The intermediate-risk preoperative patient can be defined as a patient without severely symptomatic or unstable heart disease who, nonetheless, has clinical predictors of adverse perioperative cardiovascular events. Newer data have created an awareness of competing considerations in managing these patients. There is still debate about how to appropriately select patients for noninvasive cardiac testing, invasive coronary testing, coronary revascularization, beta-blockers, or a combination of these. In this article, we review the evidence pertaining to these issues. We conclude that intermediate-risk preoperative patients are best managed by an approach that emphasizes the following points: intermediate-risk patients should be identified and risk stratified using a clinical tool (eg, the Revised Cardiac Risk Index); noninvasive cardiac testing should be reserved for those patients with multiple clinical predictors of risk or the presence of other modifying factors; preoperative coronary revascularization does not appear to reduce perioperative risk in patients with significant but stable coronary artery disease; and medical therapy should be optimized for these patients, including the application of beta-blockers in all intermediate-risk patients that do not have contraindications.