Diagnosis of myocardial ischemia requires integration of ECG, pulmonary artery pressures, and TEE data. ST depression of 1 mV or elevation of 2 mV remains the mainstay of diagnosis of ischemia. Increases of pulmonary artery pressures of 5 mm Hg are common but not reliably diagnostic of ischemia. Transesophageal echocardiography is the most sensitive monitor of ischemia, where the spectra of SWMA evolve. Diastolic dysfunction (elevations in LVEDP) is a more sensitive marker of ischemia, but requires measurement of several Doppler patterns. After diagnosis, treatment should include optimization of hemodynamics (beginning with beta-blockers and nitrates), anesthesia, and oxygen-carrying capacity (e.g., normothermia, oxygen saturation, hematocrit more than 28%).