Cardiac diseases, particularly coronary artery disease and its risk factors, are associated with the majority of perioperative complications in patients undergoing major noncardiac surgery. Risks are remarkably low overall, yet for selected patients undergoing high-risk procedures, the chances of complications remain reasonably high. The literature has focused largely on identifying patients in whom complications are most likely to occur, using clinical assessment, including RFI, specialized cardiac testing, and perioperative monitoring. Characteristics of the patient and the surgery both influence outcomes. Current practices may have swung toward excessive testing, especially in patients whose surgical risks are low or moderate. Surprisingly little attention has been devoted to the evaluation of preoperative interventions for reducing perioperative risk. Some observations support the feasibility of performing noncardiac surgery in some high-risk groups using support devices or temporizing techniques. The general application of percutaneous or surgical revascularization as a means of reducing perioperative risk has not been assessed and to date represents an expensive and perhaps risky strategy. In patients who satisfy the usual symptomatic or prognostic criteria for coronary revascularization, its timing should depend on the urgency and risk of the noncardiac procedure. Finally, patients with cardiac devices--pacemakers, prosthetic valves, implantable debrillators, and antitachycardia devices--and survivors of congenital and transplant surgery have specific needs that require careful attention, going beyond the usual vigilance required in the perioperative period.