Perioperative myocardial infarction (PMI) is one of the mostimportant predictors of short- and long-term morbidity and mortalityassociated with non-cardiac surgery. Prevention of a PMI is thus aprerequisite for an improvement in overall postoperative outcome.The aetiology of PMI is multifactorial. The perioperative periodinduces large, unpredictable and unphysiological alterations incoronary plaque morphology, function and progression, and maytrigger a mismatch of myocardial oxygen supply and demand. Withmany diverse factors involved, it is unlikely that one singleintervention will successfully improve cardiac outcome followingnon-cardiac surgery. Perioperative plaque stabilization bypharmacological means may be as important in the prevention ofPMI as an increase in myocardial oxygen supply or a reduction inmyocardial oxygen demand.