To develop an integrated strategy for the identification and subsequent management of high-risk patients in order to reduce both morbidity and mortality. Prospective consecutive series in which all patients underwent cardiopulmonary exercise (CPX) testing. CPX laboratory and level 3 ICU and high-dependency unit (HDU) of a metropolitan teaching hospital. Five hundred forty-eight patients >60 years of age (or younger with known cardiopulmonary disease) scheduled for major intra-abdominal surgery. The patients were assigned to one of three management strategies (ICU, HDU, or ward) based on the anaerobic threshold (deltaT) and ECG evidence of myocardial ischemia as determined by CPX testing that was performed as part of the presurgery evaluation, and by the expected oxygen demand stress of the surgical procedure. Overall mortality was 3.9%. Forty-three percent of deaths were attributed to poor cardiopulmonary function, as detected preoperatively. There were no deaths related to cardiopulmonary complications in any patient deemed fit for major abdominal surgery and ward management, as determined by CPX testing. In elderly patients undergoing major intra-abdominal surgery, the AT, as determined by CPX testing, is an excellent predictor of mortality from cardiopulmonary causes in the postoperative period. Preoperative screening using CPX testing allowed the identification of high-risk patients and the appropriate selection of perioperative management.