Whether anesthetic technique affected the incidence of myocardial ischemia in 60 patients undergoing carotid endarterectomy was investigated. The patients were randomly assigned to receive halothane or isoflurnne (with nitrous oxide) either nt a low concentration alone or at a higher concentration with phenylephrine added to support blood pressure. Blood pressure wns maintained within 20% of each patients average ward systolic pressure. Seven leads of electrocardiograms (ECC) and echocardiograms were analyzed for segmental wall motion. The echocardiograms were analyzed using standard formulae for end-systolic meridional wall stress (SWS) and rntecorrected velocity of fiber shortening (Vcfc). Because of the nature of these calculations, only echocardiograms with normal regional wall motion could be accurately analyzed. The patients had postoperative ECG and creatinine phosphokinase (CPK)isoenzyme determinations and regularly scheduled clinical examinations to detect perioperntive myocardial infarction and neurologic deficits. Although blood pressures were similar, the patients who received a higher concentration of anesthetic plus phenylephrine had a higher wall stress, regardless of the choice of anesthetic agent. All four techniques allowed provision of the same stump pressures (the marker surgeons used for adequacy of collateral carotid flow). No difference could be found in wall stress or incidence of myocardial ischemia between isoflurane and halothane. The patients who received phenylephrine had a threefold greater incidence of myocardial ischemia than did the patients who had light anesthesia to maintain similar systolic blood pressures and stump pressures. The groups were demographically and hemodynamicnlly similar; in particular, the heart rates were not different. Increased wall stress in anesthetized patients is associated with an increased incidence of myocardial ischemia as evidenced by new segmental wall motion and wall thickening abnormalities (SWMA).