Background: The aims of this study were to determine (1) the prevalence of an abnormal ankle brachial index (ABI; <0.90) and (2) the association of serum high sensitive C-reactive protein (hs-CRP), a marker of systemic inflammation, with the abnormal ABI in asymptomatic older adults (>50 years old). Methods: Study subjects were 1,271 Koreans (263 males; mean age=65.8±8.5 year-old) in a rural area in Daegu city, Korea. They were enrolled from August to November 2008 for a cohort study. The ABI was performed after subjects rested for at least 10 minutes in a supine position. Study subjects were classified into a low (ABI <0.9) and normal ABI group. Baseline levels of serum hs-CRP were measured by immunoturbidimetric assay. Results: Of 1,271 asymptomatic older adults, 42 (3.3%) had a lower ABI. Based on univariate analysis for low ABI, age, gender, body mass index, systolic blood pressure, status of smoking, diabetes mellitus, and serum level of uric acid were significantly related to a lower ABI. Baseline hs-CRP levels were significantly higher in low ABI group compared to normal ABI group (2.34±2.41 mg/L versus 1.46±1.38 mg/L, p=0.023). Baseline hs-CRP levels were significantly negatively correlated with ABI (r=-0.142, p<0.001). In multivariate analysis log transformed hs-CRP (odds ratio [OR] 2.639, 95% confidence interval [CI] 1.026-6.787; p=0.044) in addition to age(OR 1.082, 95% CI 1.035-1.131; p=0.001) were independent predictors of low ABI after adjusting for gender, body mass index, systolic blood pressure, status of smoking, diabetes mellitus, and serum level of uric acid. The likelihood ratio test showed that hs-CRP added incremental value to the combination of serum uric acid concentrations and conventional risk factors in predicting low ABI. Conclusions: This study provides evidence that baseline levels of hs-CRP are modestly associated with low ABI. These data suggest that inflammation may have a potentially important role in part in the development of peripheral vascular disease in asymptomatic older adults.