Background: Urinary zinc has been associated with cardiometabolic endpoints including diabetes and peripheral artery disease (PAD), but evidence from prospective studies is limited. Objective: Our goal was to evaluate the prospective association between urinary zinc levels and incident PAD and amputation events in a large population-based cohort of American Indian adults in the US, the Strong Heart Study (SHS) cohort. Methods: A total of 2,049 PAD-free and 2,184 amputation-free participants at the baseline examination (1989-91) were included (mean 56 years, 61% female). The median (IQR) urinary zinc levels were 538 (388, 765) μg/g creatinine among PAD-free participants and 547 (396, 784) μg/g creatinine among amputation-free participants. PAD (defined as ankle brachial index <0.9 or >1.4) and amputation events were collected through the second (1993-1995) and third (1997-1999) SHS examination visits. We used logistic regression models to evaluate the progressively adjusted odds ratios (ORs) of PAD and amputation by increasing quantile of urinary zinc. Results: Over the two prospective study visits, 345 participants developed PAD and 23 underwent amputation. After adjustment for CVD risk factors including age, sex, location, body mass index, smoking and alcohol use status, cholesterol levels, estimated glomerular filtration rate, hypertension and diabetes, the ORs per IQR change in urine zinc levels were 1.16 (95% CI: 0.98, 1.38) for PAD, and 1.74 (95% CI: 1.04, 2.92) for amputation. Further adjusting the models for plasma fasting glucose reduced the magnitude of the association between high urinary zinc levels on PAD (OR: 1.09, 95% CI: 0.91, 1.31) and amputation (OR: 1.32, 95% CI: 0.72, 2.44). Conclusions: High urinary zinc levels were prospectively associated with PAD and amputation events, an association that appears to be partly related to lack of glycemic control. Further research is needed to better understand the complex relationship between urinary zinc, glycemic control and CVD.