Alpine skiing is one of the most popular recreational winter sports and attracts millions of tourists every year alone in the Alpine region. Several studies highlight the positive effects of alpine skiing as aerobic physical training and isometric muscle activity that is able to increase exercise capacity and reduce cardiovascular risk factors. However, a certain cardiovascular risk mainly related to an abrupt increase of myocardial oxygen consumption during skiing especially in otherwise sedentary subjects and effects of hypoxia in untrained patients have to be acknowledged. In this article, we provide an up-to-date evaluation of risks and benefits of alpine skiing in relation of cardiovascular disease and elderly persons. Narrative Review. In the first section, the current recommendations of physical activity and effects of alpine skiing - with particular attention to the elderly population - are described. In the second section, the present knowledge regarding cardiovascular risk and alpine skiing is summarized and possible pathophysiological mechanisms are highlighted. Finally, a summary regarding actual clinical recommendations is provided. Alpine skiing may safely be recommended also to the elderly if certain precautions are applied, as the benefits outbalance the potential risks in most subjects. Copyright © 2019 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.