Although perioperative macrovascular events (eg, myocardial infarction, stroke) are readily evident, their absolute incidence remains relatively low. In contrast, microvascular dysfunction and its role in perioperative morbidity is not easily measured. Microvascular dysfunction is likely to have a greater impact on noncardiovascular complications (eg, wound healing and end-organ failure), through impaired perfusion, than that which is readily appreciated. Inflammation and oxidative stress, such as that induced by surgical trauma, disrupts endothelial homeostasis thereby decreasing the bioavailability of nitric oxide. This predisposes blood vessels to vasoconstriction, inflammation, leukocyte adhesion, thrombosis-factors that contribute to perioperative cardiovascular events at both macrovascular and microvascular level. Current clinical strategies applicable to the perioperative setting that improve microvascular health include preoperative exercise therapy, pharmacologic interventions (eg, statins, newer beta-blockers) and attempts to stimulate mobilization and homing of bone marrow-derived endothelial progenitor cells. Many of these strategies are still in their infancy and large prospective trials that investigate the impact of these therapeutic options on postoperative outcome are eagerly awaited.