Patients with undifferentiated systolic murmurs present commonly during the perioperative period. Traditional bedside assessment and auscultation has not changed significantly in almost 200 years and relies on interpreting indirect acoustic events as a means of evaluating underlying cardiac pathology. This is notoriously inaccurate, even in expert cardiology hands, since many different valvular and cardiac diseases present with a similar auditory signal.The data on systolic murmurs, physical examination, perioperative valvular disease in the setting of non-cardiac surgery is reviewed.Significant valvular heart disease increases perioperative risk in major non-cardiac surgery and increases long term patient morbidity and mortality. We propose a more modern approach to physical examination that incorporates the use of focused echocardiography to allow direct visualization of cardiac structure and function. This improves the diagnostic accuracy of clinical assessment, allows rational planning of surgery and anaesthesia technique, risk stratification, postoperative monitoring and appropriate referral to physicians and cardiologists.With a thorough preoperative assessment incorporating focused echocardiography, anaesthetists are in the unique position to enhance their role as perioperative physicians and influence short and long term outcomes of their patients.