Background: Unmanaged perioperative pain may trigger the sympathetic nervous system, the surgical stress response, and the coagulation cascade, all of which may increase the risk of cardiac morbidity. Myocardial oxygen demand can rise due to increased sympathetic nervous system activity via raising heart rate, arterial blood pressure, and contractility. Additionally, sympathetic activity may increase perioperative hypercoagulability, which might lead to coronary thrombosis or vasospasm and decrease the amount of oxygen delivered to the myocardium. Objective: To compare the effect of three analgesic techniques used during hip arthroplastic surgery for patients who are at risk for, or had, ischemic heart disease as regards hemodynamic stability, incidence of ischemia, pain control and incidence of complications. Patients and Methods: This study was carried out in Al-Azhar University Hospital Assiut and Aswan University Hospital in period from March 2020 to March 2022, following written informed agreement and Ethics Committee permission, 60 adult patients with ASA III and IV had hip arthroplasty and were enrolled in the study. Results: Continuous epidural analgesia attenuated NT-proBNP release in patients undergoing hip arthroplasty. More likely, the addition of local anesthetic bupivacaine to fentanyl epidurally had enhanced this effect. Increased left ventricular wall stress secondary to transitory myocardial ischemia and short bouts of myocardial dysfunction may have contributed to the considerably higher plasma BNP levels in individuals who received IV controlled analgesia. Conclusion: Epidural analgesia concomitant with general anesthesia by opioids with local anesthetics is a good choice for hip arthroplasty in ischemic heart patients that it is accompanied with less postoperative complications, more stable hemodynamics and less neuroendocrinal stress response. Also, NT-proBNP is a marker of choice for detecting subclinical myocardial ischemia during perioperative periods.