Approximately 50% of people with diabetes will at some point undergo surgery related to their disease. Since patients with diabetes mellitus are four times more likely to have silent ischemia and coronary artery disease compared to the risk of non-diabetic patients, they are at a higher risk for perioperative complications. Preoperative evaluation can identify many patients at increased risk of an adverse cardiac event, and appropriate perioperative management can reduce that risk. Although there is great potential to reduce perioperative cardiovascular risk, it is also impractical to perform cardiovascular testing prior to non-cardiac surgery in all patients. Therefore, it is important to determine perioperative risk and the appropriateness of cardiac testing and to provide prophylactic treatment to reduce risk. Perioperative cardiac risk stratification is determined by comorbidity, other cardiovascular risk factors, functional status, and type of surgery. By categorizing the cardiac risk, physicians can perform surgery in low risk patients without the need for cardiac testing. When preoperative risk assessment identifies intermediate- and high-risk patients, further cardiac testing might be warranted. This article reviews the perioperative evaluation of patients with diabetes with a clinical focus on cardiovascular risk.