This study evaluated the prevalence of left-ventricular (LV) dysfunction in vascular surgery patients and pharmacological treatment, according ESC guidelines. Echocardiography was performed pre-operatively in 1005 consecutive patients. Left ventricular ejection fraction (LVEF) < 50% defined systolic LV dysfunction. Diastolic LV dysfunction was diagnosed based on E/A-ratio, pulmonary vein flow, and deceleration time. Optimal pharmacological treatment to improve LV function was considered as: (i) angiotensin-blocking agent (ACE-I/ARB) in patients with LVEF < 40%; (ii) ACE-I/ARB and beta-blocker in patients with LVEF < 40% + heart failure symptoms or previous myocardial infarction; and (iii) a diuretic in patients with symptomatic heart failure, regardless of LVEF. Left-ventricular dysfunction was present in 506 patients (50%), of whom 209 (41%) had asymptomatic diastolic LV dysfunction, 194 (39%) had asymptomatic systolic LV dysfunction, and 103 (20%) had symptomatic heart failure. Treatment with ACE-I/ARB and/or beta-blocker could be initiated/improved in 67 (34%) of the 199 patients with (a)symptomatic LVEF < 40%. A diuretic could be initiated in 32 patients (31%) with symptomatic heart failure (regardless of LVEF). This study demonstrates a high prevalence of LV dysfunction in vascular surgery patients and under-utilization of ESC recommended pharmacological treatment. Standard pre-operative evaluation of LV function could be argued based on our results to reduce this observed care gap.