Up to 40% of cardiac surgery patients present with preoperative anemia, which is associated with significant risks and management challenges. This review highlights the increased perioperative risk attributable to preoperative anemia as well as recommended optimization strategies. This includes screening for anemia and iron deficiency as well as the appropriate use of intravenous iron replacement, vitamin B12, folic acid, and erythrocyte stimulating agents. The mechanism of action, optimal dosing, and anticipated time to response are also described. The benefits of proactive treatment of preoperative anemia within the context of a comprehensive patient blood management program are also explored. Finally, a discussion is provided on how to overcome common barriers in the treatment of preoperative anemia.