Diastolic heart failure leads to an increase in perioperative morbidity and mortality. The prevalence of this disease is rising and multiple risk factors have already been identified. Besides higher age and female gender, arterial hypertension, diabetes mellitus and coronary artery disease in particular have to be considered. Clinical examination and laboratory analyses are important for preoperative evaluation; however, echocardiography plays the most important role in the diagnostics of diastolic heart failure. The transmitral flow profile can be used to differentiate the grades of diastolic dysfunction using the ratio between early passive ventricular filling (E) and late active filling due to atrial contraction (A). Data concerning the ideal anesthesia technique are for the most part lacking; however, the application of thoracic epidural anesthesia seems to be beneficial. A great deal of attention has to be paid to the intraoperative volume status of patients with diastolic dysfunction as hypovolemia and hypervolemia can both have detrimental effects. Arrhythmias and major changes in blood pressure put this special group of patients at additional risks.