BackgroundIncreasingly, patients undergoing non‐cardiac surgery are older and have more comorbidities yet preoperative cardiac assessment appears haphazard and unsystematic. We hypothesised that patients at high cardiac risk were not receiving adequate cardiac assessment, and patients with low‐cardiac risk were being over‐investigated.AimsTo compare in a representative sample of patients undergoing non‐cardiac surgery the use of cardiac investigations in patients at high and low preoperative cardiac risk.MethodsWe examined cardiac assessment patterns prior to elective non‐cardiac surgery in a representative sample of patients. Cardiac risk was calculated using the Revised Cardiac Risk Index.ResultsOf 671 patients, 589 (88%) were low risk and 82 (12%) were high risk. We found that nearly 14% of low‐risk and 45% of high‐risk patients had investigations for coronary ischaemia prior to surgery. Vascular surgery had the highest rate of investigation (38%) and thoracic patients the lowest rate (14%). Whilst 78% of high‐risk patients had coronary disease, only 46% were on beta‐blockers, 49% on aspirin and 77% on statins. For current smokers (17.3% of cohort, n = 98), 60% were advised to quit pre‐op.ConclusionsPractice patterns varied across surgical sub‐types with low‐risk patients tending to be over‐investigated and high‐risk patients under‐investigated. A more systemised approach to this large group of patients could improve clinical outcomes, and more judicious use of investigations could lower healthcare costs and increase efficiency in managing this cohort.