The preoperative assessment of the high risk patient undergoing noncardiac surgery has traditionally been based on history, physical examination, and preoperative testing. We propose a method of assessing preoperative risk based on the presentation of coronary artery disease, exercise tolerance, and extent of the surgical procedure. Since this is an evolving field, as new information and perioperative management techniques become available, the preoperative evaluation of the high risk patient will change. We have presented one approach based on our interpretation of data from the current anesthesiology and cardiology literature. In the patient with a recent MI, the predischarge symptom-limited stress test and the electrocardiographic classification can be used to better stratify risk. In the patient with angina, testing should be reserved for those patients who are candidates for coronary revascularization or alternative surgical procedures. In the patient at risk of but without overt symptoms of coronary artery disease, the number of clinical risk factors can determine the probability of coronary artery disease in the individual patient. The decision to perform preoperative revascularization should be based on its anticipated improvement of both the short- and long-term prognosis of the patient considering the risk of such procedures. The objective assessment of LVEF should be performed in patients with a poor exercise tolerance with either a high risk of perioperative ischemia or a suspicion of cardiomyopathy.