Adequate myocardial oxygenation during the perioperative period is crucial for a good postoperative outcome. This requires the maintenance of myocardial oxygen supply demand ratio, which can be disrupted by various perioperative events. Normally there is a significant reserve in the myocardial oxygen supply, but it can be reduced in pathologic conditions like coronary artery disease, anemia and hypoxemia, which can result in myocardial ischemia. Though myocardial oxygenation is autoregulated over a wide range of perfusion pressures, perioperative events that affect the heart rate, myocardial contractility and coronary perfusion pressure can precipitate myocardial ischemia. Optimal outcome of these patients require good anaesthetic planning and prompt manipulation of any adverse hemodynamic events during the perioperative period.