Objective-To determine whether a low ankle brachial pressure index is associated with an increased risk of cardiovascular events and death, and whether the prediction of such events could be improved by including this index.Design-Cohort study. Setting-11 practices in Edinburgh, Scotland. Subjects-1592 men and women aged 55-74 years selected at random from the age-sex registers of 11 general practices and followed up for 5 years.Main outcome measures-Incidence of fatal and non-fatal cardiovascular events and all cause mortality.Results-At baseline 90 (5.7%) of subjects had an ankle brachial pressure index <0.7, 288 (18.2%) had an index 's0.9, and 566 (35.6%) < 1.0. After five years subjects with an index <0.9 at baseline had an increased risk of non-fatal myocardial infarction (relative risk 1.38, 95% confidence interval 0.88 to 2.16), stroke (1.98, 1.05 to 3.77), cardiovascular death (1.85, 1.15 to 2.97), and all cause mortality (1.58, 1.14 to 2.18) after adjustment for age, sex, coronary disease, and diabetes at baseline. The ability to predict subsequent events was greatly increased by combining the index with other risk factors-for example, hypertensive smokers with normal cholesterol concentrations had a positive predictive value of 25.0%, increasing to 43.8% in subjects with a low index and decreasing to 15.6% in those with a normal index.Conclusion-The ankle brachial pressure index is a good predictor of subsequent cardiovascular events, and improves on predictions by conventional risk factors alone. It is simple and accurate and could be included in routine screening of cardiovascular status. IntroductionCoronary heart disease is the main cause of death and disability in elderly people,' and numerous primary and secondary prevention trials have attempted to reduce its impact.2 Important risk factors include hypercholesterolaemia, hypertension, and cigarette smoking,3 and attempts have been made to target those at greatest risk by using scoring systems such as the Dundee method4 or by identifying subjects with early