Underlying significant coronary artery disease (CAD) is an important component in the pathophysiologic processes of perioperative myocardial infarction (MI) (
5). Patients with no history of MI have a low risk of perioperative MI (0.1% to 0.6%); those with a history of MI are at significantly higher risk (2.8% to 7%) (
6,
7,
8,
9); and the highest risk is in patients who sustained MI within 3 months before noncardiac surgery (
7). The majority of perioperative MIs are known to occur in the first 3 days after surgery, with peak incidence on day 2 (
8,
9). The lack of classic symptoms of chest pain and, instead, an atypical presentation with new-onset congestive heart failure, hypotension, arrhythmias, nausea, or altered mental status makes the clinical diagnosis challenging. Perioperative MI is associated with greater than 50% mortality rates (
8,
10). Therefore it is important to identify patients who are at risk for untoward outcomes after surgery by using a systematic stepwise preoperative assessment strategy. A contemporary composite algorithm is thus provided in this chapter the better to incorporate the consensus-derived algorithms (
11,
12), such as those suggested by the American College of Cardiology/American Heart Association (ACC/AHA) Task Force on
Practice Guidelines (
11), and empiric risk indices (
13,
14), such as the Revised Cardiac Risk Index (RCRI) (
14).