Among 4,121 participants tracked across 30 years in the ARIC cohort, group-based trajectory modeling identified three distinct ankle-brachial index (ABI) patterns from mid- to late-life: high-normal, low-normal, and declining. Cardiovascular health, scored via the American Heart Association's Life's Essential 8 (LE8) framework, diverged sharply across groups—68 points in high-normal versus just 50 points in the declining trajectory. Black participants experienced earlier, faster, and more severe ABI decline than White participants, while women showed delayed but more frequent decline than men.
PAD affects over 230 million people globally, yet 20–50% of cases remain asymptomatic and undetected, partly because guideline bodies don't recommend screening in asymptomatic high-risk individuals. This analysis challenges that conservative posture by demonstrating that poor LE8 scores in midlife—capturing sleep, diet, activity, weight, smoking, blood glucose, lipids, and blood pressure—reliably predict who enters a declining ABI trajectory decades later. The racial disparity finding is particularly striking and aligns with broader evidence on differential cardiovascular risk burden in Black Americans, likely reflecting cumulative exposure to social determinants of health. Practically, the data suggest that targeted midlife ABI screening using LE8 as a risk-stratification tool could surface subclinical PAD earlier, opening a window for preventive intervention. Limitations include potential survivor bias, predominantly community-dwelling participants, and observational design precluding causal inference. As a preprint not yet peer-reviewed, these trajectory groupings and effect estimates require independent validation before informing clinical guidelines.
