The high-risk surgical patient is a growing challenge to modern health care. This cohort, although comprising only 10-15% of surgical procedures, accounts for approximately 80% of postoperative deaths and suffers a high rate of postoperative morbidity. Developing robust systems to help identify and better manage this patient group should be a priority. Risk stratification has become a valuable clinical tool for shared decision-making and the development of individualized care plans. Methods for stratifying individual risk include assessment tools, measures of functional capacity and plasma biomarker assays. Routine evaluation of perioperative risk is central to the delivery of high quality, appropriate surgical care.