Background: Identification of patients at high risk for perioperative cardiac events (POCE) is important. Many noninvasive tests are being used to predict perioperative cardiac complications. This study aimed to determine whether preoperative measurement of plasma NT-proBNP could predict POCEs when compared with conventional cardiac risk factors in patients who underwent major vascular surgery. Methods: Patients who were scheduled for major noncardiac vascular surgery were prospectively enrolled. Clinical risk factors were used to categorize patients by the Revised Cardiac Risk Index (RCRI). NT-proBNP, transthoracic echocardiography and thallium scan were also evaluated. POCE was the composite of acute myocardial infarction, congestive heart failure including acute pulmonary edema, or primary cardiac death within 5 days after surgery. Receiver operating characteristic (ROC) curves were used to assess and compare prognostic value of NT-proBNP with RCRI and modified RCRI; including significant perfusion defect [large (> 3 walls), moderate to severely decreased, reversible defect] on thallium scan, chronic renal insufficiency (creatinine clearance less than 30 ml/min or on dialysis), NT-proBNP level above 75 percentile and abdominal aortic surgery. Results: A total of 456 patients had a median NT-proBNP level of 107.4 pg/ml (range of quartile, 47.9 – 355.8 pg/ml). POCEs occurred in 64 (14%) patients. After adjustment for confounders, significant perfusion defects on thallium scan (OR 4.9, 95% CI 1.2 to 19.9, p=.026), NT-proBNP (OR 4.4, 95% CI 2.4 to 9.2, p<.001), chronic renal insufficiency (OR 3.5, 95% CI 1.4 to 8.6, p=.006), and abdominal aortic surgery (OR 2.3, 95% CI 1.3 to 4.3, p=.007) were independent predictors for POCEs. The area under the ROC curves for predicting POCEs did not show statistical difference among NT-proBNP, RCRI and modified RCRI (0.72 for NT-proBNP, 0.68 for RCRI, and 0.74 for modified RCRI; p>0.05). Conclusion: Preoperative measurement of NT-proBNP provides useful information to predict POCEs as a single parameter and may help guide risk stratification of high risk patients undergoing major noncardiac vascular surgery.