Cardiac pre-operative evaluation must aim to estimate the perioperative cardiovascular risk, taking into consideration the individual clinical setting along with the type of surgery. Pre-operative assessment and management comprise evaluation of risk scores and the potential performance of some paraclinical tests to better prepare the patient for surgery. Pain management, adequate hydration, and thromboembolic prophylaxis constitute the main axis to decrease perioperative cardiovascular complications; moreover, the presence of previous cardiac conditions along with hypersympathetic activity is involved in a significant percentage of perioperative morbidity. Patients with minimal perioperative risk may not require systematically a cardiology consultation, whereas patients with moderate or high surgical risk often require a multidisciplinary approach for better perioperative management. The use of paraclinical tests to evaluate cardiac condition, such as cardiac biomarkers, echocardiogram, and other noninvasive or invasive cardiac testing, should be tailored on a case-by-case basis. Such professional practice aims to limit unnecessary healthcare expenses without compromising clinical outcome. Pre-operative surgical risk is not only based on cardiovascular condition but also on other factors and comorbidities such as diabetes, renal function, and functional status. In this regard, the role of the anesthesiologist is essential to evaluate the pre-operative risk (mild, moderate, or high), also to manage the whole perioperative period.