Cardiac complications such as myocardial infarction and congestive heart failure are the primary source of perioperative morbidity and mortality in elderly surgical patients. This is the result of structural and functional age-related changes in the heart and the vasculature and an increasing incidence of cardiovascular disorders. Appropriate perioperative management of the elderly patient should be based on the extent of functional compromise, the type and severity of pre-existing disease, and the invasiveness of the surgical procedure. Current studies suggest that appropriately administered medical therapy, particularly &bgr;-adrenergic blockade, may reduce perioperative cardiovascular morbidity and mortality in these patients. In this article, we review changes in cardiovascular structure and function that occur with advancing age and describe perioperative medical interventions that may improve cardiac outcome in the elderly critically ill patient.