BACKGROUND: Until now no randomized trial can be considered powered enough to show a reduction on both perioperative myocardial infarction and mortality. METHODS: We performed an extensive research of the literature to identify dugs or technique that could have an effect on perioperative myocardial infarction in cardiac and non-cardiac surgery. RESULTS: Volatile agents reduce myocardial infarction (NNT=37) and mortality (NNT=83) in cardiac surgery when compared to total intravenous anesthesia. No data regarding the use of volatile agents in non-cardiac surgery exists. Levosimendan reduces myocardial infarction (NNT=21) and mortality (NNT=12) in cardiac surgery when compared to placebo or other inotropic agents. No data regarding its use in non-cardiac surgery exists. Epidural analgesia has promising beneficial effects in both cardiac and non-cardiac surgery. In non-cardiac surgery statins and calcium antagonists have minor beneficial effects while alpha(2) agonists could reduce perioperative myocardial infarction and are included in the American College of Cardiology/American Heart Association Guidelines. Beta blockers are also included in the international guidelines but benefits and hazards should be careful considered. CONCLUSIONS: Volatile agents and levosimendan consistently reduce perioperative myocardial infarction and mortality in cardiac surgery but they have not been properly studied in non-cardiac surgery. Minor (epidural analgesia, statins, calcium antagonists and alpha(2) agonists) or doubtful (beta-blockers) results were found in non-cardiac surgery.