Normal ageing of the cardiopulmonary system overlaps with the development of cardiovascular disease. It is characterised by changes which decrease cardiovascular reserve through senescent changes in myocardial function and volumes. These changes are compounded by co-existing cardiovascular disease, multisystem co-morbidities and polypharmacy. Indices of vascular ageing permit risk prediction in the perioperative setting. The investigation of these changes using arterio-ventricular coupling has highlighted preload sensitivity and beta-adrenergic and baroreflex insensitivity as the cardinal features which influence cardiovascular performance. Anaesthesia interferes with each of the components and poses substantial challenges. Comprehensive preoperative evaluation and optimisation assist in choosing an individualised approach. This approach, outlined here, must aim where possible to maintain tight haemodynamic control and to limit exhaustion of cardiopulmonary reserve.
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