Background: This study investigated the association between high-risk perioperative medications (HRPOMs) and postoperative cardiac complications in older adults undergoing spinal surgery. Methods: This retrospective cohort study included patients aged 75 years and older who underwent elective spinal surgery under general anesthesia between January 2020 and December 2022. We collected data on demographic characteristics, comorbidities, preoperative hemoglobin level, intraoperative details and postoperative cardiac complications. Univariate and multivariate regression analyses were conducted to identify risk factors for postoperative cardiac complications. Results: Of 427 patients who underwent spinal surgery included in the study, 301 were found to be using high-risk cardiac medications. Postoperatively, 28 patients experienced cardiac complications, an incidence rate of 6.6 %. Multivariate analysis identified several significant predictors of these complications: lower preoperative serum hemoglobin levels (adjusted odds ratio (AOR) = 0.969; p = 0.017), intraoperative blood loss (AOR = 1.124; p = 0.010) and preoperative long-term use of beta-blockers (AOR = 2.708; p = 0.026). In particular, a failure to resume the use of beta-blockers after surgery (AOR = 159.942; p<0.001) seems to be the most significant factor. Conclusion: In summary, our study highlights important risk factors for postoperative cardiac complications in older adults undergoing spinal surgery, especially the standardized use of HRPOMs in the perioperative period. Future research should aim to validate these findings through prospective studies and ensure the safety of perioperative medications for patients.