Plasma A42 and A40 levels are putative biomarkers for Alzheimer's disease (AD), but their significance and predictive value have been inconclusive. In AD transgenic models, plasma and cerebrospinal fluid levels of A42 and A40 increase with age but subsequently decrease when A begins to accumulate in brain and with the onset of cognitive impairment. To determine the predictive value of A levels in elderly populations, we investigated how plasma A42, A40, and a protofibrillar subspecies of A42 changed over time and with the onset of cognitive impairment or AD. In a cohort of 1,125 elderly persons without dementia, 104 (9.2%) of the participants developed AD over 4.6 years of followup. Higher plasma A42 levels at the onset of the study were associated with a threefold increased risk of AD. However, conversion to AD was accompanied by a significant decline in plasma A42, a decreased A42/A40 ratio and, with the onset of cognitive impairment, decreased protofibrillar A42 levels. Our results suggest individuals with elevated plasma A42 are at increased risk of AD and that with the onset of disease, the decline in some forms of A may reflect compartmentalization of A peptides in the brain.plasma amyloid beta40 and beta42 ͉ protofibrillar Abeta A myloid -peptides A40 and A42 are the two major species generated by sequential proteolytic cleavage by -and ␦-secretases of the amyloid precursor protein (APP) (1). Subsequent deposition of A42 has been considered an initial and critical step in the pathogenesis of Alzheimer's disease (AD). Brain levels of A42 increase with the development of dementia and are correlated with cognitive decline (2). Mutations in the APP and presenilin (PSEN1 and 2) genes, which result in a dominantly inherited form of early-onset AD, are accompanied by an increase in plasma A42 and A40 levels in patients before disease onset and are elevated in their unaffected relatives as well (3-5). Furthermore, both A42 and A40 plasma levels are increased in cognitively normal first-degree relatives of cases with late-onset AD without known mutations (6).The relation between brain and plasma A in health and disease is complex, but studies of AD transgenic mice have provided some insights. Within a few months of birth, APP transgenic mice secreted more A42 and A40 than their wild-type littermates (7,8), and A secretion is increased throughout the life of APP transgenic mice. Both plasma and cerebrospinal fluid (CSF) levels of A42, and to a lesser extent A40, increase with age, but both precipitously decrease as A42 and A40 levels rise in the brain (7). By 1 year, there are frank A plaques, and subsequently there are characteristic agerelated behavioral changes in memory. However, Lesne and colleagues (9) reported that the behavioral effects are not the result of the A accumulation in brain, but the increase in the protofibrillar subspecies of A.These observations in mice represent a model for changes in plasma A as a biomarker associated with AD in humans.Among nondemented...