Paskiewicz A, Wang FM, Yang C, et al. - Findings demonstrate an independent and robust association of lower ankle‐brachial index (ABI) with elevated risk of severe ischemic leg outcomes in a middle‐aged community‐based cohort. ABI ≤0.90 as a threshold diagnosing peripheral artery disease (PAD) is further backed, and recognizing the prognostic value of ABI 0.91 to 1.10 for limb prognosis is important.

• An analysis of 13,735 ARIC (Atherosclerosis Risk in Communities) study participants who were without clinical symptoms of PAD (mean age, 54 [SD, 5.8] years; 44.4% men; and 73.6% White) at baseline (1987–1989).

• Post-adjustment for demographics, a ≈4‐fold higher risk of critical limb ischemia and ischemic leg amputation was observed in relation to ABI ≤0.90 vs 1.11 to 1.20 (hazard ratios, 3.85 and 4.39).

• Post- multivariable adjustment, a modest attenuation in the magnitude of the association was evident (hazard ratios, 2.44 and 2.72, respectively).

• ABI 0.91 to 1.00 and 1.01 to 1.10 were also related to these severe leg outcomes, with hazard ratios ranging from 1.7 to 2.0 post- accounting for potential clinical as well as demographic confounders.

• Across various subgroups, the links were identified to be largely consistent.