Older patients are underrepresented in major cardiovascular trials, and only relatively healthy elderly patients, with few comorbidities or functional impairments, have been enrolled. As a result, current guidelines are unable to provide evidence-based recommendations for anesthesia treatment of patients aged ≥75 years, undergoing non-cardiac surgical procedures. Effective strategies, aimed at reducing the risk of perioperative cardiac complications, should involve cardiac evaluation using mostly medical history. A key component is the evaluation of active or unstable cardiac conditions, surgical and cardiac risk factors, and functional capacity of the patient.Patient at low cardiac risk, based on clinical features, functional status, and low-risk surgery, do not generally require further cardiac evaluation, and can be operated on safely without further delay. Additional preoperative testing is indicated in patients at intermediate risk, with poor or unclear functional status. Patients at high-risk based on clinical features, poor functional status, undergoing high-risk surgery may benefit from further evaluation with noninvasive/invasive stress testing. In case of emergency surgical procedures, patient or surgery-specific factors dictate the strategy and do not allow further cardiac testing or treatment.Successful perioperative evaluation is best achieved by combining an integrated multidisciplinary approach, with good communication between the patient, anesthesiologist, cardiologist, geriatrician and surgeon.