Perioperative acute myocardial infarction is a life-threatening event. The aim of preoperative evaluation is identifying at-risk patient of developing postoperative complications and to undertake risk reduction measures to prevent such complications. We report a case of male patient with good functional capacity and unknown history cardiovascular disease undergoing radical cystectomy who suffered intra-operative cardiac arrest and ST-segment elevation myocardial ischemia. Postoperative urgent coronary revascularization was done and dual antiplatelets therapy was prescribed. Postoperative course was uneventful with no bleeding complication. Major perioperative cardiac events in noncardiac surgery are still probable despite the current guidelines of preoperative evaluation. Early revascularization and antiplatelet administration were feasible and did not produce critical surgical bleeding.