The number of older people having surgery is increasing and geriatrician involvement is being increasingly sought. This article uses guidance from the European Society of Cardiology1 and the American College of Cardiology to provide a practical guide for geriatricians advising on preoperative cardiac optimisation in older people. Preoperative investigations should be justified according to risk. These include blood tests, electrocardiograms (ECGs), echocardiograms, stress tests and angiography. Optimising and initiating treatment for cardiac disease reduces adverse postoperative outcomes.