Coronary angiography was performed during the evaluation of a prospective series of 506 patients (mean age, 65 years) presenting with extracranial cerebrovascular disease and previous neurologic symptoms (N = 288) or asymptomatic carotid bruits (N = 218). Severe, surgically correctable coronary artery disease was documented in 37% of patients suspected to have coronary artery disease by conventional clinical criteria, compared with 16% of those who were not. Severe inoperable coronary disease was present in 9.8% and 1.5% of these respective subsets and was especially common (14%) among diabetics. As the result of this investigation, an algorithm for perioperative cardiac screening has been developed in an attempt to reduce the eventual mortality caused by myocardial infarction in patients who require extracranial reconstruction.