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Myocardial infarction after noncardiac surgery in patients with coronary artery disease results from the interplay of patient-specific, anesthetic-specific, and surgery-specific factors. Surgery-specific factors include the stress response to injury, both neurohormonal and hemostatic alterations, and clinically-significant operative parameters such as urgency, duration, blood loss, body core temperature, fluid shifts, and location of surgery. The impact of these factors bears out during the entire perioperative period and influences preoperative risk assessment, cardiac evaluation and intervention, intraoperative strategy, and postoperative management. Overall, the morbidity and mortality of surgery is minimal even in high-risk patients, and the contribution of surgery-specific factors to operative risk is subtle compared with that of patient specific-factors such as severity of coronary disease and other comorbid conditions. Nonetheless, the optimal surgical management of patients with coronary disease requires the collaborative effort of the anesthesiologist, cardiologist, and surgeon.