OBJECTIVE: To analyze the relationship of ideal cardiovascular health to disease-specific death. PATIENTS AND METHODS: We used data from the Aerobics Center Longitudinal Study from October 9, 1987, to March 3, 1999, to estimate the prevalence of ideal cardiovascular health in 11,993 individuals (24.3% women) and to examine its relationship with deaths from all causes, cardiovascular disease (CVD), and cancer. RESULTS: During a mean follow-up of 11.6 years, 305 deaths occurred: 70 (23.0%) from CVD and 127 (41.6%) from cancer. In the entire cohort, only 29 individuals (0.2%) had 7 ideal metrics. After adjusting for age, sex, examination year, alcohol intake, and parental history of CVD, risk of death due to CVD was 55% lower in those participants who met 3 or 4 ideal metrics (hazard ratio, 0.45; 95% confidence interval, 0.27-0.77) and 63% lower in those with 5 to 7 ideal metrics (hazard ratio, 0.37; 95% confidence interval, 0.15-0.95), compared with those who met 0 to 2 ideal metrics. Although not significant, there was also a trend toward lower risk of death due to all causes across incremental numbers of ideal metrics. No association was observed for deaths due to cancer. CONCLUSION: The prevalence of ideal cardiovascular health was extremely low in a middle-aged cohort of men and women recruited between 1987 and 1999. The American Heart Association construct reflects well the subsequent risk of CVD, as reflected by graded CVD mortality in relation to the number of ideal metrics.