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Adeqate preoperative cardic risk stratification for noncardiac surgery revoles largely around a thorough clinical assessment. Specfic clinical variables tage, previous myocardial infarction (MI), history of angina or diabetes or diabetes mellitus, presence of congestive heart failure (CHF), valvular heart disease, or arrhythmias) that impact cardiac risk are discussed. In the intermediate risk subgroup, futher stratification can be accomplished by using an appropriate noninvasive test. Indiscriminate testing is not recommended. Such a combined appoach optimizes resource utilization without compromising care. The impact of type of surgery, nature of anesthesia, and use of hemodynamic monitioring on cardiac risk is discussed. Finally, the pathophysiology of perioperative ischemia is discussed, and available data on different therapeutic modalities (anti-ischemic medications, percutaneous transluminal coronary angioplasty, or coronary artery bypass graft) are reviewed.