In this review, we consider the main pathophysiological processes involved in ischaemia and reperfusion injury and stunning. Mechanisms involved are low-energy state, intracellular sodium and calcium overload, damage due to increased production of free radicals, and dysfunction in the excitation-contraction coupling process. These different pathophysiological mechanisms, and the fascinating phenomenon of ischaemic preconditioning that renders the heart resistant to ischaemia after brief periods of ischaemia, lead to therapeutic possibilities for myocardial protection. New developments in myocardial protection through administration of cardioplegia, prevention of myocardial oedema, uncoupling of excitation-contraction, inhibition of adenosine and nucleoside transport, and Na+-H+exchange, and antioxidant therapy are discussed.