both myocardial ischaemia and infarction are preventable in high-risk patients undergoing surgery, and that therapeutic agents such as adenosine-related agents, alpha 2-agonists, and other stress modulators can be safely administered to these patients. Regarding perioperative stroke, approximately 3 to 7% of patients undergoing cardiac surgery suffer stroke, with an additional 30% or more suffering in-hospital CNS dysfunction, and 10% suffering moderately severe long-term CNS dysfunction. Few data are available for noncardiac surgery. The number of outcome studies addressing prophylactic or therapeutic options in these patients is quite limited. In fact, only one recent study has established that perioperative stroke is preventable with the use of an adenosine-regulating agent. Thus, it appears that it may be possible to prevent stroke, even though these results require confirmation. Because of the aging of our population, and the medical, financial and social impact of cardiovascular disease, the development of anti-ischaemic therapy, particularly in the surgical patient, will be a critical area of medical research for the next several decades.