Conclusion: Despite high rates of POMI therapy with statins, beta-blockers, and antiplatelet agents, vascular surgery patients still suffer high mortality rates at 1 year.Commentary: Mortality after MI in the general population is about 4% compared with >20% in patients who suffer POMI after vascular surgery. The Revised Cardiac Risk Index is the most widely used model to calculate cardiac risk after general surgery, but this model is less accurate in predicting postoperative complications in vascular surgery patients. I was not surprised that this study reported independent predictors of 1-year mortality to be diabetes, congestive heart failure, and chronic obstructive pulmonary disease. However, I was struck by the finding that almost one-half of patients in this series who underwent a peripheral bypass and suffered a POMI were dead 1 year later.The biggest problem with any cardiac risk assessment is that we know who the worst risk patients are and maybe it is only a matter of time before they suffer a cardiac event. All vascular surgeons have encountered patients who suffered an MI literally a day or two before a planned vascular operation. If the event had happened the day after surgery, the operation (and the vascular surgeon) would have been blamed for the outcome. I am not trying to be fatalistic regarding this issue, but as I frequently remind my fellows, sometimes it is better to be lucky than good.