The estimation of an individual patient's "resistance" to major surgery has become an complex matter. Clinical parameters allow risk stratification in a large number of patients who are about to undergo noncardiac surgery. Low risk patients can be "cleared" for surgery. Moderate risk patients should undergo further testing. Exercise testing and pharmacological stress testing with myocardial perfusion imaging can refine risk estimation in these patients. This risk stratification is well backed by scientific data, although most of it is derived from studies in the same very high risk population, i.e. patients scheduled for vascular surgery. Less hard evidence exists when it comes to the management of the high-risk patient. Coronary bypass surgery should probably be reserved for those in whom additional indications for this procedure exist. The perioperative use of beta-blockers can possibly reduce operative risk. Data on perioperative monitoring and anesthetic technique are not yet convincing. The relative merits of various perioperative management strategies will remain uncertain until randomised trials are performed to evaluate the alternatives systematically.