Patients with significant cardiovascular disease continue to present for non cardiac surgery in increasing numbers worldwide and are a very high cause of cardiovascular morbidity and mortality in the perioperative period.The anesthesiologist as perioperative physician is charged with the crucial responsibility of providing safe anesthetic care to this high risk group.This lecture will aim to provide some of the latest pre operative guidelines essential for the management of these patients.The revised ACC/AHA guidelines are the key source of periopcrative risk stratification and this lecture will focus on them.