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Cadmium is a widespread toxic metal with potential cardiovascular effects, but no studies have evaluated cadmium and incident cardiovascular disease. We evaluated the association of urine cadmium concentration with cardiovascular disease incidence and mortality in a large population-based cohort.We conducted a prospective cohort study of 3348 American Indian adults 45–74 years of age from Arizona, Oklahoma, and North and South Dakota, who participated in the Strong Heart Study in 1989–1991. Urine cadmium was measured using inductively coupled plasma mass spectrometry. Follow-up extended through 31 December 2008.The geometric mean cadmium level in the study population was 0.94 μg/g (95% confidence interval [CI] = 0.92–0.96). We identified 1084 cardiovascular events, including 400 deaths. After adjustment for sociodemographic and cardiovascular risk factors, the hazard ratios (HRs) (comparing the 80th to the 20th percentile of urine cadmium concentrations) was 1.43 for cardiovascular mortality (95% CI = 1.21–1.70) and 1.34 for coronary heart disease mortality (1.10–1.63). The corresponding HRs for incident cardiovascular disease, coronary heart disease, stroke, and heart failure were 1.24 (1.11–1.38), 1.22 (1.08–1.38), 1.75 (1.17–2.59), and 1.39 (1.01–1.94), respectively. The associations were similar in most study subgroups, including never-smokers.Urine cadmium, a biomarker of long-term exposure, was associated with increased cardiovascular mortality and increased incidence of cardiovascular disease. These findings support that cadmium exposure is a cardiovascular risk factor.