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Background: The American Heart Association (AHA) introduced the concept of cardiovascular health (CVH) and defined “ideal,” “intermediate,” and “poor” CVH categories for adults based on cardiovascular disease risk factors and health behaviors. We sought to examine the association between these levels of CVH and incident atherosclerotic cardiovascular disease (ASCVD) events in a large diverse population.Methods: In a large integrated healthcare delivery system in Northern California , we gathered 6 AHA metrics (smoking status, physical activity, body mass index, blood pressure, total cholesterol, and blood glucose) during 2013-2014, graded on a scale of 0 to 2, with 2 indicating "ideal" status, 1 "intermediate" status, and 0 "poor" status. Points were summed to define three categories of Poor (0-6), Intermediate (7-9) and Ideal (10-12) CVH. ASCVD was defined as non-fatal myocardial infarction (MI), fatal coronary heart disease (CHD) and fatal and non-fatal stroke from electronic medical records and state death certificates during 2015. Incident ASCVD rates per 100,000 person-years were calculated.Results: Among 1,103,583 adult members (55.5% female) receiving outpatient care with all 6 metrics, there were 194,957 (17.7%) age 18-39, 585,449 (53.0%) age 40-64, and 323,177 (29.3%) age >65 years. There were 74,737 (6.8%) Blacks, 171,058 (15.5%) Hispanics and 225,303 (20.4%) Asian/Pacific Islanders. Poor CVH was present in 240,831 (21.8%), Intermediate in 584,013 (52.9%) and Ideal CVH in 278,739 (25.3%). During 2015, incidence of overall ASCVD, CHD (non-fatal MI and fatal CHD) and stroke (fatal and non-fatal stoke) was lower with better CVH metrics (p < 0.0001 for trend) (Figure).Conclusions: In a diverse “real world” population, a significantly lower incident of ASCVD was noted among individuals with Ideal CVH. This indicates continued need for large scale efforts to track and improve cardiovascular risk factors and behaviors.