Hypoxia-inducible factor (HIF) is the principal transcription factor involved in the regulation of transcriptional responses to hypoxia. During hypoxia, HIF-alpha levels accumulate and trigger an increase in expression of genes involved in glycolysis, glucose metabolism, mitochondrial function, cell survival, apoptosis, and resistance to oxidative stress. In this regard, HIF activation plays an essential role in triggering cellular protection and metabolic alterations from the consequences of oxygen deprivation. This suggests that HIF activation should confer protection against ischemia-reperfusion (I/R) injury, although this protection might require HIF activation before the onset of lethal ischemia. Studies using enhanced expression of HIF-1alpha suggest that its upregulation may be a beneficial therapeutic modality in the treatment or prevention of ischemic injury. HIF-regulated gene expression may mediate the late phase of preconditioning, and constitutive HIF activity may influence the expression of genes that are required for the cell to be able to respond to acute preconditioning. This article reviews the current literature on the role of HIF in balancing protection and cell death in the face of ischemia and I/R injury.