Perioperative cardiac complications remain a great concern during noncardiac surgeries since a large majority of patients undergoing such procedures are elderly, who have a greater prevalence of coronary artery disease. Thus, it is imperative to assess risk of perioperative cardiac complications in all patients scheduled for noncardiac surgery. The current review attempts to outline a systematic approach to assess cardiac risk for noncardiac surgery and suggest strategies to minimize these risks. This approach uses a combination of the urgency of noncardiac surgery, interval since prior revascularization to noncardiac surgery, the interval between prior evaluation of coronary artery disease, patients clinical risks for cardiac complications, and patients functional status to decide their perioperative cardiac risks. If surgery is urgent or the estimated risk for perioperative event is low, then irrespective of the risk, patients should proceed with noncardiac surgery under the influence of appropriate medical strategy to minimize risk. If patients risk of perioperative events is high, then postponing or canceling surgery and referral for invasive approach to identify and when appropriate revascularize coronary artery disease may help reduce the perioperative cardiac risk. In contrast, patients at intermediate risk for perioperative events may benefit from noninvasive assessment for coronary artery disease and referral for appropriate patients for coronary revascularization based on the results of such noninvasive testing. Medical perioperative strategy that should be part of all patients undergoing noncardiac surgery who have or are at risk for coronary artery disease, should include betablockers, adequate analgesia, monitoring fluid status, and maintaining hematocrit > 30 gm /dl. Finally, the physician-patient interaction during the hospitalization during noncardiac surgery should be recognized as an important opportunity to institute secondary prevention strategies for coronary artery disease in patients at risk for coronary atherosclerosis.