Cardiovascular complications are the major cause of perioperative morbidity and mortality of patients undergoing major vascular surgery. This is related to the frequent presence of an underlying coronary artery disease. This paper reviews the pathology of perioperative cardiac complications and cardiac risk assessment and risk reduction strategies. Guidelines of the American College of Cardiology and American Heart Association for the evaluation of cardiac risk for noncardiac surgery may provide the necessary framework for the assessment and management of patients undergoing major vascular surgery. Based on the American College of Cardiology and American Heart Association guidelines and data from contemporary studies, patients without risk factors are considered to be at low risk and do not require additional evaluations for coronary artery disease. Patients with 1 or 2 cardiac risk factors represent an intermediate-risk group for perioperative cardiac complications. If beta-blockers are prescribed, the probability of cardiac complications is low and there is no need for further noninvasive testing. Patients with 3 or more risk factors are at high risk for cardiac complications and the use of noninvasive testing may help further refine cardiac risk based on the presence and absence of test-induced myocardial ischemia. beta-Blockers should be prescribed to all patients, and coronary revascularization should be reserved for high-risk patients who have a clearly defined need for revascularization independent of the need for major vascular surgery.