Purpose <p>Post-induction hypotension (PIH) is a common anesthesia-related complication associated with increased perioperative morbidity, particularly in elderly surgical patients. This cohort study aimed to assess the validity of the preoperative pleth variability index (PVI) and perfusion index (PI) as non-invasive screening tools for identifying elderly surgical patients at risk of PIH.</p> Methods <p>We included 85 elderly patients (≥ 65 years) with ASA PS I &amp; II who underwent elective surgeries under general anesthesia. Preoperative baseline PVI and PI were recorded. PIH was defined as a ≥ 20% decrease in mean arterial pressure (MAP) or MAP ≤ 65 mmHg within the first 20 min post-induction. The patients were divided into two groups: those with hypotension and those without hypotension. The primary outcome was the predictive validity of preoperative PVI for PIH development. Secondary outcomes were the incidence of PIH and the predictive ability of preoperative PI for PIH.</p> Results <p>PIH occurred in 38 of the 85 patients (44.7%). Baseline PVI was significantly higher in the hypotensive group (18.4 ± 3.6 vs. 13.3 ± 5.4; P = 0.001). ROC curve analysis demonstrated an area under the curve (AUC) of 0.78 for PVI with a cutoff value of &gt; 14.67, yielding a sensitivity of 97% and a specificity of 66%. Logistic regression analysis confirmed PVI as an independent predictor of PIH (OR = 1.18; P = 0.002). The PI did not demonstrate a significant predictive value.</p> Conclusion <p>Pre-anesthesia PVI is a reliable, non-invasive predictor of PIH in elderly patients undergoing general anesthesia. A cutoff value &gt; 14.67 demonstrated high sensitivity, supporting PVI as a preoperative screening tool in this high-risk population.</p> Clinicaltrials.gov identifier <p>ID: NCT04886089, April 2021.</p>