Objective: To compare the hemodynamic stability of etomidate and remimazolam during painless gastroscopy and evaluate the safety of remimazolam in elderly patients undergoing gastroscopy. Methods: A total of 100 elderly patients aged 65–80 years, with American Society of Anesthesiologists (ASA) physical status I–II, who underwent painless gastrointestinal endoscopy were included in this study. The patients were randomly assigned to receive either 0.2 mg/kg of remimazolam (Group R) or 0.3 mg/kg of etomidate (E group) in combination with alfentanil for anesthesia induction. Results: The mean arterial pressure (MAP) and heart rate (HR) were significantly higher in the E group compared to Group R (P < 0.05). Ephedrine was administered more frequently in the Group R (30%) than in the Group E (10%), with a statistically significant difference (P = 0.023). The incidence of myoclonus was markedly lower in the Group R (0%) compared to the Group E (60%, P < 0.01). Conclusion: During gastroenteroscopy with alfentanil, remimazolam was associated with lower MAP and HR compared to etomidate. Patients receiving remimazolam experienced a higher incidence of post-induction hypotension. Nonetheless, the safety and efficacy of remimazolam were comparable to those of etomidate, supporting its suitability as a sedative for ASA I–II elderly patients undergoing gastrointestinal endoscopy.