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The clinical role of B-type natriuretic peptide (BNP) in preoperative evaluation is not clear. We designed a prospective study to investigate the predictive value of BNP in comparison with established clinical risk scores for the outcome of major orthopedic surgery.Overall 242 elderly patients [80 (74–85) years] undergoing orthopedic surgery were included. Inhospital cardiovascular events and 1-year mortality were the main endpoints.In total 20 (8.3%) patients had major cardiovascular events (MACE) and 41 (21.1%) died in 1 year. Logistic regression analysis for prediction of cardiac events and 1-year mortality, respectively, revealed a significant prognostic value for the BNP (P < 0.001 and P = 0.041), Goldman (P = 0.013 and P = 0.003), Lee (P = 0.022 and P = 0.200), Detsky (P < 0.001 and P < 0.001), and functional capacity indices (P = 0.034 and P = 0.001). BNP cutoff 149 ng/ml improved discrimination of all scores to predict MACE, and BNP cutoff 89 ng/ml improved discrimination of all scores to predict 1-year mortality (Net Reclassification Improvement, P values < 0.05 in all cases). Age [hazard ratio (HR): 1.100, 95% confidence interval (CI): 1.039–1.166, P = 0.001] and BNP (HR: 1.002, 95% CI: 1.000–1.003, P = 0.041) were independent associates of 1-year mortality.Preoperative levels of BNP compare favorably with the Goldman, Lee, Detsky, and functional capacity indices for prognosis of orthopedic surgery. Implementation of natriuretic peptides in cardiac risk scores is promising.